Problem: From January to April 2020, there were eight missed organ acceptance opportunities for 12 actively waitlisted patients to perform a kidney transplant at our center where the organ offers were coded out as “Serum Not Available”, indicating a lack of patients’ current serum samples available for HLA cross matching.
Measurement: We used an A3 structured template for Systematic Problem Solving in a continuous manner. This was multi-disciplinary approach to solving larger-scale issues, where the team defined the problem via structured root cause analysis methods including a fishbone diagram, Pareto chart, prepared a goal, and ran several PDSA cycles.
Analysis: Through discussions with the multidisciplinary team, we identified leading root causes of missing sera with a Pareto chart and made the decision to implement alternate ordering and shipping processes, as well as revise the communication tools for dialysis units.
Implementation: We implemented updates for the ordering and shipping processes for serum storage kits beginning in August 2020. As a phase two of this project, we began revising the report that includes serum-drawing requirements for patients shared with dialysis units, beginning in January 2021.
Results/Discussion: We reported preliminary data that showed 25% increase in patients with serum. drawn within the previous 90 days. Since implementation of the revised communication tool with dialysis units, we have exceeded 98% of patients. This allowed us to code out three fewer opportunities for transplantation over the course of 2021.