Issue link: https://beckershealthcare.uberflip.com/i/1414493
34 QUALITY IMPROVEMENT & MEASUREMENT Cleveland's University Hospitals changes organ transplant protocol after kidney mix-up By Erica Carbajal U niversity Hospitals in Cleveland is strength- ening its organ transplant procedures aer a patient received a kidney meant for another patient, Cleveland.com reported. In a July 23 letter to employees, Cliff Megerian, the health system's CEO, said the error occurred due to "a breakdown in following protocol during the organ verification process." "We recognize the pain this situation has caused our patients, their families and also our caregivers. e er- ror should have never happened, and it runs counter to the goals for safety and excellence we advocate throughout our health system," the letter said. e CEO said transplant policies and procedures have been modified to "increase redundancy in the verification of organs and patients." Other actions the health system is taking include: • Establishing a zero harm executive cabinet. • Conducting training with appropriate transplant personnel that reinforces compliance with organ verification protocols. • Determining the feasibility of incorporating bar code validation in organ verification. • Expanding evaluation of the incident to include a broader assessment of the system's transplant program. • Engaging a third-party expert to conduct a cultural safety assessment of the transplant program. e transplant mix-up occurred July 2, and two caregivers were placed on administrative leave. e kidney was compatible with the patient who inadver- tently received it. Transplant surgery for the patient for whom the organ was intended has been delayed. "e way we will prevent mistakes is attentiveness to detail and dedication to a culture that puts safety first," Mr. Megerian said in the letter, according to Cleveland.com. "e lessons we learn from this event will be shared systemwide and with other health systems to improve safety everywhere." n Yale New Haven wins quality award from American Hospital Association By Mackenzie Bean Y ale New Haven (Conn.) Health is the 2021 recipient of the American Hospital Association's Quest for Quality Prize, the association said July 26. Yale New Haven was chosen for its exceptional work in addressing social determinants of health, using data to drive quality improve- ment and engage staff in quality work. The association also recognized Yuma (Ariz.) Regional Medical Center and Memorial Healthcare System in Hollywood, Fla., as award finalists. The awards were presented July 28 at the virtual AHA 2021 Lead- ership Summit. n Memorial Health develops online tool to assess health equity for hospitals: 4 things to know By Hannah Mitchell S pringfield, Ill.-based Memorial Health System is launching an as- sessment tool to gauge race- and income-based health dispari- ties for hospitals, The State Journal-Register reported July 5. Four things to know: 1. The tool will include 31 questions designed to measure how hospitals track and actively try to address social determinants of health in patient care. It will inquire if the hospital is supporting minority-owned and environmentally friendly vendors and whether it tries to reduce racial bias in clinicians. The tool also analyzes how the hospital's board of directors and leadership team represents the diversity of its community. 2. Based on leaders' answers to these questions, an algorithm will develop a "Racial Equity in Healthcare Progress Report" that is only shared with the organization. The assessment will allow hospitals to track their progress. 3. The goal is for the tool to become the gold standard for health equity assessment in Illinois, and eventually nationwide. "My hope is that it will put friendly pressure on organizations to advance their own equity work," said Becky Gabany, Memorial's director of community engagement. "I hope it inspires change and drives people to participate." 4. The tool was developed in partnership with the Illinois Health and Hospital Association. Memorial will serve as one of the assessment tool's pilot sites. IHA and Memorial will be working with several other health systems as the tool is tested and released. n