CMS initiated the Conditions of Participation (CoPs) for Organ Transplant programs on June 28, 2007. Five of the 500+ Medicare Certified organ transplant programs were found to have "significant deficiencies that affect or had the potential for affecting the health and safety of transplant recipients and living donors". These centers completed a rigorous retooling mandated under an agreement with CMS referred to as a Systems Improvement Agreement (SIA) to avoid termination of the programs.

Since those initial five "graduated" from their SIA, more than a dozen additional transplant programs have entered into SIAs with CMS. In addition to these programs, several requested and received consideration due to "mitigating factors" to elude the issuance of a Statement of Deficiencies.

To date, Guidry & East has assisted approximately one-third of the centers cited under the CoPs. This entailed the furnishing of four and six-person Independent Peer Review Teams and the insertion of an onsite independent Quality Consultant for eight to ten days a month for the term of the SIA (generally one year).

If your program receives an SIA, you will be required by CMS to follow very tight time-lines associated with the Agreement. Guidry & East has a committed team of transplant professionals with the experience to work with you and CMS in developing a Root Cause Analysis Report, the subsequent Corrective Action Plan, and provide the onsite independent Quality Consultant required to assist the hospital with improving patient and graft outcomes and implementation of the recommendations brought forth by the Independent Peer Review Team.

Guidry & East also provides transplant centers with a Preemptive SIA Review. Our staff will examine your SRTR data and conduct an offsite GAP Analysis of your transplant program's policies as outlined in the CoPs for organ transplant programs. Any deficiencies will be noted and an Action Plan developed that can, hopefully, lessen the severity of actions taken by CMS down the road. If more intensive consultation is required, Guidry & East will provide a written Needs Assessment outlining our findings and associated consulting costs.