Transplant Center SRTR Report – March 3, 2014

The long awaited confidential release of center-specific SRTR data will occur on Monday, March 3, 2014 and the public release on March 20th. This data is used by CMS to monitor and regulate Solid Organ Transplant Centers under the CMS Conditions of Participation.

As we stated in our last communiqué, Guidry & East has assisted approximately one-third of Transplant Centers cited under the CMS Conditions of Participation with their quality systems improvements. The assistance falls in the securing of three categories of consultants:

  • Mitigating Factors Application Review Team
  • Onsite Transplant Consultant/s
  • Independent Peer Review Team


Mitigating Factors Application Review Team: Guidry & East provides a three-consultant team (Transplant Surgeon, Physician and Administrator) to review the application presented by the Transplant Center and make recommendations prior to submission to CMS. The review team will also conduct a mock CMS conference call to prepare senior leadership for the actual CMS Q&A.

Following the filing and defense of your Mitigating Factors Application ("MFA"), you may still find yourself in the unfortunate position of accepting a Systems Improvement Agreement ("SIA") to maintain Medicare Certification for your transplant program (As of 04/02/2012, per CMS, approximately 38% of those filing MFA's received SIA's or withdrew).

Under an SIA you will be required by CMS to follow very tight time-lines, including the securing of an Onsite Transplant Consultant/s to partner with the hospital-based transplant team for eight to ten days a month for the term of the SIA - generally one year. This Onsite Transplant Consultant will observe and analyze the day-to-day operations of the entire transplant program, wait-list management, and assist the Transplant Center implement the Independent Peer Review Team's (six to eight consultants) recommendations developed in their Root Cause Analysis report.

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 CoP's for organ transplant programs. Any deficiencies will be noted and Guidry & East will help develop an Action Plan that can, hopefully, lessen the severity of actions taken by CMS. If more intensive consultation is required, Guidry & East will provide a written Needs Assessment outlining our findings and associated consulting costs.

We welcome the opportunity to listen and learn about the goals and objectives for your Transplant Center. It is likely that we offer services that are a great fit for you. Feel free to call to speak with Jim about how Guidry & East may provide proven strategies and solutions to issues within your Transplant Center.

Jim Guidry, MEd, MBA
Chief Executive Officer

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