*Purpose: Hackensack University Medical Center’s (HUMC) kidney transplant program struggled with patient outcomes. Multi-disciplinary engagement with development of a comprehensive patient safety and quality initiative optimized patient outcomes and created program growth with high reliability in a competitive market.

*Methods: Multi-disciplinary team creation and involvement were fostered to create better transparency and collection of expert knowledge and implementation of best practices. Creation of a quality assurance initiative with a renewed reporting structure fostered hospital-wide accountability for transplant performance measures.

As part of this initiative a series of key committees and meetings were established to ensure continuous identification, investigation and improvement. These committees include; quality assurance and process improvement, morbidity & mortality, deceased donor offer and waitlist mortality reviews. In addition, all current policies and processes were audited to identify barriers and improvement opportunities.

*Results: Over 240 events including each 30-day readmission were discussed during bi-weekly morbidity and mortality meetings from April 2017 through October 2019 resulting in over 60 actions to correct and improve processes and systems. An interesting trend was that despite performing more transplants fewer events occurred. Implemented performance improvement projects lead to reduced 30-day readmissions by almost 10%, while transplant volume increased from 40 transplants in 2016 to over 115 in 2019. Urinary tract infections and length of stay as well as waitlist mortality and patient wait times also significantly improved. In May 2018, the transplant program was audited by UNOS and achieved 100% clinical and 99% administrative compliance. UNOS complimented on proactively recognizing opportunities for improvement and on the timely implementation of corrective actions. Another key success was that in the spring of 2019 HUMC for the first time had better survival outcomes than national benchmarks and ranked among the best centers based on outcome data reported by SRTR (Table 1).

*Conclusions: The culture created at HUMC at the organ transplant division can be replicated at any hospital in almost any service line with leadership vision and collaboration. Key factors to success were transparency, just culture, and acknowledgment of opportunities and deficiencies with a drive for higher reliability and continuous improvement.

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