Pre-Transplant Evaluation Period Efficiency Through the Use of an Electronic Scheduling Template

Practice Problem: Candidacy for transplant evaluation is a complex and lengthy evaluation process. Delays in National Organ Registry have significant unfavorable impacts on patient outcomes as 22 people a day die awaiting a lifesaving treatment. Operational efficiencies can improve the pre-transplant evaluation period and significantly improve patient outcomes. PICOT: In an outpatient transplant clinic (P), will leveraging an evidence-based scheduling template (I) compared to the current practice of first available appointment (C) reduce the evaluation period by 66% from a 3–4-week evaluation to a 1-week evaluation resulting in expedited listing on the National Organ Registry (O), when applied over a 10-week period (T)? Evidence: Electronic scheduling templates are evidenced to improve access, workflow efficiencies, and reduce patient wait times by 25% (Suss et al., 2017). Leveraging a value stream mapping tool, gaps in process time can be identified while improving quality outcomes Intervention: An evidence-based scheduling template was applied to measure impact on access availability to appointments for pre-liver transplant patients. Pre-and-post intervention data measured the impact of the scheduling process efficiency, process waste, and total lead time. Outcome: The scheduling template was found to have a statistically significant impact on scheduling efficiency, resulting in a 65.2% (p<.001) reduction in total lead time, reducing evaluation days from an average of 22.71 days (545.04 hours) to an average of 7.9 days (189.6 hours). Conclusion: The new scheduling template improved appointment access and expedited patient’s National Organ Registry by 15 days. Operational efficiencies gained by use of an electronic scheduling template not only have favorable impacts to patient outcomes, but also on organizational costs through improved workflows, and a favorable staff and patient experience. TRANSPLANT EVALUATION EFFICIENCY 4 Pre-Transplant Evaluation Period Efficiency Through the Use of an Electronic Scheduling Template Patients who suffer from chronic organ failure spend a tremendous amount of time searching for expert medical advice and a glimmer of hope. To be considered for a life-saving organ transplant, patients must undergo an extensive evaluation process including numerous medical appointments with a variety of specialists. The United Network for Organ Sharing (UNOS) defines standard criteria for peer reviewed patient selection prior to listing on the National Organ Registry. Coordination of appointments, patient schedules, and expert review panels takes several weeks. Delays have a significant impact on a critically ill patient’s outlook and outcome. Due to worsening illness, 22 individuals die on average each day waiting for transplantation (LifeSource, 2022). Transplant centers have a professional obligation to create safe, timely, efficient, effective, patient-centered care delivery processes resulting in a no-harm evaluation period and timely access to an effective treatment plan leading to optimal outcomes. Significance of the Practice Problem On average, pre-transplant evaluation period can range from days up to 6 weeks (about 1 and a half months) depending on the transplant center (Beaumont Health, n.d.; University of Pittsburgh Medical Center [UPMC], n.d.). Coordination of available appointments and patient schedules create challenges resulting in delayed treatment. A significant portion of treatment delays are a result of decreased access and appointment availability. The health of patients requiring transplantation declines rapidly as organ failure progresses. Delayed registry often leads to patients with poor health contributing to poor outcomes and often death. In 2020, the pre-transplant mortality rate was 12.2 per 100 waiting-list years, women had a higher mortality rate than men, and 19 deaths per 100 waiting-list years (Kwong et al., 2022). Early identification TRANSPLANT EVALUATION EFFICIENCY 5 and successful transplantation extend life expectancy and increases quality of life (Hepatitis C Online, n.d.; Martin et al., 2014). Pre-liver transplant evaluations are equally complex as evaluations for other organs. Patients with advanced liver disease are at a high risk for rapid decline and treatable only through transplantation. National registry listing delays contribute to declining health with an average of 22 active registry patients a day dying before receiving the benefits of a new organ (Murray & Carithers, 2005). Transplant centers reporting shortened evaluation periods are evidenced to have better outcomes. Presumably, these transplant centers have optimized operational efficiencies that maximize resource allocation (Gumabay et al., 2021). The U.S. Department of Health and Human Services Healthy People boldly states access to care as a human right and required to achieve quality outcomes (U.S. Department of Health and Human Services, n.d.). Appointment limitations and access reduction are significant contributing factors lengthening the pre-transplant evaluation period and delays in the National Organ Registry. Huang and Allen (2017) suggested standardization of required evaluation appointments could reduce appointment delays and decrease the total evaluation period and days prior to UNOS enrollment. A growing body of evidence suggested scheduling optimizations leveraging electronic health record (EHR) templates consolidate schedules and improve patient access (Hribar et al., 2018). These optimizations reduce waste, re-distribute, and standardize tasks, and promote improvement (Stellmaker et al., 2022). EHR scheduling templates consolidate appointments and reduce patient travel burden by decreasing the number of trips to the facility (Gumabay et al., 2021). The largest integrated transplant center in the United States completes over 2000 transplants annually, 500 of those are liver transplants. The average pre-liver transplant TRANSPLANT EVALUATION EFFICIENCY 6 evaluation at this center is greater than three weeks, exceeding the national average by more than two weeks. This evidence-based change project aims to evaluate the impact of an electronic scheduling template on improved appointment and access efficiency resulting in a reduced preliver evaluation process.


Pre-Transplant Evaluation Period Efficiency Through the Use of an Electronic Scheduling Template
Patients who suffer from chronic organ failure spend a tremendous amount of time searching for expert medical advice and a glimmer of hope. To be considered for a life-saving organ transplant, patients must undergo an extensive evaluation process including numerous medical appointments with a variety of specialists. The United Network for Organ Sharing (UNOS) defines standard criteria for peer reviewed patient selection prior to listing on the National Organ Registry. Coordination of appointments, patient schedules, and expert review panels takes several weeks. Delays have a significant impact on a critically ill patient's outlook and outcome. Due to worsening illness, 22 individuals die on average each day waiting for transplantation (LifeSource, 2022). Transplant centers have a professional obligation to create safe, timely, efficient, effective, patient-centered care delivery processes resulting in a no-harm evaluation period and timely access to an effective treatment plan leading to optimal outcomes.

Significance of the Practice Problem
On average, pre-transplant evaluation period can range from days up to 6 weeks (about 1 and a half months) depending on the transplant center (Beaumont Health, n.d.; University of Pittsburgh Medical Center [UPMC], n.d.). Coordination of available appointments and patient schedules create challenges resulting in delayed treatment. A significant portion of treatment delays are a result of decreased access and appointment availability. The health of patients requiring transplantation declines rapidly as organ failure progresses. Delayed registry often leads to patients with poor health contributing to poor outcomes and often death. In 2020, the pre-transplant mortality rate was 12.2 per 100 waiting-list years, women had a higher mortality rate than men, and 19 deaths per 100 waiting-list years (Kwong et al., 2022). Early identification and successful transplantation extend life expectancy and increases quality of life (Hepatitis C Online, n.d.;Martin et al., 2014).
Pre-liver transplant evaluations are equally complex as evaluations for other organs.
Patients with advanced liver disease are at a high risk for rapid decline and treatable only through transplantation. National registry listing delays contribute to declining health with an average of 22 active registry patients a day dying before receiving the benefits of a new organ (Murray & Carithers, 2005). Transplant centers reporting shortened evaluation periods are evidenced to have better outcomes. Presumably, these transplant centers have optimized operational efficiencies that maximize resource allocation (Gumabay et al., 2021).
The U.S. Department of Health and Human Services Healthy People boldly states access to care as a human right and required to achieve quality outcomes (U.S. Department of Health and Human Services, n.d.). Appointment limitations and access reduction are significant contributing factors lengthening the pre-transplant evaluation period and delays in the National Organ Registry. Huang and Allen (2017) suggested standardization of required evaluation appointments could reduce appointment delays and decrease the total evaluation period and days prior to UNOS enrollment. A growing body of evidence suggested scheduling optimizations leveraging electronic health record (EHR) templates consolidate schedules and improve patient access (Hribar et al., 2018). These optimizations reduce waste, re-distribute, and standardize tasks, and promote improvement (Stellmaker et al., 2022). EHR scheduling templates consolidate appointments and reduce patient travel burden by decreasing the number of trips to the facility (Gumabay et al., 2021).
The largest integrated transplant center in the United States completes over 2000 transplants annually, 500 of those are liver transplants. The average pre-liver transplant evaluation at this center is greater than three weeks, exceeding the national average by more than two weeks. This evidence-based change project aims to evaluate the impact of an electronic scheduling template on improved appointment and access efficiency resulting in a reduced preliver evaluation process.

PICOT Question
In an outpatient transplant clinic (P), will leveraging an evidence-based scheduling template (I) compared to the current practice of first available appointment (C) reduce the evaluation period or total lead time by 66% from a 3-4-week evaluation to a 1-week evaluation by reducing the process waste resulting in expedited listing on the National Organ Registry (O), in a 10-week period (T)? The setting for this project was a high-volume, fast-paced outpatient transplant clinic coordinating care for adult solid organ transplant candidates and recipients 18 years of age and older. The project re-designed the clinical evaluation process and appointment availability by implementing an EHR scheduling template designed to reduce time between appointments. Project implementation examined the post-intervention average evaluation time in days and hours for 34 patients with successful liver-transplant evaluations and compared the group to the pre-intervention average evaluation time in days and hours for 34 patients that had already completed a successful liver transplant evaluation. The expected outcome of this project was to condense the liver evaluation process total lead time by 66% from a 3-4-week evaluation period to a 1-week evaluation period. The project was completed over a 10-week period which allowed for enough time to collect and measure the post-intervention data.

Evidence-Based Practice Framework & Change Theory
Incorporating an evidenced based framework ensures a thoughtful and systematic approach to quality improvement processes aimed at identifying the root causes of a specific problem. The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model guides bedside nurses with a method to translate evidence-based research into their daily practice by a problemsolving approach that integrates best evidence, influences practice, and encourages nurses to use critical thinking when providing care (Melnyk & Fineout-Overholt, 2015). The JHNEBP model is easily adopted by transplant nurses who are responsible for coordinating transplant evaluations and presenting a patient's case to an interdisciplinary peer-reviewed team for listing selection.
Delays in the transplant evaluation period as measured by industry benchmarks are considered a direct reflection of nursing quality. The JHNEBP framework supports nurses in evaluating and adopting evidence-based strategies.
Change management theory is critical to any quality improvement project. Change management supports teams adapting to complex change by systematically outlining the need for change, change expectations, and sustainable processes for continued outcome success. Change management can be described as a discipline and research shows that for success to occur, team members and leaders must prepare, equip, and support each other so that change can be sustained (Prosci, n.d.). Awareness, Desire, Knowledge, Ability, Reinforcement (ADKAR) is a common change management model that aligns a need for complex change with the knowledge, skill, and ability of the team impacted.
Through use of the ADKAR model (see Figure 1), leaders can focus their activities on what promotes individual change and achieve results. Therefore, the ADKAR model was the best fit for this project as it guides team members through the change project and ensures that they embrace and sustain the change. Change within an organization usually fails because the team members do not understand the importance of the change and are not provided with the tools to be successful with the change. Too often, leaders focus on change management and fail to acknowledge the "why" behind the change. Failing to address any segment of the ADKAR model would have resulted in a predictable failure and prevent teams from full practice adoption of the new change due to predictable resistance (Prosci, n.d.). The ADKAR model is goal oriented and addresses challenges by providing leaders with the right tools, resources, and strategies to motivate and be successful with organizational changes.

Evidence Search Strategy
The search strategy used to search articles for this project included several different databases. The databases used were CINAHL complete, Gale Academic One File, Health Business Elite, and Google Scholar. These databases were obtained by using the University of St. Augustine for Health Sciences library and Google. When searching for articles the Boolean operator term "AND" was utilized. Inclusion criteria for this search used the following key search terms interchangeably: "operational efficiency," AND "organizational efficiency," AND "care coordination," AND "electronic appointment scheduling and template" AND "value stream mapping," AND "electronic medical record," AND "scheduling template," AND "lean management." In addition, search filters included articles written within the last 10 years (2012-2022), English, full-text, and academic journals. Duplicates were removed. Exclusion criteria consisted of articles that focused on inpatient or acute care hospitals and abstract only.

Evidence Search Results
An in-depth literature review was utilized to retrieve articles that address operational efficiency, scheduling templates, and value stream mapping in outpatient clinics. A PRISMA diagram (see Figure 2) was used to reflect the literature review and articles that met criteria for use in this project.
This search yielded 226 articles to be reviewed for use. Initially, the search began with keywords such as (operational efficiency) AND (organizational efficiency) AND (care coordination) AND (electronic appointment scheduling and template) AND (value stream mapping) AND (electronic medical record) AND (scheduling template) AND (lean management). These articles were narrowed down using specific criteria such as English, fulltext, academic journals, and dated within last ten years (2012)(2013)(2014)(2015)(2016)(2017)(2018)(2019)(2020)(2021)(2022). Duplicate articles were removed. The inclusion criteria yielded a total of 11 usable articles (see Appendix A). The literature search eliminated articles that did not occur in an outpatient clinic, health care, or did not address improvement in efficiency or positive outcomes through use of a scheduling template. Several articles were reviewed after the initial literature search from other sources and were included in the review.
The JHNEBP model uses the practice, evidence, translation (PET) process to implement change. The evidence phase is where an evidence search is conducted through a literature review and articles are graded based on level and quality. The JHNEBP model can be used in a variety of settings where nursing is practiced (Melnyk & Fineout-Overholt, 2015). The JHNEBP model was utilized to grade the level and quality of the final six articles. The grading of level and quality of each article is important to ensure each article is relevant and addresses the practice problem. The articles consisted of one Level I, two Level II, three Level III, and five Level V and all were of high (A) or good (B) quality (Table 1).

Themes with Practice Recommendations
A review of the literature (see Appendix A) for the project revealed several themes.
Through the themes of scheduling template, lean management (LM), and value stream mapping (VSM), a practice recommendation was identified. The VSM tool helped identify gaps in process time leading to a lengthy suboptimal evaluation process. The VSM tool demonstrated areas of waste where the process redesign for pre-liver evaluations could be condensed. The condensed evaluation process allows patients to be presented at the selection committee the following week and placed on waitlist sooner if all criteria are met and they are approved.

Scheduling Templates
EHR scheduling templates can improve operational efficiency and workflow in the outpatient setting. A study by Hribar et al. (2018) demonstrated EHR scheduling templates improved patient wait times and met growing patient demand. In one ophthalmology clinic, the electronic scheduling template reduced appointment waste by 40% allowing five additional patients daily (Hribar at al., 2018). Suss et al. (2017) found that using a scheduling template reduced wait times by 25% on average. Redesigning an appointment schedule, with use of lean methods, decreases patient wait times and provides more timely access to care (Al Hroub et al., 2019). After the implementation, patient wait times improved. The use of a template for scheduling allows the project lead and scheduling supervisor to have more control over the flow of patients for scheduling (Gavriloff, 2017). EHR scheduling optimizations create efficiencies improved, care coordination, timely information sharing, streamlined workflows, and improved patient experience and outcomes.

Lean Management
Lean Management (LM) is a quality improvement process evidenced to improve quality outcomes. LM is a well-established improvement science approach that focuses on production, optimizing areas of organizational value, and eliminating waste through workflow efficiencies that improve productivity (Al Hroub et al., 2019;Gavriloff, 2017;Johannessen & Alexandersen, 2018;Morell-Santandreu et al., 2021;Ramaswamy et al., 2017;Stellmaker et al., 2022;Tibor et al., 2016). LM tools identify efficiency opportunities and increase organizational value. In the transplant clinic, LM process can be applied to transplant evaluation appointments to identify sub optimal processes or operational inefficiencies impacting evaluation periods and time to listing on national registry (Gavriloff et al., 2017). Lean practices consist of the right process to obtain the right results and are patient centered (Ramaswamy et al., 2017;Stellmaker et al., 2022). For organizations to be successful in having a lean culture, managers must fit into the culture and lead by example. All team members within the organization must be in alignment with the same purpose and principles. Standardization is critical in the success of LM practices.

Value Stream Mapping
VSM is a LM tool that creates visualization of process benefits and process opportunities.
Visualization with VSM reveals the root cause of process waste where tailored interventions are more likely to have a favorable impact on the defined problem. This is done using a formula to measure total lead time (LT) as the sum of the process productive time (PT) and non-productive process time or waste time (WT) (Ramaswamy et al., 2017). VSM provides an end-to-end view of workflows identified at each step of the process, and who or what is involved in each step (Al Hroub et al., 2016;Dadashnejad & Valmohammadi, 2019;Gonzalez et al., 2014;Ramaswamy et al., 2017;Tibor et al., 2016). This tool is an established best practice to validate practices and solutions implemented (Tibor et al.,201).
In the transplant clinic, VSM was applied to the patient appointment scheduling operations by measuring the total evaluation period (LT), process productive appointment process time (PT) and wasted time between appointments (WT). The VSM formula used to measure outcomes is evaluation period (LT)= appointment time (PT) + time waiting for appointments (WT) or LT = PT + WT.
A growing body of knowledge supports scheduling template adoption to improve appointment access. VSM in a LM approach for quality improvement identified large periods of waste time related to specific appointments for evaluation. Adopting a scheduling template is hypothesized to significantly reduce appointment waste time, without changing the productive appointment time resulting in a reduced total process lead evaluation period.
This evidenced-based change project aimed to reduce the liver transplant evaluation period by 65% from an average of 21 days to 7 days by using an electronic scheduling template to reduce waste time between appointments without changing productive time. Therefore, answering the PICOT question that a scheduling template for the pre-transplant evaluation process decreased the total evaluation period by reducing waste time between appointments expediting national registry listing.

Setting, Stakeholders, and Systems Change
The setting for this project was a high-volume kidney, liver, heart, and lung transplant clinic affiliated with an academic teaching hospital in northeast Florida. The outpatient transplant clinic is one of the largest transplant centers in the region, completes 500 transplants annually, and has a minimal waiting period once formally listed compared to other regions. The clinic's trusted reputation as a destination medical center creates an added challenge to provide timely access to services. Despite the program's success and brief activation period post evaluation, the evaluation period itself lags industry benchmarks due to delays in appointment access. Pre-intervention, the average evaluation period or lead time was 21 days (545.04 hours) requiring an average of 22 appointments (20.5 hours) of productive time resulting in an average of 525.6 hours of non-productive waste time. An evaluation period of 21 days before UNOS listing far surpasses industry standard for transplant centers. The organizational need identified opportunities for improvement of the evaluation process and implemented a change that would improve length of time from initial evaluation appointment to final physician visit prior to being presented to the selection committee for approval to be listed. The organization's mission is to inspire hope and promote health through clinical practice, education, and continued research.
The organization has several values that guide the mission such as compassion, teamwork, innovation, healing, integrity, and respect but most importantly, the needs of the patient come first (Mayoclinic, n.d.). The mission aligned with the project proposal and outcome of intervention by placing the patient needs first and increasing timeliness of evaluation period.
Key stakeholders were identified prior to project implementation. Stakeholders make decisions, grant access or permission, may benefit from the project, and include anyone that may be touched by the project (Kogon et al., 2015). Stakeholders identified to assist and ensure success of the project included the liver team medical director, scheduling team supervisor, quality improvement lead, operations manager, nurse manager of outpatient transplant clinic, ancillary department leaders, pre-transplant clinic nurses, medical secretary to physicians, project lead, and patients. The stakeholders needed to understand the importance, benefit, and potential outcomes of the project as well as their accountability in achieving project success. After meeting with the stakeholders and expressing the need to implement a schedule template to assist with getting patients through the evaluation process in a timely manner, the stakeholders were able to understand the benefit the outcome would have for the patients, transplant department, and organization and approved project. The interprofessional collaboration of all stakeholders was critical throughout the project with different departments being involved during the intervention phase. Education, training, communication, and recognizing success were key factors that helped this project be successful with continued sustainability once the project was completed.
A strengths, weakness, opportunity, and threat (SWOT) analysis was performed and involved a specific department, which is considered a micro system change, to gather more information regarding the organizational need for the project and intervention used to achieve the outcome. A strength of this project was utilizing experience and knowledge from other areas within the system. Several weaknesses were identified during the analysis. The most significant was the limited availability of specialized nurses required to process the increased number of evaluations likely to increase as a result of improved lead time. Added efficiency increased the number of evaluations performed and potentially created an unintended consequence of increased workload burden on existing nursing resources.
The leadership team and project team needed to continuously assess the intervention's impact and unintended consequences to ensure that pre-transplant and post-transplant coordinators could meet the business need with an increase in total evaluations. The recent addition of a new transplant hepatologist physician created an opportunity to provide additional appointments. New appointment openings appeared unavailable in the absence of a scheduling template reserving set appointments in a set schedule for added efficiency, creating additional appointments. Another opportunity that had a positive impact on the condensed evaluation process was that the department began to offer a test that could be completed in the clinic and eliminating the need to schedule within another department, therefore shortening the evaluation time. This project and intervention depended on multiple ancillary departments approving and agreeing to using the new template. However, a threat to the project came from the ancillary departments not agreeing to the priority hold of appointments for transplant evaluation patients.
This led to appointments having to be scheduled at the first available time and extended the evaluation process. After the SWOT analysis (see Figure 3) was complete, it was noted that there were more strengths and opportunities compared to the weaknesses and threats. Therefore, the project and intervention had the potential to be successful.

Implementation Plan with Timeline and Budget
This evidence-based change project was aimed at creating a scheduling template to condense the pre-liver transplant evaluation process time (PT) from 21 days to 7 days. The SMART objectives for this project were to 1) decrease total evaluation time (LT) by 60% from 21 days to 7 days by January 27, 2023, 2) decrease waste time by 60% from 483 hours to 290 hours by January 27, 2023, and 3) and increase designated appointment timeslots per department to 5 to 7 holds per week from the current practice of zero designated timeslots. Pre-transplant evaluations are time intensive and complex scheduling significantly delays a patient being listed depending on when testing is complete. Scheduling optimization leveraging evidence-based electronic health record templates consolidate appointments and significantly condenses the total evaluation period by up to 3 weeks.
Condensing the evaluation period from 483 hours down to 290 hours will result in a more timely patient presentation to the selection committee and subsequently formal listing by UNOS. Schedulers utilized the weekly EHR scheduling template (see Appendix B) balancing appointments for two different physicians. The budget allocated for this project was $640 and was limited to labor hours of informatic technology staff who assisted in building the evidence based EHR template and training hours for schedulers (see Table 3). The change model chosen for this project implementation included the five milestones of the ADKAR model. The ADKAR model is goal oriented and identifies each milestone that must be achieved for the change to be successful (Glegg et al., 2019).

Awareness
This phase discusses the impact and need of organizational change. The project idea came from the current practice of scheduling pre-transplant evaluation appointments and procedures anywhere there was an available time slot. Those time slots could be 1 to 3 weeks away which pushed being placed on the waitlist further out than what is best for the patient. Therefore, the need for a new process was determined to enhance the pre-liver transplant evaluation process and improve the operational efficiency. Without adequately addressing this phase, the project's sustainability was threatened.

Desire
In the desire phase, support was provided for change of culture. The project lead communicated to all team members, physicians, and other clinic leaders the reason for the change and outcomes. The project lead discussed with the pre-transplant nurses how the new schedule template would positively impact the evaluation process by condensing all appointments to 1 week and allowing the patient to be presented to selection committee in a timely manner. The new template improved the process for the more critical patients and provided hope of receiving a new liver. Without adequately addressing this phase, full practice adoption could potentially not be achieved.

Knowledge
The third phase of ADKAR is knowledge. In this phase, coaching of the staff and sharing the new change in process was essential for success. A statement, along with three power point slides was shared via email stating the following: "Team, to shorten the pre-liver transplant evaluation process to 1 week to allow the patient to be presented at the selection committee meeting sooner, a condensed evaluation process will be implemented with two physicians completing the evaluation process weekly. The evaluation process will start with an initial visit with the physician, followed by all patient appointments and testing to be scheduled within the time slots given and agreed upon, and the wrap-visit to go over testing and next steps will be complete by the end of the week. The following week the patient will be presented at the selection committee and a final answer will be determined if the patient is approved or denied for listing. Please see attached slides with new schedule template for future reference" (see Appendix C). Without adequately addressing this phase, communication to patients may be misguided, and adherence to practice adoption threatened.

Ability
The ability phase provides access to experts, places responsibility of team members to use the template for increased efficiency in evaluation process. The project lead and the scheduling supervisor, through demonstrating transformational leadership skills, provided an open-door policy that allowed team members to communicate and voice concerns or ideas.
Allowing voices to be heard and explaining the "WHY" for the change, aided in team members feeling empowered. In addition, the project lead and the scheduling supervisor asked team members what is working well and what improvements could be made. Stakeholders were made aware of the findings and solutions given to adjust workflow as needed. Throughout the project and after the 10-week period, it was important that these discussions were continuous. Failure to adequately address this phase could result in failed adoption, confusion, and minimal impact.

Reinforcement
The last milestone in the change model focuses on sharing results, holding team members accountable for sustaining practice change, and celebrating successes. The change in culture was not difficult to sustain since the project did not completely change the process or implement a brand-new evaluation process. The only change that occurred was the template for appointments.

Results
This evidence-based change project evaluated the implementation of a scheduling template within an EHR designed to assist in decreasing the LT, WT, and increasing number of appointment slots for the pre-liver transplant evaluation process. The change project was implemented over a 10-week time frame that began in November 2022 after submitting all necessary forms to the EPRC committee at the University of St. Augustine for Health Sciences (USAHS) and facility. Final approval was received to begin project implementation. There were no Health Insurance Portability and Accountability Act (HIPPA) violations noted as patient names were removed from the spreadsheet. There was no missing data to address, however, if missing data had been identified, the team had a plan in place to research and find the data. The project manager would research the charts and EMR to find the data needed to complete the data collection spreadsheet.
The project team leaders (project manager, scheduling supervisor, and quality analyst) took a pre-selected group of 34 participants (see Appendix D) that completed the pre-transplant evaluation process prior to implementation and determined the average number of hours (545.04 hours) it took for the evaluation process to be completed (see Appendix D). The selected group of 34 participants prior to implementation was compared to a random group of 34 participants (see Appendix E) that utilized the new scheduling template with an average number of hours (189.6 hours) to complete the evaluation process. The data for each group was analyzed to determine the average hours it took to complete the evaluation process pre-and-post project implementation.
Baseline data was sourced from the EHR via manual audit of transplant patient charts of patients who already completed their transplant evaluation. The pre-and-post data collection consisted of a baseline cohort (ordinal), baseline evaluation days (scale), post remeasure cohort (ordinal), and the post remeasure evaluation days (scale). The transplant evaluation start and end times were collected in a raw patient list format. Data collected were aggregated by taking the average of raw data from each group of selected patients at the end of the 10-weeks. After the data was analyzed, data was stored using a Microsoft excel spreadsheet (see Appendix D; Appendix E). The Data Dictionary (see Table 4) provided all detailed and necessary information that explained what data existed and what data were collected for analysis of the change project.
All patients were given the same opportunity to be included in the data collection.
The expected outcome of this project was to condense the liver evaluation process total lead time by 60% from a 3-4-week evaluation period to a 1-week evaluation period. The patients marked in green were the patients that completed their evaluation in 1 week and were presented to the selection committee the following week. The project team leaders marked patients in yellow if they still had appointments to complete but would not have an impact on the completion of the final physician visit. Patients that would not meet requirements and unable to complete their evaluation within 1 week were marked red. The team discussed any barriers that delayed the evaluation process from being completed in 1 week and how those barriers could be rectified.
A two-tailed paired samples t-test (see Table 5) was used to evaluate the data collected to determine the difference between the pre-and post-group of patients during the 10-week project.
The baseline evaluation days were compared to the post-remeasure evaluation days which resulted in a statistical significance of p < .001. The average baseline evaluation days was 22.71 or 545.04 hours, while the average post-remeasure evaluation days was 7.9 or 189.6 hours. The waste time prior to use of the template was 21.9 days or 525.6 hours and was reduced to 7.05 days or 169.2 hours after implementation and set appointment time slots increased from 0 weekly to 5-7 weekly (see Table 6). The data analysis shows that the condensed pre-liver transplant evaluation process not only proved a statistical significance but clinical significance as well. The decrease in the evaluation process was achieved by implementing specific and designated appointment times for the patients to complete their evaluation within the specified timeframe of 1 week. By decreasing the number of days of the evaluation process, patients were able to be presented at the selection committee meeting and placed on the active list awaiting a transplant. This led to a positive impact on patient care within the liver transplant department as well as on the financial status of the department because more patients can complete the evaluation process. Not only does the new evaluation process help patients get placed on the National Registry sooner, but it also decreases travel and financial burden because the patient will only need to be available for 1 week versus taking time off multiple times over multiple weeks.

Impact
This evidence-based change project exceeded the aim; improving the liver transplant evaluation period by 67.8% from 21.9 days to 7.05 days (p<.001) using an electronic scheduling template to reduce waste time between appointments. The template for a condensed evaluation process led to less travel, less money spent, and less time the patient or caregiver may have missed at their job. The transplant clinic used this project as a performance benchmark that provided patients and caregivers with an idea of what to expect in the evaluation process. By improving the evaluation process and condensing the time frame from 3 weeks to 1 week, the clinic can promote better outcomes, reduce the transplant center's costs, and improve workflow for staff. The incorporation of a template within the EMR forced schedulers to utilize the template that was set up rather than manually placing appointments where they felt was best or where there was an open spot. The template ensures all appointments are scheduled within the timeframe allowing for more evaluations to be completed, which will lead to an increase in the financial well-being of the department. To sustain this project and continue moving forward, the project team will monitor and continue collecting data monthly, add information to the scorecard, present at monthly department meetings, as well as address any variability at the quarterly quality transplant meetings. As the transplant center continues to grow especially in liver transplant, it will be imperative that department leadership accommodates for this growth.
Some of the barriers and limitations experienced during the 10-week project implementation included leadership changes in a few of the ancillary departments. These changes led to information not being passed along that was agreed upon in the initial phase of project planning and several appointment slots not being saved to accommodate patients going through the evaluation process. A second barrier was that the wrap visit was scheduled with a provider who did not have availability or was out of the office leading to an increase in the evaluation timeframe. In addition, certain appointments such as social work, infectious disease, and psychology would not fit into the week due to timing of other testing. These barriers were discussed at each meeting with the medical director, project lead, and scheduling supervisor. A decision was made by the medical director that certain appointments were not needed to complete the evaluation but would need to be completed prior to reviewing the patient during selection committee.
At the end of the project timeline, the project team decided to continue the data collection and identified opportunities that could potentially improve the evaluation process and reduce the days needed to complete the evaluation process in the future. The pre-transplant nurses, scheduling, and medical director discussed setting timelines that will determine the timeframe for each level and when each evaluation should be scheduled. Another opportunity identified by the team was if a patient does not have an urgent need to be seen, evaluated, and presented at selection and an essential test cannot be scheduled within 1 week, the evaluation should be scheduled around the testing. The scheduling team noted that it was going to be difficult to schedule stress testing, so the medical director will go back to the other hepatologist and discuss if a stress test is truly needed or can a computed tomography angiogram (CTA) be scheduled due to access issues with stress testing. The last opportunity that was identified to improve evaluation process for future transplant patients is to have the provider determine during the initial visit if a psychology visit is needed or can it be cancelled. With the clinical and statistical significance of this project, there is potential to carry this project to the other organ groups and implement a template schedule within the EMR to improve patient access and patient outcomes.

Dissemination Plan
The completed change project was reviewed for any final corrections that may have been needed prior to submitting manuscript to the student preceptor and program director for approval. Once approval was obtained, the results were presented to the stakeholders and clinic staff by email and through the liver transplant department monthly meeting via Zoom. In addition, the results were made available to the other transplant programs within the organization.
The project lead completed the third-party copyright and Scholarship for Open Access Repository (SOAR) @USA forms and then submitted to USAHS. SOAR is a repository for student scholarly projects. The project results were presented to the professional community within the nursing department at the USAHS via Power Point presentation. The faculty advisor, student preceptor and the nursing administrator of the transplant department were invited to attend the presentation.
A rough draft of the project manuscript was available for editing via peer review, faculty, and preceptor before submission to the professional journal. A completed manuscript of the project and outcomes was submitted to the American Journal of Transplantation. This journal is a peer reviewed medical journal, highly ranked, and is published monthly. The journal discusses change, promotes understanding, shares improvement results, aids in advancing science, and serves as a resource for other transplant professionals (American Journal of Transplantation, n.d.). By submitting the project manuscript to the journal and SOAR@USA will allow for a wider audience to review the results

Conclusion
This evidence-based change project leveraging an electronic scheduling template to improve access had significant favorable impacts on the organization's operational efficiency and patient health outcomes. Scheduling templates increased access to care and life-saving treatments. Completing the pre-transplant evaluation process in a timely manner resulted in an expedited evaluation process and listing on the National Organ Registry. The evaluation process is complex and lengthy; however, appointment access delays as a result of operational inefficiencies can be controlled resulting in optimal operational, financial, and patient health

Level
Article Count

High quality (A) Good quality (B)
Level I 1 0 Level II 2 0 Level III 2 1 Level V 3 2    Table 5 Two-tailed paired samples t-test

Figure 3
SWOT Analysis ØEvaluations will start on Monday/Tuesday ØWrap visits will be completed Thursday/Friday ØPatient will be presented at selection the following Wednesday • Project lead and Scheduling supervisor will be available as a resource and to assess any barriers that may arise and address in real time.

for intervention SWOT analysis x
Preimplementation data spreadsheet complete x

Project
Proposal Submission