SOPs – MOTP Sharepoint

Introduction

No Files Available

Organization Structure

MOTP Identity, Scope, Accountability and Organizational Structure-QMS-OR-10-01-001

Personnel

MOTP Employee Requirements and Responsibilities Policy-QMS-PE-11-01-001
Surgical Co-Lead Position Profile-QMS-PE-11-02-001
Medical Co-Lead Position Profile-QMS-PE-11-02-002
Health Services Management Co-Lead Role Description-QMS-PE-11-02-003
MOTP Living Donation Coordinator Job Description-QMS-PE-11-03-001
MOTP Recipient Coordinator Job Description-QMS-PE-11-03-002
MOTP Employee Training, Development and Competency Assessment Policy-QMS-PE-11-04-001
MOTP Orientation Form-QMS-PE-11-04-002
MOTP Competency for New Hire Form-QMS-PE-11-04-003
MOTP Annual Education Form-QMS-PE-11-04-004
MOTP Annual Updates Form-QMS-PE-11-04-005
MOTP-SOPs Training Form-QMS-PE-11-04-006
Annual List of SOPs for review Form-QMS-PE-11-04-007

Facilities

MOTP Facility Management Policy-QMS-FS-12-01-001
MOTP Facility Security Procedure-QMS-FS-12-01-002
Patient Access to In-Patient Facility Procedure-QMS-FS-12-01-003
Patient Access to Out-Patient Facility and After Hours Support Procedure-QMS-FS-12-01-004
MOTP Facility Cleaning Procedure-QMS-FS-12-01-005

Infection Control and Safety

MOTP Workplace Hazard Identification and Safety inspection and Compliance Procedure-QMS-IC-13-01-001
MOTP Accident Reporting and Prevention Procedure-QMS-IC-13-01-002
MOTP Evacuation Plan Procedure-QMS-IC-13-01-003
MOTP Fire Emergency Plan Procedure-QMS-IC-13-01-004
MOTP Hand Washing Procedure-QMS-IC-13-01-005

Process Control

No Files Available

Audits

Live Donor Program Audit

Living Kidney Donor Program Audit Policy-QMS-AS-15-01-001
Living Kidney Donor Program Audit Plan and Checklist-QMS-AS-15-02-002
Living Kidney Donor Program Audit Summary Report From-QMS-AS-15-02-003
Living Kidney Donor Program Audit Log-QMS-AS-15-02-004
MOTP Program Activity Audit Form-QMS-AS-15-02-001

Live Donor Chart Audit

Live Donor Chart Audit Procedure-QMS-AS-15-01-002
Live Donor Chart Audit Checklist-QMS-AS-15-01-003
Live Donor Chart Audit Report Form-QMS-AS-15-01-004

Infectious Diseases Testing Kits Audits

Infectious Diseases Testing Kits Audit Procedure-SOP-LD-10-03-009
Infectious Diseases Testing Kits Letter-SOP-LD-10-03-010
Infectious Diseases Testing Kits Mail-out Form-SOP-LD-10-03-011

Occurance Management

Management and Reporting of Errors, Adverse Reactions and Complaints Policy-QMS-OM-16-01-001
Reporting Guide of Errors, Adverse Reactions and Complaints Process-QMS-OM-16-01-002
Management and Reporting of Errors, Accidents and Adverse Reactions as a Source Establishment Procedure-QMS-OM-16-01-003
Management and Reporting of Errors, Accidents and Adverse Reactions as Non Source Establishment Procedure-QMS-OM-16-01-004
Identification and Reporting of Transplantation Errors and Accidents Reference Guide-QMS-OM-16-01-005
Identification and Reporting of Transplantation Adverse Reactions and Events Reference Guide-QMS-OM-16-01-006
Management and Reporting of Complaints, Concerns and Adverse Outcomes Within the QEII Procedure-QMS-OM-16-01-007
Organs Recall-Retrieval Establishment Procedure -QMS-OM-16-01-008
Organs Recall-Transplant Site-Source Establishment Procedure -QMS-OM-16-01-009
Organs Recall Tracking Form-QMS-OM-16-01-010
Incident Report Form-QMS-OM-16-01-011
Incident Report Log-QMS-OM-16-01-012

Documents and Records

Documents and records Policy-QMS-DR-17-01-001
Document Format Procedure- QMS-DR-17-02-001
Document Control Designation Chart- QMS-DR-17-02-002
MOTP Manuals Management, Scope and Contents Procedure QMS-DR- 17-02-003
MOTP Definitions Procedure-QMS-DR-17-02-004
MOTP Abbreviations-Acronyms Procedure-QMS-DR-17-02-005
Document Numbering System Procedure-QMS-DR-17-02-006
Document Change Request Procedure- QMS-DR- 17-03-001
Document Creation, Revision and Approval Process- QMS-DR- 17-03-002
MOTP Manuals Policy Template-QMS-DR-17-04-001
MOTP Manuals Process Template-QMS-DR-17-04-002
MOTP Manuals Procedure Template-QMS-DR-17-04-003
Document Change Request Form- QMS-DR-17-04-004
Document Distribution Process-QMS-DR-17-05-001
Document Maintenance, Retrieval, Archival and Destruction Process-QMS-DR-17-06-001
Record and tracking management policy-QMS-DR-17-08-001
Live Kidney Donor Record and Tracking Procedure-QMS-DR-17-09-001
Living Donor Assessment Checklist- NS-LDA
Live Donor Chart Records Transfer Checklist- NS_LDCRTC
Live Donor Chart Records Transfer Form-QMS-DR-17-09-004
Kidney Recipient Record and Tracking Procedure-QMS-DR-17-10-001
Kidney Recipient Assessment Checklist-CD3186MR
Kidney Recipient Chart Records Transfer Checklist-CD2681MR
Recipient Chart Records Transfer Form-QMS-DR-17-10-004
MOTP Live Donor Database Consent Form-CD2616MR-2019
MOTP Recipient Database Consent Form-CD2975MR-2019
Identification, Reporting and Management of Deviations Procedure-QMS-DR-17-01-002
Deviation Form-QMS-DR-17-04-006
Deviation Report Log-QMS-DR-17-04-007
Live Donor Health Record Chart Review Checklist-QMS-DR-17-09-005
Health Canada Registration Policy-QMS-DR-17-12-001

Process Improvement Projects

MOTP SharePoint Policy- QMS-PI-18-01-001

Information Management

Computer Systems-Data Processing Control, Access, Security and Maintenance Procedure-QMS-IM-19-01-001

Customer Service and Satisfaction

No Files Available

Agreement

Working Agreement of LOL and MOTP -QMS-AG-21-01-001
Infectious Diseases Testing Kits Laboratory Services Agreement Procedure-SOP-LD-10-03-012
Service Agreement with the RTB for Packaging and Labelling of Living Kidney for Distribution-SOP-LD-10-06-004
OTDT MOU with Signatures October 2015
IWK MOU with signatures May 2012
Lab Services MOU with Signatures October 2015
Services Agreement with the Central Zone Microbiology Services for Live Kidney Donor Infectious Diseases Testing-SOP-LD-10-07-001 with Signatures
Protocol for Live Kidney Donor Infectious Diseases Testing- SOP-LD-10-07-002
Lab Services MOU (Chaleur Regional) with Signatures December 2015
Lab Services MOU with Signatures-PEI
Georges L-Dumont MOU with Signatures

Living Kidney Donor Referral and Preliminary Evaluation

Living Kidney Donor Referral Process-SOP-LD-10-01-001
Living Kidney Donor Preliminary Evaluation Procedure-SOP-LD-10-01-002
Living Kidney Donor Preliminary Evaluation Checklist- SOP-LD-10-01-003
Letter to Family Doctor for Potential Donor Preliminary Assessment- SOP-LD-10-03-004
Public Solicitation of Living Kidney Donation Policy-SOP-LD-10-01-005
Public Solicitation of Living Kidney Donation- Consent and Surge Plan-SOP-LD-10-01-006

Living Donor Consent and Compensation

Living Kidney Donor Consent for Live Donation Procedure-SOP-LD-10-02-001
Living Kidney Donor compensation Procedure-SOP-LD-10-02-002
Important Facts About Giving a Kidney Form – CD2556MR-08-12
Approved_CL-AP-035 Live Donation Expense Reimbursement_2021-10-28

Living Kidney Donor Suitability Assessment

Living Kidney Paired Donation and Non-Directed Anonymous Donation

NDAD Assessment and Registration Procedure-SOP-LD-10-04-001
PKD Assessment, Notification and Registration Procedure-SOP-LD-10-04-002
Living Kidney Donor Consent for KPD Procedure-SOP-LD-10-04-003
Living Kidney Paired Donation Program Consent Form- CD2566MR-12-2015
CTR Privacy Notice Consent 2020-04-01
CTR Withdrawal of Consent 2020-04-01

Living Kidney Packaging, Labeling and Distribution

Packaging, Labeling and Distribution of Living Donor Kidney Policy-SOP-LD-10-06-001
Labeling and Packaging of Living Kidney On Site Procedure-SOP-LD-10-06-002
Packaging and Labeling of Kidney for Distribution Procedure-SOP-LD-10-06-003
Transportation of Living Kidney Procedure- SOP-LD-10-06-005-IWK
Transportation of Living Kidney Procedure- SOP-LD-10-06-017-KPD
Living kidney On Site Labeling Form-SOP-LD-10-06-006
Living Kidney Packaging Insert Form-SOP-LD-10-06-007
Living Kidney Procurement Form-SOP-LD-10-06-008
Living Kidney Interior and Exterior Labels Form-SOP-LD-10-06-009
Living Kidney Receipt and Tracking Form-SOP-LD-10-06-010 Approval of LD for Shipping of Kidney Checklist -SE-SOP-LD-10-06-012 Approval of LD for Shipping of Kidney Checklist Guide- Transplant Sit- SE – SOP-LD-10-06-013 Approval of LD for Shipping of Kidney Checklist – Retrieval Establishment-SOP-LD-10-06-014 Approval of LD for Shipping of Kidney Checklist Guide-Retrieval E-SOP-LD-10-06-015 Airline Transportation of Live Vital Organs Form-SOP-LD-10-06-016 Living Kidney Donor OR Delay Receipt and Tracking Form-SOP-LD-10-06-018

Living Kidney Post-Donation Care

Living Kidney Donor Post-Donation Follow-up Procedure-SOP-LD-10-05-001
Living Kidney Donor Post-Donation Data Collection Form-SOP-LD-10-05-002
Living Kidney Donor Post Donation Education and Consent-SOP-LD-10-05-003
Living Kidney Donor Post-Donation PCP Initial Letter -SOP-LD-10-05-004
Living Kidney Donor Post-Donation Annual Letter -SOP-LD-10-05-005
Living Kidney Donor Post Donation PCP Annual Data Collection Form-SOP-LD-10-05-006
Living Kidney Donor Post-Donation Medical Attention Letter-SOP-LD-10-05-007

Common SOPs for all Transplntations

Verification of Organ Receiver Procedure-SOP-TS-10-01-001
Kidney Transporter Malfunction Incident Form-SOP-TS-10-01-004
Receiving Exceptional Distribution Organs Procedure-SOP-TS-10-01-002
Recipient Exceptional Distribution Form-CD3114MR_10_2017
MOTP Evidence-Based Guidelines and Best Practice Procedure- SOP-TS-10-03-001
Recipient Notification and Registration of Kidney Paired Donation Program Procedure-SOP-TS-11-03-001
Privacy_Notice_and_Consent_-_KPD_Recipient_V2_2015-03_Final1
SOP 18.3.1.1 Standard Operating Procedure DCD
SOP 18.5.4.3.1 – VTE Prophylaxis
Physicians and Transplant Coordinator On-Call Communication -SOP-TS-11-02-001
SOP Kidney Protocols 21 – 1 doc
Kidney Summary Sheet Report-015
Recipient Screening Procedure -Covid 19 -SOP-TS-10-04-001
Recipient Screening Form-Covid-19-SOP-TS-10-04-002
Using of organs from Increased Risk Donor Procedure-SOP-TS-10-05-001

Heart Transplantation Services

No Files Available

Liver Transplantation Services

Liver Transplantation Protocol-Using DCD-SOP-TS-13-03-001
Adult Liver Transplant Referral Form-SOP-TS-13-01-001
Adult Liver Transplant Referral Form Guide – SOP-TS-13-01-002
Liver Transplant Referral Procedure-SOP-TS-13-01-003
Use of HCV Positive Donors in Liver Transplantation Protocol-SOP-TS-13-03-002
HCC exception points, listing and surveillance for Liver Transplant Procedure-SOP-TS-13-01-004
Hepatocellular Carcinoma Surveillance Form-SOP-TS-13-01-005
Cardiovascular Assessment of Liver Transplant Recipients Procedure-SOP-TS-13-01-006
Post Liver Nursing Patient Assessment-NS_PLNPA
Post Liver Document Transfer Procedure-SOP-TS-13-05-001
Post Liver Document Transfer to MOTP from Another Program Letter-SOP-TS-13-05-002
Post Liver Document Transfer out of MOTP to Another Program Letter -SOP-TS-13-05-003
Post Liver Transfer of Information Summary Letter-SOP-TS-13-05-004

Kidney Transplantation Services

Kidney Transplant Protocol Draft – October 19 2022
Kidney Recipient Assessment and Listing Procedure-SOP-TS-11-02-001
Kidney Recipient Smart Match Selection Criteria Procedure-SOP-TS-11-04-001
Smart Match Malfunction Procedure-SOP-TS-11-04-002
Physicians and Transplant Coordinators On-Call Communication for HSP Offer-SOP-TS-11-02-002
Adult Kidney Transplant Referral Form-NS_AKTR
Adult Kidney Recipient Referral and Selection Criteria Procedure-SOP-TS-11-01-001
Important Facts for Patients about Kidney Transplant- CD1395MR
Kidney Recipient Worksheet-CD1397MR
Policy IWK 4900 Patient Referral and Pre assessment for Renal Transplant Final
Kidney Recipient Education of Public Solicitation Checklist-SOP-TS-11-01-003
Use of HCV Viremic Donors in Kidney Transplantation Protocol-SOP-TS-11-02-002
Post Kidney Nursing Patient Assessment Form-SOP-TS-11-05-001

HSP – Requirement to Offer Kidney
CTR 50 004 HSP – Kidney – Inter-provincial Balancing v2 0 HSP Matching and Ranking Methodology
Approval of Interprovincial Organ Donation and Trans Policies Protocols Procedures and Guidelines
CTR 10 001 -Heart Recipient Eligibility v1.0
CTR 10 002 – Heart Allocation v1.0
CTR 10 003 – Requirements to Offer Heart v1.0
CTR 10 004 – Heart Exports and Imports v1.0

Regulations

Safety of Human Cells, Tissues and Organs for Transplantation Regulations-SOR-2007-118-20220927
CTO-2018 Guidance Document-20180531-EN
CTO-2018 Ligne Directrice-20180531-FR
guidance-document-safety-human-cells-tissues-organs-transplantation-eng

CSA Standards

CSA Z900-1-22
CAN-CSA-Z900.2.3-17- November 2017

Organ and Tissue Transplant Standards v.14
Organ Donation Standards for Living Donors-ODLD-2016-EN

KPD – Protocol for Participating Donors 2019_61 012 v4

Labeling and Packaging of Living Kidney On Site Procedure-SOP-LD-10-06-002
Living kidney On Site Labeling Form-SOP-LD-10-06-006
Living Kidney Receipt and Tracking Form-SOP-LD-10-06-010
Living Kidney Interior and Exterior Labels Form-SOP-LD-10-06-009
Living Kidney Packaging Insert Form-SOP-LD-10-06-007
Living Kidney Procurement Form-SOP-LD-10-06-008
Packaging and Labeling of Kidney for Distribution Procedure-SOP-LD-10-06-003
Physicians and Transplant Coordinator On-Call Communication -SOP-TS-11-02-001
Receiving Exceptional Distribution Organs Procedure-SOP-TS-10-01-002
Verification of Organ Receiver Procedure-SOP-TS-10-01-001
Kidney Transporter Malfunction Incident Form-SOP-TS-10-01-002