Session #2: The Evolution of Donation Process and Planning Doug Miller 2013

Connect to Purpose “Dear Medical staff, I would like to thank all of you for the care you gave to my donor and their family members. I believe the care you provided allowed for my successful transplant. …. I work in a military hospital serving active duty military, their families, and veterans. This is a job I have always loved and because of your efforts, I will be able to continue to do so. I have found that there is no greater gift in the healthcare field than being able to provide services for those in need as I’m sure you all well know. I just want to remind you that the work you do is vital and so important. It is most appreciated and I ask that you all please continue being the best care givers that I know you are. Again, I send you all (nurses, social workers, doctors, surgeons, aids and any other staff) a heartfelt thanks for taking care of my donor and the needs of the family.”

Today’s Discussion: Evolution Planning for Donation Donation in Process

Donation Planning: Current State Regulations require OPOs work with hospitals and specify pieces of information that must be shared Hospital development (HD) plans/yearly organ donation assessment (YODA)/hospital profile Completed annually Different requirements depending on size/volume of hospital Auditable -Association of Organ Procurement Organizations determines what is included in assessments and planning; OPO can control the ‘how’ -Larger, higher volume hospitals require customized assessments and plans that have documentation (signature) that they were completed and shared with the hospital. -Smaller hosps get templated plans mailed to them annually. -Process typically done 1 on 1 with Hospital Development staff and liaison. Maybe at a committee meeting. Usually takes no more than 1 hour. Can get kind of ‘dusty.’

Yearly Organ Donation Assessment (YODA)

Hospital Development Plan

Switching Gears

Donation Planning Evolved: Forward Focus Hospital Teams Yearly Assessment: Pre-Work Value stream mapped donation process HD Plan: PDSA Mutually defined problem statement, created goals, piloted actions, measured improvement Pre Work: much more thorough, higher quality data. Required longer time and more individuals to participate. Removed guess work from what should be the focus. PDSA: narrowed focus and use all efforts, time, resources on piloting potential solutions to a quantifiable data-driven problem.

Overview of Key Steps 1. Supportive Family Care and Donor Management 2. Referral 3. Monitoring Patient Status 4. Medical Eligibility Determination 5. Obtain Consent 6. Initial Donor Data 7. Donor Organ Evaluation 8. Organ Placement 9. Resource Allocation for Organ Recovery 10. Organ Recovery 11. Post-Case Follow-up 1. Supportive Family Care and Donor Management

Pre-Work Instructions For each of the 11 key steps, fill in the current way these steps happen at your hospital with the WHO, WHAT and HOW Hooray or headache? Reflect if this is a part of the process that works really well currently (hooray!) or needs some improvement (headache) You may complete this part by either directly observing an actual donor case or reflecting on previous donor cases Also consider how the process steps may vary if it’s a brain dead (DBD) versus cardiac dead (DCD) donor

- Example - Step 2: Referral WHO? ICU Nurse (typically) What’s happening? Patient meets criteria for a referral to UW OTD WHO? ICU Nurse (typically) HUC (sometimes delegated to if busy) WHAT? Makes the initial call to UW OTD HOW? Identifies patient met clinical triggers Calls Statline Provides information from chart Create plan for follow-up communication with UW OTD Hooray or Headache? Hooray - works well This work was the foundation for all of the projects and best practices that are being shared at this symposium.

Another sample assessment tool

PDSA

Only-Child Mentality: So, how does this effect my life? Why are we telling you this? Because you and your hospitals represent the next step in the Quality Improvement journey.

What is a Potential Donor?

Other Potential Donors Not Declared Brain Dead Other Potential Donors What Is The True Denominator for Potential Organ Donation? Eligible Deaths Other Potential Donors Not Declared Brain Dead Other Potential Donors (DCD, > age 70, etc.) Medically suitable (to the best of our knowledge – ex: serologies) Within our normal practice to pursue either DBD or DCD donation This made us at the OPO pause and reflect on what we consider an eligible death for organ donation. We know we have defined parameters from regulatory agencies such as CMS and UNOS for what is considered an eligible death—these patients are clinically brain dead and under age 70. We also know that we have a significant number of donors that do not meet this parameter. These are our donors after cardiac death and those donors older than age 70. In the past 5 years we have had 167 donors after cardiac death and 20 donors older than 70. Beyond these patients we know there is a greater definition of eligible deaths for donation. We see referrals come in and we’ve seen the missed potential on patients that did not become organ donors and did not meet these strict definitions. We’ve defined this group of eligible deaths as potential donors: they are patients who are medically suitable to the best of our knowledge and it would be within our normal scope and practice to pursue either donation after brain death or donation after cardiac death. Consent and the donation process are our limiting factors in making this happen. 16

Maybe already familiar with this data/term of “potential” as we have begun to use it on our dashboard data in addition to the regulatory “eligible” definition.

Potential Donor Data for Next Hospital Cohort

DSA Metrics and Outcomes Date Range: 01/01/2011-03/31/2013 DSA Hospitals True Donor Potential True Conversion Rate (Goal=90%) Organs Transplanted Per Donor (Goal 3.45) Forward Focus Team Hospitals 332 61% 3.03 Hospital A 24 42% 3.30 Hospital B 18 44% 3.00 Hospital C 17 59% 2.50 Hospital D 35% 3.17 Hospital E 15 60% 2.78 Hospital F 11 45% 3.80 Hospital G 7 43% Hospital H 71% 2.20 Hospital I 6 33% Hospital J 67% 3.75 Other Hospitals 26 46% 2.83 Entire DSA 486 57% 3.01 -The hospitals in this room represent 26% (#128)of the true donor potential in 2+ year cohort -True donor potential = actual donors + potential donors -Actual number of donors = 57 -Potential opportunities = 71……translates to 213 additional organs being transplanted. -Regulatory conversion rate for most of these hospitals is >85%. For example, Hospital C had 100% regulatory conversion rate in 2011 and 2012. This only takes into account the ‘green circle’ of eligible deaths. Brain dead donors under 70. The True Conversion Rate looks at all of the circles, red, green, and blue. -The opportunity to save more lives is real, it is now and it is in this room. -This cohort is the next to adapt a quality improvement framework for donation planning and process 19

How Do We Start?

Donation Planning: Priming the Pump Expect a different assessment model and planning tools to be used in 2013 Emphasis on more thorough assessment; consider multi-disciplinary group No more than 1-2 defined projects; emphasis on improving consent rate Assessments and plans need to be completed and signed by July 1, 2013 -We can’t expect different results if we keep doing things the same way. Work smarter, not harder. -Need to start at the beginning and identify variances, determine why they happen, before we can understand how to make adjustments -Using this platform opportunity to introduce new way of planning for when HD reaches out (usually sometime in May). -HDS will lead and help facilitate -Process map the entire donation process or just the consent process? Assessment can be scalable.

Donation in Process: Best Practices from Forward Focus Forward Focus has demonstrated best practices over the last 18 months Collecting potential donor data, real-time huddles, after action review of potential donors (not just actual) Process is evolving from pilot testing at original 9 Forward Focus teams Expand on best practices. -Probably felt differently at your hospitals; more OPO involvement during a case and interest post case even if case did not proceed to donation. -Every case, regardless of recovery of organs, is a learning opportunity.

Group Discussion What excites you most about this transition? What is something you can do by next Tuesday to help get ready for this transition?

Volunteer to Report out to Plenary?