Theda Clark Medical Center Organphiliacs Theda Clark Medical Center Neenah, WI Eric Nelson, Erin Halpin, Maria Novy, Rachel Janzen, Sue Broeren How we selected our team members, multidisciplinary, multi-departmental. Lost a member for the OR and added a rep prior to LS2.

Historical Data Theda Clark Medical Center has consistently been a high performing organ donation hospital in the state of Wisconsin Seven time winner of the HRSA medal of honor Participated in the 2003 national collaborative Five year average conversion rate of 94% Regulatory conversion rate as above for brain death donors

Actual Donor and Potential Donor Data Analysis January – November 2011 Donors After Brain Death 13 Donors After Cardiac Death 3 Actual Donors 16 Eligible, No Consents 1 Actual Conversion Rate 94% (16/17) Potential Donors 8 Identified on potential donor detail report Potential Conversion Rate 67% (16/24) At time of approach to participate in the forward focus process, we were presented with the above data analysis and recognized we had an opportunity to improve our metrics Actual Donors + Potential Donors = 24

Pre-work for Forward Focus Hooray Headaches Recognizing an opportunity for donation early Passion for donation throughout the hospital Good working relationships and problem solving with the UW OTD staff Fliers to communicate case results within the different departments Staff members reminding each other to keep the option of donation in the back of their minds Building a relationship with families; recognizing when the time is right to approach Senior leadership support Family in the OR for DCD cases; OR staff not comfortable Knowing if a referral was called in Knowing if a referral was open or closed Overall communication line with UW OTD and keeping families updated with the most information available Re-approaching after getting an initial no FPA refusal; no plan or process in place to support family and staff while honoring the donors decision Summary of our thoughts related to our current state with organ donation within Theda Clark

ThedaCare Improvement System

Tools We Used to Prioritize Our Work Prioritized our Headaches and Hoorays

Root Cause Analysis Using the 5-Why’s Problem Root Cause Countermeasures No huddle with OPO and TC before meeting with the family Not expected, no standard process Develop standard for having huddle with OPO and TC team prior to talking with each family on each case, even if family not present at hospital -checklist for process added to donation binders Inconsistent communication from OPC’s, have to push them to get information on where we are at in the process No communication standard Work with OPC’s to establish clear guidelines and expectations for communication during cases -specific time points -specific information -direct contact information Lab management process not timely We don’t have clear expectations established -Work with OPC’s to establish clear guidelines and expectations related to lab management -timely review of labs -timely communication to RN for interventions -OPO flowsheet in EPIC Mindset and understanding of additional testing unclear Work with OPC’s to establish clear guidelines and expectations related to testing management -Communication related to need for testing Clarity of case/teams coming/organs recovered/set-up required unknown to OR No standard for communication with team Work with OPO and OR to establish standard for communication guidelines and expectations OPO to OR communication inconsistent No standard for communication from OPC to OR

PICK Chart

Process Flow Mapping

Began our PDSA (Plan, Do, Study, Act) Team identified the need to focus on communication between UW OTD and Theda Clark staff We collected data on five actual donors (March 2012-May 2012) Goals and Targets established Have zero occurrences of lost donors post-consent. Have one process established for flow of information from Theda Clark to UW OTD and UW OTD to Theda Clark. Reliable and consistent two-way communication during case progression of the donation process post-consent to recovery. No unnecessary delays in donation process due to communication issues.

Developed Our Problem Statement During 18/18 organ donation cases for 2011, varied and inconsistent communication occurred between Theda Clark and UW OTD during the post-consent to recovery phase of the donation process. This lead to staff dissatisfaction, frustration, and additional work. Additionally, 1/18 organ donation cases was lost post-consent.

What We Started to Work On Created and implemented standard work for: Lab Management Additional Testing UW OTD to OR Communication Phone Communication with OPC DCD Pre-Huddle to OR Recovery Family Refusal with a First Person Authorization Created and implemented organ donation checklist and OPC contact list

What is Standard Work Standard Work is the Foundation for Continuous Daily Improvement Defines Who, What, When, Where, How and Why The Current Best and Safest Way   A Visible Tool for: Training Coaching Auditing Identifying Opportunities for Improvement Fosters Employee Engagement  Reduces Variation and Eliminates Waste

This is How We Do it at ThedaCare This is our process to implement and train to a new standard at ThedaCare

Communication with OR During OPO Case-Standard Work Examples

Reflections Since Starting Our Journey…What Has Forward Focus Taught Us. Increased teamwork within departments and cross departmental Work has brought donation to the forefront of people’s minds Increased communication and working relationships with UW OTD and OPCs After action reviews have occurred with increased participation Rapid recovery was possible and we were successful with a donor on 1/28/2013 We and the team understand and have more influence on the processes of organ donation

How Will We Continue Our Journey…. Donation committee meetings every other month with additional time allocated to discuss Forward Focus work Continue after action reviews with all donors Increased interdepartmental participation with all donation work Continue to attend offered learning sessions