Team Circle of Life

Team Approach: Multi-Disciplinary Not Pictured: Heather Bogacz, Pastoral Care

In January 2012, the team convened and reviewed 2011 donor data and reflected on the key steps of the donation process in order to better understand the current state of donation at SVH. Our Journey… 2011 Donor Data –Actual Donors8 –Eligible, No Consents1 –Regulatory Conversion Rate88% (8/9) –Additional Potential Donors3 –True Conversion Rate67% (8/12)

Left learning session 1 with lots of energy and a PDSA focusing on improving our consent rate. Original problem statement: Throughout the entire organization, there is not a formal and consistent process in place for obtaining consent that includes all disciplines that can impact the process.

Problem Statement: There is not a consistent process in place for approaching families about organ donation, including physicians not understanding their role in the approach process, variable use of designated requestors, and inconsistent use of team huddles, resulting in missed donation opportunities. Root Cause Analysis: This PDSA focuses on three components of the donation approach process (specifically in situations when the family does not initiate the donation discussion): 1. Physicians not understanding their role in the approach process 2. Variable use of designated requestors for every approach 3. Inconsistent use of team huddles Need to focus on the process of obtaining consent, not the outcome of consent

Why are physicians approaching families about donation? MDs use donation as a tool to demonstrate how serious a situation is (to help families understand the grave prognosis) In emergent situations (patient unstable) the MD may need/want to know if donation is going to be an option right away to determine the plan of care MDs feel it is their job to discuss donation as an option When MDs are involved in the approach, what is the impact? These are the areas we hope to improve: Process: MDs are not trained designated requestors so they may not have the best donation expertise/knowledge to share with the families and they may not be familiar with the donation process Timing: The donation approach discussion may not be occurring at the most appropriate time for the family – sometimes two separate conversations, one to discuss grave prognosis and a separate discussion about donation, is more appropriate for the family Physicians Not Understanding Their Role in the Approach Process Team decided to meet with: –Dr. Paul Reckard, Head of Trauma Surgery –Dr. John Taylor, Pediatric Intensivist

Key learning points from our discussion: Both MDs understood that discussing declaration of death with family and organ donation should be separate conversations, but often these conversations flow together naturally. Neither physician really knew what a Designated Requestor was or how a DR could support them during the approach process Both felt strongly that prepping families for a bad outcome is crucial, and the conversation needs to be blunt in these situations (no sugar- coating the conversation) Both MDs were very open to wanting more education and information on what the best practices are for donation approaches Physician Engagement/Education is a Work In Progress: Dr. Reckard left SVH for a position in Colorado Dr. Taylor became a certified DR in February 2013 Adult ICU Intensivists currently undergoing a period of change Team will continue to engage and educate physicians about role in process Physicians Not Understanding Their Role in the Approach Process

Inconsistent Use of Designated Requestors Designated requestor (DR) was not used with every approach Large amount of DRs in the adult ICU PICU only had 1 DR Bridge gap of DR training Goal - Define group of DRs

Inconsistent Use of Team Huddles Prior to Approach Why are team huddles not being used? There is no process in place to trigger a donation huddle Education was not rolled out regarding eligibility and authorization - need to be known prior to having donation discussions with family No education regarding team huddles as a best practice Fragmented process throughout the organization When a huddle does happen prior to an approach, what is the impact? Communication between the care team and between the hospital and UW OTD is much improved Even if there is a decline, the process flows better and decreases staff frustration Created potential donor huddle worksheet. Initiated upon admission to ICU if/when referral to UW OTD is made Includes eligibility, first person authorization information, code status, family notes, care team huddle names, and plan for approach Goal is to have this as a resource for RN to use to lead a more consistent approach process which would ensure a DR was part of the approach

Results: –Worksheets were not being turned in or not filled out completely –Were not increasing pre-approach huddles –The term “huddle” is used differently within the hospital, thus causing confusion –Feedback included that it was “more work” in the moment which was not the intended improvement –Potentially creating negative feelings toward the donation process Going Forward: –Discontinue use of huddle worksheet –Plan is to define DRs and determine needs for successful donation process- checklist vs. worksheet Potential Donor Huddle Worksheet in Use for Action Period 2

Back to Original Problem Statement... There is not a consistent process in place for approaching families about organ donation, including physicians not understanding their role in the approach process, variable use of designated requestors, and inconsistent use of team huddles, resulting in missed donation opportunities. Increase the experience, knowledge, and confidence of RNs during the donation process Collaborative learning from other hospital teams: –Standard process for donor patients –Donation resource team concept –Engaging physicians –Engaging senior leadership –Increased colleague and community awareness New Plan for Process Improvement?

True Potential Rate

Moving Forward  Donor resource team (DRT)  Core group of adult critical care and PICU DR trained nurses  A DRT member will be activated for each potential donor  Roles and responsibilities of team member still being worked out  Engage the attending MD  Facilitate planned communication prior to any donation approach Things to be considered as we create this team:  Staffing model in the adult critical care unit and the PICU  Are there unintended barriers to the donation process?  Assessing learning needs and identifying education opportunities

St. Vincent Forward Focus Team Still have a lot of work to do, but trending positively –No missed potential opportunities since November 1, 2012 –2013 YTD - 4 actual donors and 1 attempted DCD –100% true conversion rate YTD QI Journey has led to: –A deeper understanding of the donation process –Increased donation awareness throughout hospital –Increased donation education opportunities in hospital –The ability to trial new ideas and measure their impact –Failed attempts lead to successful learning opportunities

Thank you!