1. 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.

2. 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

3. 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

4. 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

5. ThedaCare Improvement System

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

7. 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

8. PICK Chart

9. Process Flow Mapping

10. 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.

11. 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.

12. 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

13. 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

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

15. Communication with OR During OPO Case-Standard Work Examples

17. 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

18. 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