1. Team Circle of Life

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

3. Our Journey… 2011 Donor Data
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.
2011 Donor Data
Actual Donors 8
Eligible, No Consents 1
Regulatory Conversion Rate 88% (8/9)
Additional Potential Donors 3
True Conversion Rate 67% (8/12)

4. 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.

5. 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
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.

6. Physicians Not Understanding Their Role in the Approach Process
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
Team decided to meet with:
Dr. Paul Reckard, Head of Trauma Surgery
Dr. John Taylor, Pediatric Intensivist

7. Physicians Not Understanding Their Role in the Approach Process
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

8. 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

9. 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

10. Potential Donor Huddle Worksheet in Use for Action Period 2
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

11. 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.
New Plan for Process Improvement?
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

12. 20 lives SAVED

13. True Potential Rate

14. 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

15. 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

16. Thank you!