1. Involving Senior Leadership To Get Results

2. The Key to Success Hospital Leadership Philosophy Aligns With Organ Donation Initiatives

3. Senior Leader Champion – Bob Page, Sr VP, COO Personally leads critical donation initiatives and monitors outcomes Leader in DCD policy evaluation Regularly reviews hospital performance Champions donation awareness in leadership forums

4. Accountability Reviewed original findings of KU PI Task Force on Organ Donation (2002) Commitment to change & improvement Attended HRSA collaborative meetings Process support “What can I do? What do you need?” attitude Seeks opportunities to include donation outcome measures Reports to Hospital Leadership, Physician Groups, Hospital Quality Council

5. DCD Policy Initiative Formed a Physician/Leadership Workgroup to evaluate hospital position on DCD Convened emergency meetings for a potential DCD donor before p/p implemented Approved transfer of DCD donor to another hospital Led a focused charge to implement a successful DCD program at the hospital “Roll-out” plan included ICU/OR/physician education Mock DCD case Plan for follow-up on critical issues

6. Senior Leader Champion – Tammy Peterman, RN, MSN, Sr. VP, CNO Personal commitment to quality care, donation outcomes and nursing excellence in donation Leader in integrating donation best practices for nurses Serves as resource on critical issues Recognizes nursing involvement in donation

7. Accountability Sets a top-down standard for nurses Attended HRSA collaborative meetings Disbanded Donor Council. Reformed with “effective” membership Follow-up letters to nurses on donor cases Hospital badges/office for MTN taff Includes MTN in leadership meetings MTN involved in Magnet survey Highlights success stories

8. Donor Champion – Mike Lower, RN, Nurse Manager of Organ Transplant Personal commitment to the day-to-day aspects of organ donation Co-chair of the Donor Council Leader of the PI Task Force Evaluates compliance issues Real-time awareness of each donation opportunity Leader in policy and practice initiatives Partners with MTN

9. Commitment PI Task Force/FMEA Analysis Led End-of-Life work-group Attended HRSA collaborative meetings Facilitates scheduling physician/nurse education Formed an “expanded” Collaborative Home- Team ED, Anesthesia, Nurse Educators, Palliative Care, Respiratory Therapy

10. Physician Champion – Michael Moncure, MD, FACS Personally takes ownership for the process and accountability for results Active member of the Donor Council Reviews all variances Provides follow-up on physician issues Partners on physician education Leader in policy initiatives

11. Accountability Sets the bar high for Residents regarding interactions during donation processes Actively educates residents Models effective family communications Includes MTN in crucial family meetings Promotes the importance of collaboration with MTN in the donation process

12. Involvement Allows MTN to participate in Trauma PI Committee Trauma PI goals include donation outcome measures Northeast Regional Trauma Council ATS donation champion Leads DSA Critical Care Task Force HRSA OTBC co-chair

13. Donation Champion Quality Improvement Issues Brain death determination Brain Death Checklist Physician relationships DCD initiative Catastrohpic Brain Injury Order Set Collaborates on research projects & papers

14. Gigi Vulgamott, RN, CPTC – Hospital Services Coordinator Coordinates donation initiatives Partners on policy & education efforts Champions donation QI projects AAR & gets every donor case in front of Chief of Staff In-house research Invited to speak at leadership events Seen as “part of the team”

15. KU Donation Outcomes 200120022003200420052006 ORGAN DONORS 12716121722 CONVER- SION RATE 52%41%73%63%85%76% HEART DONORS 624457 LUNG DONORS 413318 KIDNEY DONORS 12715121318 LIVER DONORS 9715131519 PANC DONORS 648465 INTESTINE DONORS 000011