1. Quality Assessment of Your Donor Program Clinton Coil, MD, Patient Safety Officer Laura Schneider, RN, BSN, Trauma Program Manager Susan Black, RNP, MSN, Admin. Director QA/RM Harbor-UCLA Medical Center

2. What is the point of a quality improvement program?

3. Is it working? Percent Compliance: Percent Compliance: Third Quarter: 50% Third Quarter: 50% Fourth Quarter: 40% Fourth Quarter: 40%

4. Is it working?

5. The Moral of the Story Always ask for data collected over a period of time Always ask for data collected over a period of time “this quarter and last quarter” or “this quarter compared to same time last year” are not good enough “this quarter and last quarter” or “this quarter compared to same time last year” are not good enough

6. PDSA: An organized approach to rapid cycle improvement Plan Plan Do Do Study Study Act Act P D S A

7. Rapid improvement cycles Plan to perform many small changes over and over

8. Research versus Quality Improvement Research Research –Medical students receive significant training in statistical methods and critique of research methodology –Searching for truth that can be generalized around the world –Focus on assuring accurate, indisputable information –A single project can take years –A single project can cost millions of dollars and have dedicated staff members Quality Improvement Quality Improvement –Medical students receive either no or limited exposure to quality improvement concepts –Finding ways to provide the best care to patients in your organization –Focus on getting enough information to run your hospital –Improvements need to take place quickly and continuously –Individual projects may not have any funding or staff

9. How many measures? Measures and countermeasures Measures and countermeasures

10. Harbor Lights Team Donor counsel was formed 11/2006 after attending a National Organ & Transplantation Donation Collaborative in New Orleans. Donor counsel was formed 11/2006 after attending a National Organ & Transplantation Donation Collaborative in New Orleans. Collaborative aim statement: Harbor Lights will work the donation process to ensure outstanding care to patients and their families throughout the entire life cycle. Collaborative aim statement: Harbor Lights will work the donation process to ensure outstanding care to patients and their families throughout the entire life cycle.

11. Our goal To improve donation outcomes by focusing on processes, policies, and protocols that will provide guidance to our staff while promoting proven best practices. To improve donation outcomes by focusing on processes, policies, and protocols that will provide guidance to our staff while promoting proven best practices.

12. Potential and eligible donors will be: Identified and referred in a timely manner Identified and referred in a timely manner Evaluated for suitability by OneLegacy Evaluated for suitability by OneLegacy The opportunity for donation will be maintained/preserved The opportunity for donation will be maintained/preserved Family will be approached by effective requestor Family will be approached by effective requestor Consults to be obtained prn for optimal organ yield Consults to be obtained prn for optimal organ yield

13. Best practices are to be implemented on all cases: Standardized clinical triggers Standardized clinical triggers Early identification and referral Early identification and referral Team huddles &communication Team huddles &communication Effective requestor team approach Effective requestor team approach Collaborative family end of life care planning and support Collaborative family end of life care planning and support Trauma MD consult on every case Trauma MD consult on every case

14. Cont… Collaborative donor management Collaborative donor management Collaborative procurement process &organ placement Collaborative procurement process &organ placement Timely after action review follow up with staff Timely after action review follow up with staff Timely reporting and review of every potential at donor counsel meeting 100% of the time Timely reporting and review of every potential at donor counsel meeting 100% of the time

15. Harbor-UCLA received recognition and award at the National Donor Symposium in New Orleans 2006

16. Keeping track of the planes in the air… Keeping Executive Leadership and your Governing Body on board

17. We were Flying!

18. Turbulence? “We’re good…right?”

19. “What? I thought we were wining awards?” No Excuses.Analyze data…

20. Rapid Cycle Improvement are supposed to be rapid… No incidences of inappropriate approaches by staff in Q 4 Q 3- reminders sent to MDs, laminated posters in all over!

21. Next destination… Reorganizing committee structure (Donor Council upgraded to Medical Staff Committee) Reorganizing committee structure (Donor Council upgraded to Medical Staff Committee) Plan to add “Improve organ donation rates to 75%” as an Organization Priority for FY 10/11. Plan to add “Improve organ donation rates to 75%” as an Organization Priority for FY 10/11. Feedback to Executive Leadership/Governing Body no less than quarterly Feedback to Executive Leadership/Governing Body no less than quarterly Feedback no less than quarterly to staff Feedback no less than quarterly to staff

22. Lessons Learned Can’t get over-confident Can’t get over-confident Improvements don’t have to cost $$$$ Improvements don’t have to cost $$$$ PDSA and Rapid Cycle-Small test of change really do work PDSA and Rapid Cycle-Small test of change really do work Partner with OneLegacy! Partner with OneLegacy! Be willing to look at how you are doing things- sometimes you have to get above the clouds to see better (Organ Donor Council) Be willing to look at how you are doing things- sometimes you have to get above the clouds to see better (Organ Donor Council) NEVER GIVE UP! (pack a parachute just in case!) NEVER GIVE UP! (pack a parachute just in case!)

23. QUESTIONS?