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Service Delivery Innovation Profile

Hospital Collaborative-Inspired Improvements in Donation and Procurement Processes Lead to Increase in Organ Donors


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Snapshot

Summary

The Memorial Hermann Healthcare System worked with the LifeGift Organ Donation Center (LifeGift) to implement the Organ Donation Breakthrough Collaborative, sponsored by the Health Resources and Services Administration; the goal was to refine practices for procuring donors to increase the conversion rate (the percentage of potential donors who become actual donors). Health system–developed strategies included ensuring timely donor referral to LifeGift; improved communication about family circumstances to a LifeGift-trained organ procurement specialist in the hospital; cultural/ethnic matching of donation requestors and families; and ongoing tracking and sharing of performance data. The program led to high conversion rates (up to 88 percent) at Memorial Hermann Healthcare System and an increase in conversion rates and total donors across collaborative participants, with many hospitals reaching or exceeding the 75-percent conversion rate goal.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on conversion rates specific to Memorial Hermann Healthcare System. Data from all collaborative participants on pre- and post-implementation conversion rates, the percentage of hospitals achieving the 75-percent goal, and total number of organ donors are also presented.
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Developing Organizations

LifeGift; Memorial Hermann Healthcare System
Memorial Hermann Healthcare System is located in Houston, TX.

LifeGift Organ Donation Center is headquartered in Houston, TX.end do

Use By Other Organizations

Several similar collaboratives have been formed in the United States and around the world, including in Australia (launched in June 2006) and Canada (November 2006).

Date First Implemented

2007
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Patient Population

Vulnerable Populations > Terminally illend pp

Problem Addressed

A significant shortage of available organs in the United States leaves many individuals waiting for transplants for long periods of time, with some patients dying before an organ becomes available. Ineffective organ procurement processes and the failure to spread best practices contribute to this problem.
  • Significant shortage of available organs, leading to many deaths: In 2008, approximately 14,200 individuals donated organs, well below the roughly 106,200 individuals waiting for a transplant. From 1999 to 2008, the national transplant waiting list grew by 56 percent. Despite isolated, single-site efforts to improve conversion rates, the number of deceased organ donors increased by only about 4 percent a year during this time period.1 Although more than 110,000 individuals were on the waiting list as of January 29, 2011, only 23,956 organ transplants occurred during the first 10 months of the year (data are updated on an ongoing basis).2 In 2010, 5,211 individuals died while awaiting an organ transplant.3
  • Ineffective hospital procurement processes: In most hospitals, a coordinator assigned by a procurement organization identifies and speaks with family members of potential donors. This process can be ineffective and inefficient because bedside nurses and physicians are often the first individuals to interact with patients and families about end-of-life care, and these interactions often represent the best moment to begin the conversation about donation. A team approach that includes providers and procurement organization staff could improve the effectiveness and efficiency of this process.4
  • Failure to spread best practices: A few hospitals have determined how to effectively increase conversion rates; in fact, 15 of the 200 hospitals with the largest potential donor pools achieved conversion rates of 75 percent or higher in 2002.5 Although a study of these organizations revealed a common set of best practices, they remain largely unknown in the broader hospital community.4

What They Did

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Description of the Innovative Activity

Memorial Hermann Healthcare System and LifeGift (the designated organ procurement organization) participated in the Organ Donation Breakthrough Collaborative to refine practices relating to organ donation processes. Strategies included ensuring timely donor referrals to LifeGift; improved communication about family circumstances to a LifeGift-trained organ procurement specialist in the hospital; cultural/ethnic matching of donation coordinators and families; and tracking and sharing of performance data. Key elements include the following:
  • Timely notification regarding potential donors: Physicians and bedside nurses in the emergency department (ED) and intensive care units (ICUs) identify patients who may be potential donors according to medical criteria supplied by LifeGift, and then call a LifeGift hotline within 1 hour of determining that death is imminent. LifeGift contacts its employed organ procurement clinical specialist within the hospital (known as the inhospital coordinator) to initiate evaluation of the patient and family members. This approach is based on research suggesting that the best time to introduce the possibility of organ donation is when family members start discussing their loved one’s condition with hospital caregivers; early referral allows the procurement organization staff to establish a strong relationship with the potential donor's family members, a practice associated with an increased probability of donation and high levels of family satisfaction.6
  • Matching coordinator to patient/family: The inhospital coordinator is matched with the family based on cultural, ethnic, and/or linguistic background.
  • Caregiver/coordinator meeting to develop plan for request: The in-house coordinator reviews the medical chart to confirm that the patient is a suitable donor from a medical standpoint. If so, the coordinator meets with the bedside nurse and/or patient's physician to devise the best plan for approaching the family based on the social dynamics of the situation. Clinicians prepare the coordinator for the conversation by providing background on the patient’s social and family situation, thus allowing the coordinator to be as prepared and knowledgeable as possible before interacting with the family.
  • Organ donation request: The inhospital coordinators determine the appropriate time to broach the subject of donation with the family, based on extensive training they have received from LifeGift (according to Centers for Medicare & Medicaid Services standards7). The first conversation provides an introduction to organ donation and focuses on building rapport. Families and the in-house coordinator typically have multiple conversations about the process, usually over a 24-hour period. The hospital performs a brainflow study to confirm death before allowing organ harvesting.
  • Caregiver as support to family: Caregivers do not discuss organ donation with families. Rather, the caregiver role involves supporting the family and caring for and sustaining the patient at a hemodynamic level so that organs remain viable. Caregivers also make referrals to appropriate support personnel (e.g., the chaplain or a child life specialist in pediatric cases) who assist the family through the grieving process.
  • Monthly donor committee meeting to review performance data: A donor committee that includes the in-house coordinator, managers and directors from the ED and seven ICUs, and patient liaisons from areas likely to be a source of organ donors (e.g., neurotrauma), meets on a monthly basis to review performance data (presented on a "dashboard") that tracks trends in key measures, such as timely notification, the number of donors and organs per donor, conversion rates, and medical examiner donation denials.
  • Ongoing education to encourage provider referrals: Memorial Hermann Healthcare System uses a variety of methods to promote referrals of potential organ donor candidates by providers, as outlined below:
    • Badge cards: All ED and ICU nurses have cards attached to the back of their badges that outline the expectations and referral process for calling LifeGift.
    • One-on-one education: When the hospital fails to follow appropriate notification guidelines, LifeGift sends the unit director and manager a notice so that they can review the circumstances with the hospital staff involved. This one-on-one communication helps to educate providers and identify opportunities for improvements in the notification process.
    • Informal unit champions: The ED and each ICU have a designated "champion" for organ donation who promotes timely referral by colleagues and distributes and explains the donation dashboard each month.
    • Sharing information about organ recipients: To convey the value of the efforts made by bedside nurses and physicians in caring for terminal patients, the donor committee shares nonidentifiable data about those who receive organs from donors. These stories help caregivers to see the difference that organ donation has made, with one donor sometimes saving six or seven other individuals. Typically a minimal amount of information (usually recipient age and organ received) is posted on the department intranet site and in the break room.

Context of the Innovation

Memorial Hermann Healthcare System is an 11-hospital integrated health system that serves the Houston metropolitan area. Memorial Hermann Texas Medical Center operates one of the largest level 1 trauma centers in the country; the medical center cares for approximately 5,500 emergency trauma patients and performs approximately 140 kidney, liver, pancreas, and intestine transplants each year. The Memorial Hermann Healthcare System worked with the LifeGift Organ Donation Center—a not-for-profit organ procurement organization dedicated to recovering organs and tissue for individuals needing transplants in 109 Texas counties—to implement the Organ Donation Breakthrough Collaborative, sponsored by the U.S. Department of Health and Human Services’ Health Resources and Services Administration's Division of Transplantation. The goal of the collaborative was to increase the conversion rate by developing and sharing best practices across hospitals. Although Memorial Hermann Healthcare System already had achieved high conversion rates (approximately 80 percent) before joining the collaborative, administrative and clinical leaders sensed a need to standardize and formalize the process of organ procurement across system hospitals, and thus agreed to participate.

Did It Work?

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Results

The program led to high conversion rates (up to 88 percent) at Memorial Hermann Healthcare System and to an increase in conversion rates and total donors across collaborative participants, with many hospitals reaching or exceeding the 75-percent conversion rate goal.

Memorial Hermann Healthcare System Results
  • High conversion rates: Memorial Hermann Healthcare System achieved very high conversion rates since implementing the program, with Memorial City reaching 88 percent (between December 2006 and November 2007), Memorial Hermann Texas Medical Center reaching 82 percent (between June 2007 and May 2008), and Memorial Hermann Southwest reaching 75 percent (between August 2006 and July 2007).8 Pre-implementation conversion rates were not collected.
  • Staff reports of improved effectiveness: Anecdotally, staff believe the program has improved the efficiency and effectiveness of the organ donation request process and enhanced communication between caregivers and transplant personnel.
Results From All Hospitals Participating in Collaborative
  • Higher conversion rates: During the two phases of the collaborative, the average conversion rate for participating hospitals increased from 51.5 percent at baseline (2003) to 65 percent in 2005. In addition, nearly half (44.2 percent) of the 95 participating hospitals in phase one reached the 75-percent conversion rate goal; the year before joining the collaborative, only 20 percent of these hospitals reached this figure. During phase two, nearly a third (31.3 percent) of the 131 hospitals achieved the 75-percent goal, compared with just 17.5 percent in the year before participation.
  • More organ donors: The total number of organ donors in participating hospitals increased by 14.1 percent in the first year (well above the 8.3 percent increase among hospitals that did not participate and the 2.4 percent increase that occurred in the year before the collaborative). Between October 2003 (when the collaborative began) and September 2006, the total number of organ donors in the United States rose by 22.5 percent, well above the 5.5-percent increase achieved during a similar length time period before the collaborative.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on conversion rates specific to Memorial Hermann Healthcare System. Data from all collaborative participants on pre- and post-implementation conversion rates, the percentage of hospitals achieving the 75-percent goal, and total number of organ donors are also presented.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Attending learning session: A Memorial Hermann Healthcare System representative attended one 2-day learning session with other participating hospitals. These sessions, held every 3 or 4 months, were taught by expert faculty drawn in part from high-performing organizations. Session participants learned about the collaborative's goal (to reach a 75-percent or higher conversion rate at each hospital), change strategies, data measurement and submission requirements, and an established model for improvement. Participants also learned about and shared best practices on improving donation processes and developed plans to test and implement changes within their organizations.
  • Tasking donor committee with process improvement: The hospital’s donor committee was charged with evaluating and improving the current organ procurement process and with developing a measurement system to gauge their success (which ultimately led to creation of the aforementioned dashboard). This committee now meets monthly to discuss each unit's performance data, including conversion rates, the number of timely and untimely referrals, consent rates, number of organs recovered, and organ yield.
  • Networking and sharing of best practices: During the 2-year collaborative, members of the donor committee received ongoing e-mail updates on participant performance, and, through e-mail and telephone, communicated with colleagues at other hospitals to share best practices.
  • Education by procurement specialists: During the collaborative, the LifeGift regional manager and other LifeGift personnel attended staff meetings in the ED and the seven ICUs (not including the burn unit and neonatal ICU) where there is a high potential for organ donation, educating staff about the coordinator role and the kinds of conversations the coordinator typically has with the family. LifeGift staff members returned to provide a "refresher" to the staff of units where performance fell short of goals, as measured by the monthly dashboard.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff. However, an onsite organ procurement specialist/coordinator (employed by the organ procurement organization) must be available. Memorial Hermann Healthcare System hired a quality improvement specialist to focus on transplant services before participation in the collaborative; that individual spends approximately 10 percent of her time on this program.
  • Costs: Memorial Hermann Healthcare System incurred no costs beyond the time staff spent on related activities as part of their regular duties.
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Funding Sources

Health Resources and Services Administration; LifeGift; Memorial Hermann Healthcare System
The Division of Transplantation within the Health Resources and Services Administration funded the overall collaborative; LifeGift funded expenses related to individual hospital representatives' travel to collaborative meetings.end fs

Tools and Other Resources

Information about LifeGift is available at http://www.lifegift.org/.

Adoption Considerations

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Getting Started with This Innovation

  • Partner with organ procurement organization: Establish an inhospital office for the organ procurement organization and work with representatives to develop innovative methods to improve the donation process. Build rapport between procurement specialists and hospital staff, in the context of a team effort to improve conversion rates.
  • Secure leadership support: Secure leadership support at all levels of the hospital to remove organizational-level barriers. For example, the nursing director needs to make sure that nurses follow appropriate procurement processes.
  • Define roles: Nurses and in-house coordinators should understand each other’s roles and follow a defined process for communicating.

Sustaining This Innovation

  • Share recipient information: Help bedside caregivers recognize the value of their efforts by sharing basic (nonidentifiable) information, such as age and gender, about patients who receive donor organs.
  • Maintain rigorous data measurement and reporting: Rigorous data measurement and reporting keep participants focused on the ultimate goal of increasing conversion rates, and reinforces commitment to the collaborative.
  • Encourage team huddles: Team huddles that include all those involved in the patient's care can be an effective way to devise the best plan for approaching a potential donor's family.
  • Provide opportunity for teams to network: Host periodic conference calls and/or provide a Web-based mechanism that allows for dialogue across multiple hospitals, including sharing best practices and lessons on overcoming barriers to donation.

Spreading This Innovation

Memorial Hermann currently hosts representatives from other hospitals and procurement organizations who want to learn about the institution’s organ donation process.

Use By Other Organizations

Several similar collaboratives have been formed in the United States and around the world, including in Australia (launched in June 2006) and Canada (November 2006).

More Information

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Contact the Innovator

Rhonda Thompson, RN, BSN, MBA
Clinical Director of Pediatric Services
Children's Memorial Hermann Texas Medical Center
Houston, Texas
(713) 867-4600
E-mail: Rhonda.Thompson@memorialhermann.org

Innovator Disclosures

Ms. Thompson has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Institute for Healthcare Improvement. Improvement report: organ donation breakthrough collaborative. Available at: IHI Improvement Stories 

Shafer TJ, Wagner D, Chessare J, et al. US organ donation breakthrough collaborative increases organ donation. Crit Care Nurs Q. 2008;31(3):190-210. [PubMed]

Howard DH, Siminoff LA, McBride V, et al. Does quality improvement work? Evaluation of the Organ Donation Breakthrough Collaborative. Health Serv Res. 2007;42(6 Pt 1):2160-73; discussion 2294-323. [PubMed]

Shafer TJ, Wagner D, Chessare J, et al. Organ Donation Breakthrough Collaborative: increasing organ donation through system redesign. Crit Care Nurs. 2006;26(2):33-49. [PubMed]

Labb DA. Increasing organ donation and procurement: The hospital leader's role. Healthcare Exec. 2005 May/June;20(3):25-8. [PubMed]

The Joint Commission. Health care at the crossroads: strategies for narrowing the organ donation gap and protecting patients. 2004 White paper. Available at: http://www.jointcommission.org/assets/1/18/organ_donation_white_paper.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

Footnotes

1 U.S. Department of Health and Human Services Health Services Resources Administration. 2009 OPTN/SRTR Annual Report. Candidates and Recipients, All Donors, 1999-2008. Data Tables. Available at: http://www.ustransplant.org/annual_reports/current/data_tables_section1.htm
2 United Network for Organ Sharing [Web site]. Available at: http://www.unos.org/
3 Organ Procurement and Transplantation Network. Data Reports: Waiting List Removals. Removal Reasons by Year. Available at: http://optn.transplant.hrsa.gov/latestData/viewDataReports.asp
4 Shafer TJ, Wagner D, Chessare J, et al. Organ donation breakthrough collaborative: increasing organ donation through system redesign. Crit Care Nurs. 2006;26(2):33-49. [PubMed]
5 Dickerson J, Valadka AB, LeVert T, et al. Organ donation rates in a neurosurgical intensive care unit. J Neurosurg. 2002;97(4):811-4. [PubMed]
6 Siminoff LA, Gordon N, Hewlett J, et al. Factors influencing families' consent for donation of solid organs for transplantation. JAMA. 2001;286(1):71-7. [PubMed]
7 Centers for Medicare & Medicaid Services. Transplant Center Certification & Compliance. Available at: http://www.cms.hhs.gov/certificationandcomplianc/20_transplant.asp
8 Memorial Hermann Healthcare System Hospitals Recognized For Saving Lives Through Organ Donation. Memorial Hermann press release. December 23, 2008. Available at: http://www.memorialhermann.org/newsroom/content.aspx?id=4902
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: February 17, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 07, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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