Quality Assessment Quality Assessment of Your Donor of Your Donor

ProgramProgramClinton Coil, MD, Patient Safety OfficerClinton Coil, MD, Patient Safety Officer

Laura Schneider, RN, BSN, Trauma Program ManagerLaura Schneider, RN, BSN, Trauma Program Manager

Susan Black, RNP, MSN, Admin. Director QA/RMSusan Black, RNP, MSN, Admin. Director QA/RM

Harbor-UCLA Medical CenterHarbor-UCLA Medical Center

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

Is it working?Is it working?•Percent Percent

Compliance:Compliance:

• Third Quarter: 50%Third Quarter: 50%

• Fourth Quarter: 40%Fourth Quarter: 40%

0102030405060708090

100

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PercentCompliance

0102030405060708090

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PercentCompliance

Is it working?Is it working?

0102030405060708090

100

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The Moral of the StoryThe Moral of the Story

•Always ask for data collected over a Always ask for data collected over a period of timeperiod of time

•““this quarter and last quarter” or this quarter and last quarter” or “this quarter compared to same time “this quarter compared to same time last year” are not good enoughlast year” are not good enough

PDSA: An organized approach to PDSA: An organized approach to rapid cycle improvementrapid cycle improvement

•PlanPlan•Do Do •StudyStudy•ActAct

P

D

S

A

Rapid improvement cyclesRapid improvement cycles•Plan to perform many small changes over and over

Research versus Quality ImprovementResearch versus Quality Improvement•ResearchResearch

– Medical students receive Medical students receive significant training in statistical significant training in statistical methods and critique of methods and critique of research methodologyresearch methodology

– Searching for truth that can be Searching for truth that can be generalized around the worldgeneralized around the world

– Focus on assuring accurate, Focus on assuring accurate, indisputable informationindisputable information

– A single project can take years A single project can take years

– A single project can cost A single project can cost millions of dollars and have millions of dollars and have dedicated staff membersdedicated staff members

•Quality Quality ImprovementImprovement– Medical students receive either Medical students receive either

no or limited exposure to quality no or limited exposure to quality improvement conceptsimprovement concepts

– Finding ways to provide the best Finding ways to provide the best care to patients in your care to patients in your organizationorganization

– Focus on getting enough Focus on getting enough information to run your hospitalinformation to run your hospital

– Improvements need to take Improvements need to take place quickly and continuouslyplace quickly and continuously

– Individual projects may not have Individual projects may not have any funding or staffany funding or staff

How many measures?How many measures?

• Measures and countermeasuresMeasures and countermeasures

Harbor Lights TeamHarbor Lights Team

• Donor counsel was formed 11/2006 after Donor counsel was formed 11/2006 after attending a National Organ & attending a National Organ & Transplantation Donation Collaborative in Transplantation Donation Collaborative in New Orleans.New Orleans.

• Collaborative aim statement: Harbor Collaborative aim statement: Harbor Lights will work the donation process to Lights will work the donation process to ensure outstanding care to patients and ensure outstanding care to patients and their families throughout the entire life their families throughout the entire life cycle.cycle.

Our goalOur goal

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

Potential and eligible donors Potential and eligible donors will be:will be:

• Identified and referred in a timely Identified and referred in a timely mannermanner

• Evaluated for suitability by OneLegacyEvaluated for suitability by OneLegacy• The opportunity for donation will be The opportunity for donation will be

maintained/preservedmaintained/preserved• Family will be approached by effective Family will be approached by effective

requestorrequestor• Consults to be obtained prn for optimal Consults to be obtained prn for optimal

organ yieldorgan yield

Best practices are to be Best practices are to be implemented on all cases:implemented on all cases:

• Standardized clinical triggersStandardized clinical triggers

• Early identification and referralEarly identification and referral

• Team huddles &communicationTeam huddles &communication

• Effective requestor team approachEffective requestor team approach

• Collaborative family end of life care Collaborative family end of life care planning and supportplanning and support

• Trauma MD consult on every caseTrauma MD consult on every case

Cont…Cont…

• Collaborative donor managementCollaborative donor management• Collaborative procurement process Collaborative procurement process

&organ placement&organ placement• Timely after action review follow up Timely after action review follow up

with staffwith staff• Timely reporting and review of every Timely reporting and review of every

potential at donor counsel meeting potential at donor counsel meeting 100% of the time100% of the time

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

Keeping track of the planes Keeping track of the planes in the air…in the air…

Keeping Executive Leadership and your Governing Body on board

We were Flying!We were Flying!

94%87% 92% 100%

71% 65%

40%

79%

0%

20%

40%

60%

80%

100%

2006 2007 2008 2009Calling in of All Deaths Organ Donation Rate

Calling in Target Donation Target

Turbulence? “We’re good…Turbulence? “We’re good…right?”right?”

94%87% 92% 100%

71% 65%

40%

79%

0%

20%

40%

60%

80%

100%

2006 2007 2008 2009Calling in of All Deaths Organ Donation Rate

Calling in Target Donation Target

““What? I thought we were What? I thought we were wining awards?”wining awards?”

94%87% 92% 100%

71% 65%

40%

79%

0%

20%

40%

60%

80%

100%

2006 2007 2008 2009Calling in of All Deaths Organ Donation Rate

Calling in Target Donation Target

No Excuses.Analyze data…

Rapid Cycle Improvement Rapid Cycle Improvement are supposed to be rapid…are supposed to be rapid…

PHASE 1

End of Life Family Discussion

MD informs family of grave prognosis

Family is presented with donation options

by trained OneLegacy staff only!

Family must be given time alone to process this new information

DO NOT MENTION DONATION TO FAMILIES“I will get a dedicated family specialist to

speak with you”

PHASE 2

Did you know ?

When Harbor-UCLA clinical staff mention organ donation to families- 83% decline donation compared to

17% when OneLegacy approaches the family

DO NOT MENTION ORGAN-TISSUE DONATION TO FAMILIESCall OneLegacy (800) 338-6112

No incidences of inappropriate approaches by staff in Q 4

Q 3- reminders sent to MDs, laminated posters in all over!

Next destination…Next destination…

• Reorganizing committee structure (Donor Reorganizing committee structure (Donor Council upgraded to Medical Staff Committee)Council upgraded to Medical Staff Committee)

• Plan to add “Improve organ donation rates to Plan to add “Improve organ donation rates to 75%” as an Organization Priority for FY 10/11.75%” as an Organization Priority for FY 10/11.

• Feedback to Executive Leadership/Governing Feedback to Executive Leadership/Governing Body no less than quarterlyBody no less than quarterly

• Feedback no less than quarterly to staffFeedback no less than quarterly to staff

Lessons LearnedLessons Learned• Can’t get over-confidentCan’t get over-confident• Improvements don’t have to Improvements don’t have to

cost $$$$cost $$$$• PDSA and Rapid Cycle-Small test PDSA and Rapid Cycle-Small test

of change really do workof change really do work• Partner with OneLegacy! Partner with OneLegacy! • Be willing to look at how you are Be willing to look at how you are

doing things- sometimes you doing things- sometimes you have to get above the clouds to have to get above the clouds to see better (Organ Donor see better (Organ Donor Council)Council)

• NEVER GIVE UP! (pack a NEVER GIVE UP! (pack a parachute just in case!)parachute just in case!)

QUESTIONSQUESTIONS??