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HHS launches major effort to increase organ donation by getting largest hospitals to adopt "best practices".

A comprehensive government study has come up with one of the most ambitious plans ever devised to increase organ donations in the nation's largest hospitals next year. The study calls for dramatic increases in donations, donor-conversion rates and transplants in the country's 200 largest hospitals.

To achieve such lofty goals, the government panel recommends that others emulate the nation's most successful organ procurement organizations (OPOs) and transplant centers. Those centers employ a common set of "best practices," according to the newly-released report.

The extraordinarily comprehensive study, dubbed the "Organ Donation Breakthrough Collaborative: Best Practices Final Report," was commissioned by Secretary of Health and Human Services (HHS) Tommy Thompson as the latest, and perhaps last, component in his initiative to increase organ and tissue donation in the US.

The findings of the 70-page report, which was produced by the Lewin Group, were the cornerstone of a 2-day meeting in Washington, DC September 9-10 to launch an intensive push by the secretary to increase organ donation in the nation's largest hospitals in the next year.

"If we can do it in large hospitals in Wisconsin, Houston, Colorado, St. Louis, Tampa, and Boston, we can do it in large hospital's throughout the nation," Thompson told the 404 participants representing 43 OPOs and 103 large hospitals who attended the launch.

HHS unveiled an ambitious set of goals for this phase in the initiative. They include:

*Increase the average conversion rate of eligible donors from the current average of 43% to 75% in the nation's largest 200 hospitals;

*Increase donations by up to 1,900 donors per year;

*Increase transplants by 6,000 per year.

Dennis Wagner, collaborative director of the Health Resources and Services Administration (HRSA) who heads the project, called the 2-days "one of the most important meetings to occur in organ donation in years, maybe decades."

"Seeing the extraordinary commitment being made to generating an increase in organ donation jointly expressed by OPO staff and representatives from large hospitals is what made it special," Wagner told Transplant News. "We have great expectations for this project and we will do everything possible to achieve the goals. Our goal is going to be all teach, all learn."

Participants at the meeting were schooled in ways to help OPOs and hospitals to quickly "identify, learn, adapt, replicate, and celebrate 'breakthrough' practices that are associated with higher donation rates." HHS noted that the approach is "intended to be consistent with contemporary collaborative models of identifying and spreading improvements in health care systems."

"Visits to OPOs and hospitals revealed that there is no single best approach or 'magic bullet' for success," the Lewin Group noted in the report. "Successful donation involves working simultaneously toward optimizing the outcomes during all events in the process: identification and referral of a potential donor, consent, recovery, and transplantation. While no 2 hospitals or OPOs visited conducted the organ donation process in the very same way, the underlying messages of these higher performers were largely consistent."

"This is a very exciting shift from the mom and pop approach to a very touchy process," Clifford Goodman, PHD, a senior scientist at the Lewin Group told Transplant News. "This approach is meant to make the extraordinary-asking for organ donation-into a routine business practice. It's based on a systematic approach that identifies best practices that can be shared. It's like seeing what makes a great swimmer and passing it along to others."

Here are the 7 common principles that appear to contribute to the success with some comments by the group.

1.Integrate organ donation fully into routine roles and responsibilities.

Organ donation is integrated into hospital policies and protocols, medical records systems, training, staffing, finances, data collection, and quality improvement in the manner of other services.

2.Set high standards for donation performance to reduce the unacceptable shortage of life-saving organs.

OPOs and hospitals establish clear, often "stretch goals" for their organizations and intensive care units. For OPOs, the goal is to increase the number of organ donors; for hospitals, the usual goal is to refer all potential organ donor cases to the OPO as soon as possible. Higher performing OPOs and hospitals reassess goals and revise approaches to improve results when donation dips or remains status quo.

3. Involve OPO and hospital staff in ongoing standards setting and redesign of means to achieve these standards.

OPO staff become aware of the performance expectations of their positions during the hiring process; for most OPOs, this practice appears to be more recent. While staff expectations are high, leaders and managers provide support and flexible working conditions. Staff are given responsibility, autonomy in decision-making, opportunities to provide feedback to improve the process, and new challenges.

Hospitals perform better with clear guidelines for different aspects of the organ donation process so there is no confusion about roles and responsibilities. OPOs work jointly with hospitals to develop, update, and improve protocols, and ensure that staff are educated in how to follow them.

4.Hold OPOs, hospitals, and their staff accountable for achieving these standards and recognize the staff accordingly.

In addition to being accountable for referring 100% of deaths to their OPOs, hospitals regularly review OPO data on timely referrals, family approaches, consent rates, and donations to determine how well they are following organ donation protocols. Accountability among hospital staff may be driven by hospital administration, other champions for organ donation within the hospital, or OPO staff.

5.Establish, maintain, and revitalize a network of interpersonal relationships and trust involving OPO and hospital staff, donor families, and other key agents.

The OPOs visited establish, maintain, and revitalize relationships with all levels of hospital staff as well as other individuals or organizations with roles in the organ donation process, including donor families, medical examiners/coroners, EMS staff, and community leaders.

6.Collaborate to meet the range of needs of potential donor families and achieve informed consent to donate.

There is a range of views concerning the assignment of responsibility to approach families regarding donation. While consent rates in many sites have increased in association with the shift in this role from hospital staff to OPO staff specially trained for this purpose, hospital staff are the designated requestors in some instances. Clearly, both approaches can work in their own contexts, which arise from professional, institutional, and community antecedents.

7.Conduct ongoing data collection and feedback to drive decision-making toward performance improvement.

The key measures tracked by all OPOs and used to inform organ donation operations in hospitals include, but are not limited to: donor potential, referrals of deaths, medical suitability, consent rate, conversion rate, organs recovered per donor, and organs transplanted.

Here are the 15 "best practices" identified by the Lewin Group. The complete report contains specific strategies or examples used to achieve or implement each practice. (Information on getting the report is available at the end of this article.)

1.Orient organizational mission and goals toward increasing organ donation.

OPOs and hospitals demonstrate goal-focused leadership and management toward improving organ donation performance, including orienting operations toward measurable outcomes and making organ donation an expected, routine process of the organization.

2.Do not be satisfied with the status quo; innovate and experiment continuously.

None of the OPOs and hospitals reported being satisfied with their current level of performance.

3.Strive to recruit and retain highly motivated and skilled staff.

Given high turnover in the industry, both OPOs and hospitals are highly attentive to staff recruitment and retention.

4.Appoint members to OPO board who can help achieve organ donation goals.

Boards are comprised to promote collaboration and mitigate conflicts via professionally diverse composition and balanced representation of organ donation and transplantation interests.

5.Specialize roles to maximize performance.

At least 3 critical roles are: family support, clinical coordination, and hospital relations.

6.Tailor or adapt the organ donation process to complimentary strengths of OPO and individual hospitals.

7.Be there: integrate OPO staff into the fabric of high potential hospitals.

Among the sample of higher than average OPO and hospital performers, there is a high level of ongoing, routine interaction between OPO and hospital staff.

8.Identify and support organ donation champions at various hospital levels; include leaders who are willing to be called upon to overcome barriers to organ donation in real time.

9.All aboard: secure and maintain buy-in at all levels of hospital staff and across departments/functions that affect organ donation.

OPOs and hospitals articulate the importance of "top-down, bottom-up and sideways buy-in," that is, identification with and commitment to organ donation.

10.Educate constantly; tailor and accommodate to staff needs, requests, and constraints.

Educational interactions address topics such as brain death criteria; donor identification, referral, consent and recovery processes; mechanisms for matching organs to recipients; transplantation processes; recipient care; bereavement care; and criteria for donation after cardiac death.

11.Design, implement, and monitor public education and outreach efforts to achieve informed consent and other donation goals.

OPO and hospital staff expressed differences of opinion on the impact of public education and outreach efforts on organ donation and conversion rates. Hospital respondents tended to give greater weight to the role of public education campaigns; OPO leaders more often found little or no causal relationship between such efforts and organ donation performance.

12.Referral: anticipate, don't hesitate, call early even when in doubt.

Among hospitals visited, there is a common interest and willingness to make early referrals to the OPO and to consult its experts regarding potential donations.

13.Draw on respective OPO and hospital strengths to establish an integrated consent process. One size does not fit all, but getting to an informed "yes" is paramount.

Interacting with a potential donor family to achieve informed consent to donate usually entails a sequence of time-sensitive events and carefully conveyed communications, all within a context of trust.

14.Use data to drive decision-making.

In particular, conducting regular death record reviews in all hospitals helps to determine those with the highest donor potential and ways to increase donations.

15.Follow up in a timely and systematic manner. Don't let any issues fester.

OPO and hospital staff emphasized that when the organ donation process breaks down or when an aspect of the process has been poorly handled, it must be resolved as soon as possible so as not to adversely affect future events.

The study sample consisted in following the following OPOs and hospitals:

*New England Organ Bank, Newton, MA and: Beth Israel Deaconess Hospital, Boston Medical Center, Brigham Women's Hospital, Massachusetts General Hospital (all in Boston).

*LifeLink of Florida, Tampa, FL and: Lakeland Regional Medical Center, Lakeland, and Tampa General Hospital, Tampa.

*University of Wisconsin Hospital & Clinics Organ Procurement Organization, Madison and: Gundersen Lutheran Hospital, Lacrosse; Theda Clark Regional Medical Center, Neehah; and University of Wisconsin Hospitals & Clinics, Madison.

*Mid-America Transplant Services, St. Louis, MO and: Barnes-Jewish Hospital, and St. John's Mercy Medical Center, both St. Louis.

*LifeGift Organ Donation Center, Houston, TX and: Ben Taub General Hospital, and Memorial Herman Hospital, both Houston.

*Donor Alliance, Denver, CO and: Denver Health Medical Center, Denver; Memorial Hospital, Colorado Springs; and St. Anthony Central Hospital, Denver.

The Organ Donation Breakthrough Collaborative: Best Practices Final Report is available on the HHS organ donor Web site: www.organdonor.gov/bestpractice.htm
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Comment:HHS launches major effort to increase organ donation by getting largest hospitals to adopt "best practices".
Author:Warren, Jim
Publication:Transplant News
Geographic Code:1USA
Date:Sep 15, 2003
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