Transcript Team Circle of Life Team Approach: Multi-Disciplinary Not Pictured: Heather Bogacz, Pastoral Care.

Team Circle of Life
Team Approach: Multi-Disciplinary
Not Pictured: Heather Bogacz, Pastoral Care
Our Journey…
In January 2012, the team convened and reviewed 2011
donor data and reflected on the key steps of the donation
process in order to better understand the current state of
donation at SVH.
2011 Donor Data
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Actual Donors
Eligible, No Consents
Regulatory Conversion Rate
Additional Potential Donors
True Conversion Rate
8
1
88% (8/9)
3
67% (8/12)
• Left learning session 1 with lots of energy and a PDSA
focusing on improving our consent rate.
• Original problem statement: Throughout the entire
organization, there is not a formal and consistent process
in place for obtaining consent that includes all disciplines
that can impact the process.
Root Cause Analysis:
This PDSA focuses on three components of the donation approach process
(specifically in situations when the family does not initiate the donation discussion):
1. Physicians not understanding their role in the approach process
2. Variable use of designated requestors for every approach
3. Inconsistent use of team huddles
Need to focus on the process of obtaining consent,
not the outcome of consent
Problem Statement:
There is not a consistent process in place for approaching families about organ donation, including
physicians not understanding their role in the approach process, variable use of designated requestors,
and inconsistent use of team huddles, resulting in missed donation opportunities.
Physicians Not Understanding Their Role in the Approach Process
Why are physicians approaching families about donation?
• MDs use donation as a tool to demonstrate how serious a situation is (to help
families understand the grave prognosis)
• In emergent situations (patient unstable) the MD may need/want to know if donation
is going to be an option right away to determine the plan of care
• MDs feel it is their job to discuss donation as an option
When MDs are involved in the approach, what is the impact? These are the
areas we hope to improve:
• Process: MDs are not trained designated requestors so they may not have
the best donation expertise/knowledge to share with the families and they
may not be familiar with the donation process
• Timing: The donation approach discussion may not be occurring at the most
appropriate time for the family – sometimes two separate conversations, one
to discuss grave prognosis and a separate discussion about donation, is
more appropriate for the family
Team decided to meet with:
– Dr. Paul Reckard, Head of Trauma Surgery
– Dr. John Taylor, Pediatric Intensivist
Physicians Not Understanding Their Role in the Approach Process
• Key learning points from our discussion:
• Both MDs understood that discussing declaration of death with family
and organ donation should be separate conversations, but often these
conversations flow together naturally.
• Neither physician really knew what a Designated Requestor was or
how a DR could support them during the approach process
• Both felt strongly that prepping families for a bad outcome is crucial,
and the conversation needs to be blunt in these situations (no sugarcoating the conversation)
• Both MDs were very open to wanting more education and information
on what the best practices are for donation approaches
• Physician Engagement/Education is a Work In Progress:
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Dr. Reckard left SVH for a position in Colorado
Dr. Taylor became a certified DR in February 2013
Adult ICU Intensivists currently undergoing a period of change
Team will continue to engage and educate physicians about role in
process
Inconsistent Use of Designated Requestors
• Designated requestor (DR) was not used with every
approach
• Large amount of DRs in the adult ICU
• PICU only had 1 DR
• Bridge gap of DR training
• Goal - Define group of DRs
Inconsistent Use of Team Huddles Prior to Approach
Why are team huddles not being used?
• There is no process in place to trigger a donation huddle
• Education was not rolled out regarding eligibility and authorization - need to be
known prior to having donation discussions with family
• No education regarding team huddles as a best practice
• Fragmented process throughout the organization
When a huddle does happen prior to an approach, what is the impact?
• Communication between the care team and between the hospital and
UW OTD is much improved
• Even if there is a decline, the process flows better and decreases staff
frustration
Created potential donor huddle worksheet.
• Initiated upon admission to ICU if/when referral to UW OTD is made
• Includes eligibility, first person authorization information, code status,
family notes, care team huddle names, and plan for approach
• Goal is to have this as a resource for RN to use to lead a more
consistent approach process which would ensure a DR was part of
the approach
Potential Donor Huddle Worksheet in Use for Action Period 2
Results:
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Worksheets were not being turned in
or not filled out completely
Were not increasing pre-approach
huddles
The term “huddle” is used differently
within the hospital, thus causing
confusion
Feedback included that it was “more
work” in the moment which was not
the intended improvement
Potentially creating negative feelings
toward the donation process
Going Forward:
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Discontinue use of huddle worksheet
Plan is to define DRs and determine
needs for successful donation
process- checklist vs. worksheet
Back to Original Problem Statement...
There is not a consistent process in place for approaching families about organ
donation, including physicians not understanding their role in the approach
process, variable use of designated requestors, and inconsistent use of team
huddles, resulting in missed donation opportunities.
New Plan for Process Improvement?
• Increase the experience, knowledge, and confidence of
RNs during the donation process
• Collaborative learning from other hospital teams:
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Standard process for donor patients
Donation resource team concept
Engaging physicians
Engaging senior leadership
Increased colleague and community awareness
True Potential Rate
Actual Donors
20
Potential Donors
True Conversion Rate
67%
70%
18
58%
18
53%
16
14
13
12
50%
40%
10
10
60%
9
8
30%
8
6
20%
4
4
10%
2
0
0%
2011
2012
2-Year Cohort
Moving Forward
 Donor resource team (DRT)
 Core group of adult critical care and PICU DR trained nurses
 A DRT member will be activated for each potential donor
 Roles and responsibilities of team member still being worked out
 Engage the attending MD
 Facilitate planned communication prior to any donation approach
Things to be considered as we create this team:
 Staffing model in the adult critical care unit and the PICU
 Are there unintended barriers to the donation process?
 Assessing learning needs and identifying education opportunities
St. Vincent Forward Focus Team
• Still have a lot of work to do, but trending positively
– No missed potential opportunities since November 1, 2012
– 2013 YTD - 4 actual donors and 1 attempted DCD
– 100% true conversion rate YTD
• QI Journey has led to:
– A deeper understanding of the donation process
– Increased donation awareness throughout hospital
– Increased donation education opportunities in hospital
– The ability to trial new ideas and measure their impact
– Failed attempts lead to successful learning opportunities
Thank you!