Theda Clark Medical CenterNeenah, WI

Eric Nelson, Erin Halpin, Maria Novy, Rachel Janzen, Sue Broeren

Organphiliacs

Historical DataTheda Clark Medical Center has

consistently been a high performing organ donation hospital in the state of Wisconsin

Seven time winner of the HRSA medal of honor

Participated in the 2003 national collaborative

Five year average conversion rate of 94%

Actual Donor and Potential Donor Data AnalysisJanuary – November 2011

Donors After Brain Death 13Donors After Cardiac Death 3Actual Donors 16Eligible, No Consents 1Actual Conversion Rate 94% (16/17)Potential Donors 8

Identified on potential donor detail reportPotential Conversion Rate 67% (16/24)

Actual Donors + Potential Donors = 24

Pre-work for Forward Focus

Hooray Headaches Recognizing an opportunity for

donation early Passion for donation throughout the

hospital Good working relationships and

problem solving with the UW OTD staff

Fliers to communicate case results within the different departments

Staff members reminding each other to keep the option of donation in the back of their minds

Building a relationship with families; recognizing when the time is right to approach

Senior leadership support

Family in the OR for DCD cases; OR staff not comfortable

Knowing if a referral was called in

Knowing if a referral was open or closed

Overall communication line with UW OTD and keeping families updated with the most information available

Re-approaching after getting an initial no

FPA refusal; no plan or process in place to support family and staff while honoring the donors decision

ThedaCare Improvement System

Draft 6

TIS 9 Methods to See and Remove Waste in a Process within a Value Stream

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Sequence and Continuity

50,000 ft

GROUND LEVEL

INCREASING DETAIL

STANDARD WORK

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5S

SIPOC

TAKT TIME

FLOW DIAGRAM

COMMUNICATION CIRCLE

SPAGHETTI DIAGRAM

TIME OBSERVATION

BAR CHART

STANDARD WORK COMBINATION

5S Visual Management

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Tools We Used to Prioritize Our Work

Prioritized our Headaches and Hoorays

Root Cause Analysis Using the 5-Why’sProblem Root Cause Countermeasures

No huddle with OPO and TC before meeting with the family

Not expected, no standard process Develop standard for having huddle with OPO and TC team prior to talking with each family on each case, even if family not present at hospital-checklist for process added to donation binders

Inconsistent communication from OPC’s, have to push them to get information on where we are at in the process

No communication standard Work with OPC’s to establish clear guidelines and expectations for communication during cases-specific time points-specific information-direct contact information

Lab management process not timely We don’t have clear expectations established -Work with OPC’s to establish clear guidelines and expectations related to lab management-timely review of labs-timely communication to RN for interventions-OPO flowsheet in EPIC

Mindset and understanding of additional testing unclear

We don’t have clear expectations established Work with OPC’s to establish clear guidelines and expectations related to testing management-Communication related to need for testing

Clarity of case/teams coming/organs recovered/set-up required unknown to OR

No standard for communication with team Work with OPO and OR to establish standard for communication guidelines and expectations-specific time points-specific information

OPO to OR communication inconsistent No standard for communication from OPC to OR Work with OPO and OR to establish standard for communication guidelines and expectations-specific time points-specific information

PICK Chart

Process Flow Mapping

Began our PDSA (Plan, Do, Study, Act)PLAN:

Team identified the need to focus on communication between UW OTD and Theda Clark staff

We collected data on five actual donors (March 2012-May 2012)

Goals and Targets establishedHave zero occurrences of lost donors post-consent. Have one process established for flow of information from

Theda Clark to UW OTD and UW OTD to Theda Clark.Reliable and consistent two-way communication during case

progression of the donation process post-consent to recovery.

No unnecessary delays in donation process due to communication issues.

Developed Our Problem Statement

During 18/18 organ donation cases for 2011, varied and inconsistent communication occurred between Theda Clark and UW OTD during the post-consent to recovery phase of the donation process. This lead to staff dissatisfaction, frustration, and additional work. Additionally, 1/18 organ donation cases was lost post-consent.

What We Started to Work OnCreated and implemented standard work for:

Lab ManagementAdditional TestingUW OTD to OR CommunicationPhone Communication with OPCDCD Pre-Huddle to OR Recovery Family Refusal with a First Person Authorization

Created and implemented organ donation checklist and OPC contact list

What is Standard WorkStandard Work is the Foundation for

Continuous Daily ImprovementDefines Who, What, When, Where, How and

WhyThe Current Best and Safest Way  A Visible Tool for:

TrainingCoachingAuditing Identifying Opportunities for Improvement

Fosters Employee Engagement Reduces Variation and Eliminates Waste

This is How We Do it at ThedaCare

Diagram, Work Flow, Picture, Time Grid Team Safety Critical Step WIP Tollgate Tip

Standard work is created

Determine process

owner for training

Define audience

for training

and learning

Establish training needs

Comment: This process flow is for the training of standard work(SW). SW is a specified process content, performed in a specific sequence, with consideration for takt time and work in process.

Determine method of training

Seek out education

resource if the learning requires advanced critical

thinking skills

Develop training plan

(initial & ongoing)

Develop plan for applying PDSA for learning

Communication with OR During OPO Case-Standard Work Examples

;

High Level Process Flow

Diagram, Work Flow, Picture, Time Grid Team Safety Critical Step WIP Tollgate Tip

Consent for organ

donation obtained,

ICU RN Calls OR lead to

give a heads up

Organ Procurement Coordinator calls OR to arrange OR

time

OR lead RN calls

anesthesia on-call

provider Brain

Death Case

DCD case

Can the case be done at agreed

upon time?

YES

NO

Ensure adequate OR staff

available to do case

Anesthesia suggests a new time

OR lead RN calls OPC to change time

NO OR does not

have adequate staff to

cover case

OR to call for additional

staff or have staff stay

over as extra

OR lead RN to communicate with ICU RN if time of

case needs to change or problems

arranging time Time is

confirmed with OR and

OPO

OPO calls OR lead RN prior to both take

off and landing of

team

OPO arrives at TC and brings TC

OR team to ICU

Team meeting in

TC ICU multi-

purpose room

OPC goes to OR to

inform staff that all is

ready

Patient is taken to OR

Organ Recovery Begins

YES Can the case be done at agreed

upon time?

Ensure adequate OR staff

available to do case

NO OR does not have

adequate staff to

cover case

OR to call for additional

staff or have staff stay

over as extra

Time is confirmed

with OR and OPO, OR lead Calls anesthesia on-call to notify of OPO case

Reflections Since Starting Our Journey…What Has Forward Focus Taught Us. Increased teamwork within departments and cross

departmental Work has brought donation to the forefront of people’s

mindsIncreased communication and working relationships with

UW OTD and OPCsAfter action reviews have occurred with increased

participation Rapid recovery was possible and we were successful with

a donor on 1/28/2013We and the team understand and have more influence

on the processes of organ donation

How Will We Continue Our Journey….

Donation committee meetings every other month with additional time allocated to discuss Forward Focus work

Continue after action reviews with all donors

Increased interdepartmental participation with all donation work

Continue to attend offered learning sessions