Journey Towards Improvement…It’s an AdventureOrganphiliacsTheda Clark Medical Center

PDSA SummaryPLAN:

◦ Team identified the need to focus on communication between OPO and Theda Clark staff

◦ Completed a root cause analysis from pre-work packet to identify six opportunities for future work

◦ We collected data on five actual donors since LS1 (March 2012-May 2012)

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

Theda Clark to OPO and OPO 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.

Problem StatementDuring 18/18 organ donation

cases for 2011, varied and inconsistent communication occurred between Theda Clark and UW-OPO 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.

PDSA SummaryDo

◦Created and implemented standard work for: Lab Management Additional Testing OPO to OR communication Phone Communication with OPC DCD prehuddle to OR recovery (out of scope but

needed) Family Refusal with a First Person Authorization (out

of scope but needed)◦Created and implemented organ donation

checklist and OPC contact list (for TC ICU RN staff use)

PDSA SummaryStudy/Act

◦7/1/2012- DCD then converted back to inpatient account. Standard work for lab management utilized. Every hour phone calls from OPC at change of neuro exam. OPC called HD specialist to ensure they were following the standard work. Action item- Refresher/clarification training at

July staff meeting regarding new processes Action item- Process flow mapping for OR

communication with OPO

PDSA SummaryStudy/Act

◦7/13/2012- Brain Death Donor-no issues, lab management standard work followed, patient did not require any additional testing Action item- Continue to study further

cases Action item- After Action Review

completed

PDSA SummaryStudy/Act

◦7/17/2012- Brain Death Donor-issues related to apnea testing, H/H and Calcium standing orders and contacts with OPC. Additional testing standard work followed in ICU for ECHO, Bronch and Cardiac Cath. Visiting OPO requested TEE in OR which caused communication issues Action item- After Action Review completed, in

which visiting team requests were discussed, OPO adjusted apnea testing form, OPO adjusted and clarified H/H and Calcium standing orders

PDSA Summary Study/Act

◦ 8/4/2012 attempted DCD. New DCD standard work implemented, family was split on the decision to proceed with DCD attempt, a compromise was made. Lab management standard work followed, additional testing standard work followed for bronch, OR communication standard work followed, DCD pre-huddle was informally done (not per new standard work). Significant amount of communication between ICU RN, OR RN, ICU manager and OR supervisor to mitigate issues related to timing of recovery Action item- Phone communication with OPC standard work created,

organ donation checklist created, OPC contact list created Action item- After Action Review completed, clarified a

misunderstanding in communication from a traveler OPC, stressed the importance of any OPC conversations had with family must be shared with ICU RN staff, chaplain involvement in case clarified to OPC staff

Additional Donation OpportunitiesFive actual donors during planning phase

of PDSATwo actual donors during study/act phaseOne attempted DCD during study/act

phaseOne consented DCD patient, then

converted back to inpatient accountOne missed potential donor due to family

wishes, despite multiple repeated approaches from experienced designated requestor

Team AccomplishmentsIdentified actual root causesCreated and implemented a lot of

standard work for processesBroke down communication

barriers within process After Action Reviews completed Recruited a new member from

ORHad a ton of fun working

together

There is still more work to be done and we are ready for the challenge