ODT Workforce Design Project

Midlands Regional Collaborative 2nd December 2014

Ella Poppitt, Head of Service DesignOrgan Donation and Transplantation

NHSBT

Outline

– Orientation to the ODT Workforce Project

– Phase 1- basis and objective

– Overview of Findings

– Future Modelling of the SN-OD role

– Overview of future plans and timescales

– Q&A

Taking Organ Transplantation to 2020 Strategy

– Measure 1 Consent/authorisation for organ donation

Aim for consent/authorisation rate above 80% (2012/13: 57%)

– Measure 2 Deceased organ donation

Aim for 26 deceased donors per million population (pmp) (2012/13: 19.1 pmp)

– Measure 3 Organ utilisation

Aim to transplant 5% more of the organs offered from consented, actual donors

– Measure 4 Patients transplanted

Aim for a deceased donor transplant rate of 74 pmp (2012/13: 49 pmp)

ODT Workforce Project Objectives (Phase 1)• Design a workforce model to meet the strategic aims and

targets of the TOT 2020 strategy using evidence obtained from data and statistical review, literature review and internal & external stakeholder engagement.

• Ensure staff feel involved in the process and have had their views heard.

• Phase 1 :December 2013- September 2014

• Phase 2: October 2014- December 2015

Phase One - Complete

• Flexible options to meet fluctuating demand• Most roles involve 24hr working• Family facing role = greater impact on consent• Specialist and focused roles• Variety of professional backgrounds

• The current Specialist Nurse role and the donation pathway• Current and future donor activity• National and regional service provision• Future predicted donor activity for 2020• Length of process and time of day activity happens• National, regional and individual consent rates• Audit workload

NHSBT staff Workshops

InternationalReview

Data Analysis

• Options not to work 24hrs• Remove theatre element from the role• More time required for hospital development• Time to build relationships with families• No consensus on how the role should look

• Praise for SN-OD role from hospital partners• 40% felt change required• Main purpose of role – donor co-ordination; family liaison, raising awareness

Stakeholder views

Statistics & Data Review for the Workforce Project

Areas of Data Investigated

– Current regional activity

– Configuration of the service

– Forward modelling to 2020

– The impact of non-proceeding activity & opportunities

– The donor process, associated timings & relationship to role

– The importance of consent

– SNOD consent rates

– Multivariate analysis on consent paper

– The impact of level 1, 2 and 3 activities and relationship to SNOD role

– The impact of audit and data collection

Number of potential DBD and/or eligible DCD by team, from 1 April 2013 to 31 March 2014 (PDA data as at 9 April 2014)

514

738

812

622

369

215

393

473457

321

377

439

0

100

200

300

400

500

600

700

800

900

Eastern London Midlands North West Northern NorthernIreland

Scotland SouthCentral

South East South Wales South West Yorkshire

Organ Donation Services Team

Num

ber

of p

oten

tial

DBD

and

/or

elig

ible

DCD

Regional Profile of Donation Potential

0

20

40

60

80

100

120

140

160

Pote

ntial

DBD

and

/or e

ligib

le D

CD

Trust/Boards with at least one potential DBD and/or eligible DCD

Trust/Board activity from 1 April 2013 to 31 March 2014 (PDA data as at 9 April 2014)

Potential DBD and/or eligible DCD Potential DBD (including cases where also eligible DCD) Eligible DCD only

Level 3(n=91)

Level 2(n=52)

Level 1(n=32)

Trust Activity 2013/14 by Level

Actual donors, 2013-14

Eastern

London

Midlands

North West

Northern

Northern Ireland

Scotland

South Central

South East

South Wales

South West

Yorkshire

Potential donors, 2013-14

Eastern

London

Midlands

North West

Northern

Northern Ireland

Scotland

South Central

South East

South Wales

South West

Yorkshire

The dots on the magnified London area are not to scale

Level 1s Potential and Actual 2013-14

Actual donors, 2013-14

Eastern

London

Midlands

North West

Northern

Northern Ireland

Scotland

South Central

South East

South Wales

South West

Yorkshire

Potential donors, 2013-14

Eastern

London

Midlands

North West

Northern

Northern Ireland

Scotland

South Central

South East

South Wales

South West

Yorkshire

The dots on the magnified London area are not to scale

Level 1 + 2s Potential and Actual 2013-14

Actual donors, 2013-14

Eastern

London

Midlands

North West

Northern

Northern Ireland

Scotland

South Central

South East

South Wales

South West

Yorkshire

Potential donors, 2013-14

Eastern

London

Midlands

North West

Northern

Northern Ireland

Scotland

South Central

South East

South Wales

South West

Yorkshire

The dots on the magnified London area are not to scale

Level 1, 2 + 3s Potential and Actual 2013-14

1.6

1.5

2.3

1.4

3.0

4.8

2.3

3.3

0.5

0.5

0.5

0.5

12.5

15.8

10.3

14.4

3.9

3.9

2.1

1.5

Proc 2010/11 (n=388)

Proc 2013/14 (n=586)

Non-proc 2010/11 (n=10)

Non-proc 2013/14 (n=9)

Hours

National DBD: median timings by proceeding/non-proceeding and year

Time between first discussion with SN-OD and SN-OD attendance

Time between SN-OD attendance and family approach

Time between family approach and consent/authorisation

Time between consent/authorisation and start of operation

Time between start of operation and team left theatre

27.0

25.3

34.8

26.2

Total*

* Total time from first discussion with SN-OD to end of last offices. This has been calculated for each patient by summing the time taken for each individual part of the process and including half an hour for last offices. The median has then been calculated. (The sum of the medians for each part of the process does not equal the total median.)

DBD: Length of Process

Considerable regional variation 25-45 hours

1.1

1.2

1.0

0.9

2.0

2.0

1.2

2.0

0.5

0.5

0.5

0.5

8.8

12.2

8.6

11.6

2.4

2.6

2.1

3.3

Proc 2010/11 (n=191)

Proc 2013/14 (n=342)

Non-proc 2010/11 (n=128)

Non-proc 2013/14 (n=210)

Hours

National DCD: median timings by proceeding/non-proceeding and year

Time between first discussion with SN-OD and SN-OD attendance

Time between SN-OD attendance and family approach

Time between family approach and consent/authorisation

Time between consent/authorisation and treatment withdrawal

Time between treatment withdrawal and team left theatre

20.9

15.2

21.8

17.2

Total*

* Total time from first discussion with SN-OD to end of last offices. This has been calculated for each patient by summing the time taken for each individual part of the process and including half an hour for last offices. The median has then been calculated. (The sum of the medians for each part of the process does not equal the total median.)

DCD: Length of Process

Considerable regional variation 16-30 hours

Heat Maps:Referral and SN-OD Attendance Activity

Heat Maps for all significant time points in the donation process

Consent Rate Multivariate Analysis

• Associated most strongly with family consent (p<0.0001) • Patient ethnicity; knowledge of a patient’s wish to donate; involvement of a

specialist nurse for organ donation in the family approach• The impact of the SN-OD on family consent

Stronger for DCD than DBD, and was significant even when the impact of prior knowledge of the patient’s wishes was accounted for.

• Other significant factors Cause of death; the number of family members present during the donation conversation; the relationship of the primary consenter to the patient.

• Family refusal is a major barrier to donation in the UK Represents biggest opportunity to increase donor numbers, particularly for DCD.

Improving the involvement of SN-ODs in the family approach is a key component of current strategies to increase UK consent rates

SN-OD consent/authorisation rate

DCD

DBD

• Demonstrated numerically SN-ODs in the current role do not actually approach that often (2 years data)

• Variable of rates of performance by SN-ODs

• Numbers not large (Maximum is 54 approached over 2 years- average 1 request every 2 weeks)

• Supports the need to have numerically less specialised staff requesting more often to become experts

• Impact on consent if you separate the requestor from the facilitator?

PDA not designed to measure thisCan only count cases where there is no doubt over the SNOD name.Point it time considered is who made the approach

UK average is 15 approaches per annum per SN-OD (2013/14)

 2013/14SNOD

attendedNORS

attendedActualdonors

Non proceedingdonors

(NORS attended)Organs

Transplanted

DCD 3064 804 520 258 1140

DBD 1504 802 769 33 2770

2007/08For every 1 family approached for DCD 1 patient benefited from transplantation

2012/13For every 2 families approached for DCD1 patient benefited from transplantation

The DCD Pathway

Number of proceeding and non-proceeding DBD and DCD donors (ie any consented eligible donor with a completed Core Donor Data Form)

1 April 2013 to 31 March 2014 (UKTR data as at 23 April 2014)

67

116

87 95

5332

62 60 67

26

56 60

60

64

71 47

40

14

44 47 39

19

51 43

8

15

5

4

5

3

3 6 5

2

4 3

66

79

6380

40

13

32

5842

30

68

43

0

50

100

150

200

250

300

Eastern London Midlands NorthWest

Northern NorthernIreland

Scotland SouthCentral

South East SouthWales

SouthWest

Yorkshire

Organ Donation Services Team

Num

ber

of p

roce

edin

g an

d no

n-pr

ocee

ding

don

ors

Non-proceeding DCD

Non-proceeding DBD

Proceeding DCD

Proceeding DBD

UK Total (n=1997)Non-proceeding DCD (n=614)Non-proceeding DBD (n=63)Proceeding DCD (n=539)Proceeding DBD (n=781)

Donor Activity per Regional Team

Does not reflect the levels of SNOD attendance for DCD

Respiratory failure245 referrals, 140 attendances ,28 NORS attendances, 25 donors= 37 kidneys, 1 liver transplanted

Multi Organ Failure

1113 referrals, 471 attendances, 3 NORS attendances

3 donors= 5 kidney transplantsCancer, other than brain tumour

280 referrals, 106 Attendances, 0 NORS attendances= 0 donors

Septicaemia

247 referrals, 101 attendances, 3 NORS attendances, 3 donors, 1 kidney transplant

MOF/ Cancer/ Sepsis/Renal failure as a ‘cause of death’= 688 SNOD attendances (6 NORS attendances)= 6 Donors over 1 year

DCD activity by ‘Cause of Death’1 April 2013 to 31 March 2014

Renal Failure

30 referrals, 10 Attendances, 0 NORS attendances= 0 donors

In the Context of SNOD Activity...

Cases of MOF, RF, Cancer & Sepsis combined

• 688 SNOD attendances in 2013/14 (6 NORS attendances)

• 6 Donors, 6 Transplants

• In 2013/14 NHSBT deployed a SNOD on 114 occasions for every 1 organ transplanted

• 2633 SNOD attendances over 4 years 2010/11-2013/14 (31 NORS attendances)

• 25 Donors, 30 Transplants

• Over these 4 years 2010-2014 NHSBT deployed a SNOD on 87 occasions for every 1 organ transplanted

DCDs aged > 81

• 751 SNOD attendances over 4 years 2010/11-2013/14 (27 NORS attendances)

• 11 donors, 6 transplants

• Over these 4 years 2010-2014 NHSBT deployed a SNOD on 125 occasions for every 1 organ transplanted from a patient aged >81 years

Plan: to conduct a piece of work to analyse this further: Significant impact on the volume of work within the SN-OD role

Workforce Modelling of the SNOD role

ClinicalClinical + demandStructure of the model is based on the 6 main types of activities that SNOD currently undertake

1. Consent related activity

1. Consent related activity

2. Clinical activity

2. Clinical activity 3. Theatre3. Theatre 4. Hospital

development4. Hospital

development5. Death audits

5. Death audits

6. SNOD – adm activity6. SNOD –

adm activity

Triage of incoming referrals

Attendance to referrals

Approach families for consent

Clinical activity following consent, excluding theatre time

Attendance to surgery in theatre

Activity with hospitals to drive referrals and ensure compliance with transplantation policies

Audit of all deaths in ED/ICU of patients below the age of 81

Follow-up letters to donors

File closure of donors

Prepare ODC documentation for hospitals’ committees

Consideration of Options

• Using the findings from phase 1 of the project

• Consideration of all options for each task- who could perform that role?

• Whether each ‘role’ should be SNOD/ other new NHSBT role/ non NHSBT role (i.e. a commissioned role)

• Likely impact of the National referral Centre (ODT Operational Hub) on some tasks currently performed by a SNOD

• All role options evaluated via a workforce model including the existing SNOD role

• Number of roles identified during workshops at a high level

Acknowledgement: Laura Hontorio Del Hoyo

Assistant Director, Blood donation and Strategy, NHSBT

Role Options Modelled- Revisited

• Dedicated requester/ consent role

• Audit role

• Hospital development

• Clinical Co-ordinator

• Theatre role

Additional Work

– Developing high level role profiles

– Consideration to alternative models of how staff on call are deployed to a referral

– Financial modelling of all options

Current SNOD roleConsideration of options +/- on callCommissioned/ local optionsRoles in isolation of component parts

Role Options Modelled- Considerations

• Dedicated requester/ consent role

• Audit role

• Hospital development

• Clinical Co-ordinator

• Theatre role

• Investigating the viability of all the options including the current SN-OD role against many criteria

Next Steps for the Project

–Evaluate the workforce modelling and feedback to staff the impact of the modelling on the options that

have been considered within the project- commenced–Engage with key stakeholders in relation the potential impact of

change during this period- commenced

–Trial new role as pilots within specific regions- Evaluate outcomes and impact- planning phase

–Take forward a paper based evaluation of potential triage interventions alongside current practice and evaluate findings- implement as appropriate- planning phase

–Timelines for phase 2 completion- 31st December 2015

–Implementation of any potential new workforce model for the SN-OD role- January 2016 onwards

Role Pilot- High level outline

Workshops underway across the UK to discuss this with the SN-OD workforceWorkshops underway across the UK to discuss this with the SN-OD workforce

• Potential impact on strategy

• Applies the concept of fewer individuals in a consent/ requesting only role to maximise the frequency and the expertise of the requestor

• Supported by international evidence for increasing consent (phase 1)

• Work alongside the existing clinical role (from consent to theatres)

• Allows new role options to be modelled and piloted- develop a new consent role and further develop the clinical role of the SN-OD

• Developing plans for a pilot in 2 regions of the UK

Split the existing SNOD into 2 roles (at the point of consent)

Separating consent/ requesting activity from the existing SN-OD role

What will be the focus of the project in phase 2?

A Consent/ Specialist requesting Role to be taken forward via a pilot alongside the SNOD/ Clinical Role

A Consent/ Specialist requesting Role to be taken forward via a pilot alongside the SNOD/ Clinical Role

Pilot and Implement a DCD Triage model

Thank you for your attention