EXECUTIVE SUMMARY
Introduction
One of the Nation’s most pressing public health issues is the widening gap between the supply and demand for organs and tissues. To raise awareness about the vital importance of organ and tissue donation to the Nation’s health and to increase donation rates, U.S. Secretary of Health and Human Services (HHS) Tommy G. Thompson initiated the Gift of Life Donation Initiative in April 2001. The “Organ Donation Breakthrough Collaborative” is the most recent component of Secretary Thompson’s initiative. Its purpose is to generate significant, measurable increases in organ donation by helping the national community of organ procurement organizations (OPOs) and hospitals to quickly identify, learn, adapt, replicate, and celebrate “breakthrough” practices that are associated with higher donation rates. Further, it is designed to enhance the understanding of existing knowledge as well as contribute new and vital information about increasing organ donation rates. In particular, its goals are to:

• Increase the average conversion rate of eligible donors from the current average of 43 percent to 75 percent in the Nation’s largest 200 hospitals;
• Increase donations by up to 1,900 donors per year;
• Increase transplantations by 6,000 per year; and
• Help save lives of thousands of people each year and prevent up to 17 deaths per day.

The first phase of the Organ Donation Breakthrough Collaborative consists of the identification of breakthrough or “best” practices. Subsequent phases include learning these practices, replicating the practices, and celebrating successes. This general approach is intended to be consistent with contemporary collaborative models of identifying and spreading improvements in health care systems. This report presents a set of overarching principles and best practices associated with higher rates of organ donation that were identified based on site visits, in-depth face-to-face discussions, and other data collection involving selected OPOs and hospitals across the country.

Study Design, Methods, Limitations
A qualitative case study approach was used to identify and describe best practices associated with higher organ donation performance. Six OPOs and 16 affiliated hospitals were selected that are among the higher performers nationally based on rates of consent and organ donation in their communities. Background information was gathered and reviewed on selected OPOs and hospitals and discussions with nearly 300 representatives of OPO and hospital staff were conducted about factors that contribute to organ donation. Data and observations were synthesized and analyzed to formulate overarching principles and best practices. The study sample consisted of 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 Boston)
• LifeLink of Florida (Tampa, FL) and: Lakeland Regional Medical Center (Lakeland), Tampa General Hospital (Tampa)
• University of Wisconsin Hospital & Clinics Organ Procurement Organization (Madison, WI) and: Gundersen Lutheran Hospital (Lacrosse), Theda Clark Regional Medical Center (Neenah), University of Wisconsin Hospital & Clinics (Madison)
• Mid-America Transplant Services (St. Louis, MO) and: Barnes-Jewish Hospital (St. Louis), St. John’s Mercy Medical Center (St. Louis)
• LifeGift Organ Donation Center (Houston, TX) and: Ben Taub General Hospital (Houston), Memorial Herman Hospital (Houston)
• Donor Alliance (Denver, CO) and: Denver Health Medical Center (Denver), Memorial Hospital (Colorado Springs), St. Anthony Central Hospital (Denver)

While this study is an initial step at identifying and sharing “what works” in organ donation, it has certain methodological limitations, as follows.

• Small sample. Given the available time and resources, this study was only able to conduct a limited number of site visits. Certain best practices might not have been identified within the scope of this study, may not have been confirmed as such given a larger sample of observations, or may be artifacts or otherwise specific to sampled institutions and therefore would not be applicable to other institutions.
• Selection of higher performers. Consent and conversion rates were analyzed from the Organ Procurement and Transplantation Network (OPTN) database to identify OPOs and hospitals that were promising sites for studying potential best practices. These data were self-reported by OPOs and may not accurately reflect the performance of all OPOs and hospitals. Further, these data tracked only referred “eligible” potential donors as defined by HRSA, excluding non-referred eligible donors, medically suitable organ donors older than age 70, and “non-heart beating donors,” and thereby may undercount OPO and hospital achievements.
• No control group. This study did not compare the practices of higher performing OPOs and hospitals with the practices of lower performing organizations.
• Halo effect. Labeled as higher performers, respondents may have identified more practices as “best” than they would have without that label.
• Limited perspectives. Although information was collected about potential best practices from a wide range of OPO and hospital staff, it is possible that some best practices were overlooked by not involving other parties with perspectives not encompassed in this study. In particular, the opportunity to hear the perspectives of donor families on the organ donation process was not possible given the limited study scope.

Overarching Principles
The process of organ donation is complex and delicate and relies on multiple parties working together toward common goals. The potential for organ donation is most often preceded by a tragic event. Parties involved in organ donation are keenly aware that families come to these situations in shock, usually having last seen their loved ones under normal circumstances. Supporters of organ donation view this as an opportunity to realize something that is life-affirming from something terrible, providing a “gift of life.”

Visits to OPOs and hospitals revealed that there is no single best approach or “magic bullet” for success. 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. A set of common principles emerged across sites that appear to contribute to success. In the subsequent section, more specific practices and strategies put these principles into operation.

1. Integrate organ donation fully into routine roles and responsibilities.
Organ donation performance benefits from fully integrating the organ donation process into the routine roles and responsibilities of hospital staff. Some hospitals have been implementing organ donation for decades. These hospitals often are led by individuals who consider organ donation to be firmly embedded in the hospital mission and culture, and support it accordingly. These hospitals may have influential critical care physician or nurse leaders who view organ donation as part of end of life care, and they lead and teach this by example. Other hospitals have institutionalized organ donation practices more recently. In either case, 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.
Despite their high performance, the OPO leadership and management and key hospital staff who were consulted strive continuously to improve. 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. They embrace the increasing expectations for OPOs and hospitals to close the gap between organ supply and demand. They are motivated, not discouraged, by observations of decreasing donor pools and declining donor potential.

Goals or performance standards direct OPO operations. Leaders invest resources into activities with the highest likelihood of achieving goals. Hiring, supervision, and recognition are linked to performance. OPOs redefine their goals annually or via longer-term strategic plans.

Organ donation is an infrequent event; any dip in performance or prolonged status quo triggers the higher performing OPOs and hospitals to reassess goals and revise approaches to improve results. Several of the OPOs and hospitals visited actively experiment with new approaches to improving performance.

3. Involve OPO and hospital staff in ongoing standards setting and redesign of means to achieve these standards.
Goal-focused and innovative approaches are possible because they are informed and implemented by skilled and dedicated OPO and hospital staff. There is a joint awareness and commitment among both OPO and hospital staff to meet goals. 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 within which staff are able to carry out their duties. Staff are given responsibility, autonomy in decision-making, opportunities to provide feedback to improve the process, and new challenges.

As in other aspects of health care, hospitals perform better with clear guidelines for different aspects of the organ donation process, so that 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. Some hospitals have donation committees in which OPO and hospital staff collaborate on reviewing protocols, identifying potential problems, and implementing solutions. OPO and hospital staff also review performance data on a regular basis in these or other meetings to assess and improve outcomes.

4. Hold OPOs, hospitals, and their staff accountable for achieving these standards and recognize the staff accordingly.
OPOs and most hospitals increasingly set performance standards for organ donation and assess actual performance against these. In addition to being accountable for referring 100 percent 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. OPO and hospital staff identify weak points or errors in the process, plan ways to resolve these, and implement improvements accordingly.

Accountability among hospital staff may be driven by hospital administration, other champions for organ donation within the hospital, or OPO staff. Some hospital staff remarked that reporting data by intensive care unit fosters a healthy competition among units within the institution. OPOs recognize or “celebrate” organ donation successes in hospitals. Hospitals with transplant programs often celebrate transplant successes as well. OPO staff are cognizant of their performance relative to other OPOs across the country.
Most OPO leaders and managers regularly evaluate staff performance against certain benchmarks. These evaluations are used to inform personnel decisions and, in some instances, are the basis for incentives to staff.

5. Establish, maintain, and revitalize a network of interpersonal relationships and trust involving OPO and hospital staff, donor families, and other key agents.
Organ donation operates within, and depends upon, an extensive array of interpersonal relationships. 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. The critical path of organ donation is mediated, and can be slowed or stopped, by any one of a large group of agents. Relationships with all of these agents contribute to overall performance; one misstep in the process can have a negative impact on outcomes. Maintaining and forming new relationships help to identify and overcome potential problems.

6. Collaborate to meet the range of needs of potential donor families and achieve informed consent to donate.
Potential donor families are typically thrust into these circumstances in shock and in great need. An integrated OPO and hospital approach to meeting the wide range of needs of potential donor families is also more likely to result in an informed decision to donate. Hospital staff are the first to interact with and provide support to families of potential donors as they work to save the patient’s life. Most staff report that the organ donation process works best when hospital staff call the OPO as soon as possible after the potential donor presents in the hospital. Early referrals, before brain death is determined, allow time for hospital staff to interact with OPO staff regarding the status of brain death testing and family reaction to the situation as well as allow OPO staff the time to evaluate whether the patient is eligible 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.

Preparing the family for imminent death contributes to informed decision-making and successful organ donation. Further, during the consent process, OPO staff, often with hospital staff present, can answer questions from family members about brain death and organ donation. In the event that families initially refuse to donate, OPO staff will seek to determine whether the family is denying the request to donate as such, or is denying the request at that time for another reason, which may justify reapproaching the family.

7. Conduct ongoing data collection and feedback to drive decision-making toward performance improvement.
All of the OPOs and hospitals visited rely on data to plan, monitor and measure their performance. While donors per million population has been used for OPO certification, it was not reported to be a useful indicator for monitoring or setting goals for OPO or hospital performance. 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.

All of the OPOs visited conducted regular death record reviews (involving regular review of the medical records of all their hospitals) to determine donor potential at each site. OPO staff conducted death record reviews more frequently at hospitals with higher donor potential, usually about 20 percent of the hospitals within OPO service areas.

The ability of OPOs and hospitals to employ data-driven decision-making also depends on the ability of OPOs to collect various organ donation performance data and share them with hospitals in a timely and systematic fashion. Most OPOs reported having systems in place to track, analyze, and disseminate organ performance data.

Best Practices
The 15 best practices described in this report refer to actions of OPOs and hospitals that appear to be associated with higher organ donation performance and are capable of being replicated in other OPOs and hospitals. More than one best practice may support or enhance the individual overarching principles cited above. For each best practice, the body of this report provides several specific strategies or examples used to achieve or implement it, along with other supporting evidence. The best practices are as follows.

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. In fact, some noted that maintaining the status quo is regressive. These entities regularly implement new, innovative strategies.

3. Strive to recruit and retain highly motivated and skilled staff.
Both OPOs and hospitals attributed their higher than average performance to their skilled, motivated, and tenured staff. Given high turnover in the industry, they are highly attentive to staff recruitment and retention.

4. Appoint members to OPO board who can help achieve organ donation goals.
In most of the sites, OPOs organized their boards or advisory structures to advance all of the interests of the OPO, including donation, procurement, and placement of organs. 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.
Various key roles in organ donation are assumed by different actors. At least 3 critical roles are: family support, clinical coordination, and hospital relations. OPO and hospital staff are assigned particular roles according to their professional strengths, experience, and performance.

6. Tailor or adapt the organ donation process to complementary strengths of OPO and individual hospitals.
High performing OPOs and hospitals do not approach organ donation in the same way in all settings. With experience, and over time, they tailor their approaches based on their respective strengths, experience, performance, and the broader needs and context of their institutions and communities.

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. OPO staff do not simply arrive on the scene at the time of a potential donation; they are well recognized in the settings of their affiliated hospitals.

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.
Hospital champions advocate organ donation, link the hospital to the OPO, facilitate the process of organ donation in hospitals, and break down institutional and other barriers to donation. OPOs endeavor to identify, support, and maintain relationships with these champions.

9. All aboard: secure and maintain buy-in at all levels of hospital staff and across departments/functions that affect organ donation.
OPO and hospital personnel do not rely on champions alone to achieve high levels of performance. They articulate the importance of “top-down, bottom-up and sideways buy-in,” that is, identification with and commitment to organ donation. OPOs use diverse and creative strategies for securing and maintaining buy-in.

10. Educate constantly; tailor and accommodate to staff needs, requests, and constraints.
Hospital staff in particular attributed higher than average performance, in part, to the repeated education they receive and provide to others in organ donation. 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 consent 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. Most hospital and OPO staff would concur that this type of education is a best practice when it has a specific purpose and continuing or improving it is linked to measurable outcomes.

12. Referral: anticipate, don’t hesitate, call early even when in doubt.
One of the most important messages that OPOs convey in education sessions and via regular contacts with hospital staff is to call as early as possible to facilitate consent and organ recovery. Among the hospitals visited, there is a common interest and willingness to make early referrals to the OPO and to consult its experts regarding potential donations. OPO personnel have cultivated this inclination by teaching the early signs of brain death and emphasizing the importance of not waiting until brain death declaration to place a call to the OPO.

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.
Obtaining consent can be an intricate process that is highly dependent on the cooperation, skills, and responsiveness of OPO staff and hospital-based physicians, nurses, pastoral care staff, and social workers. The roles in the consent process are largely consistent across high performing sites; however, they can be carried out by different combinations of OPO and hospital staff. 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.
All of the OPOs and most of the hospitals cited the importance of data-driven decision-making to improve organ donation and focus their resources appropriately. Using data to inform and document decisions helps OPOs and hospitals to maximize referrals, consents, and donors and improve continuously. 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 staff, physicians, and nurses affirmed that timely and systematic feedback is crucial to increasing awareness and improving organ donation processes at hospitals, thereby maximizing the number of early referrals and actual donors at hospitals. Immediate problem solving is another contributor to success. 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. OPOs conduct follow-up both formally and informally, using a variety of techniques.

Conclusions
Site visits with 6 OPOs and 16 hospitals, revealed 7 overarching principles and 15 best practices and accompanying strategies that appear to be associated with high organ donation performance. Many of these principles and best practices are interrelated, and many of the strategies and examples gleaned from the OPOs and hospitals support more than one principle or best practice. A noteworthy example is the OPO practice of providing letters of thanks to hospital staff following a donation, which is consistent with principles and best practices concerning recognizing and celebrating success, providing timely and systematic feedback, maintaining buy-in, and maintaining a network of interpersonal relationships.

Best practices can be viewed in the context of a systems approach to organ donation. Some OPOs and hospitals explicitly manage organ donation using a systems approach. Others implement various of its components. In this systems approach to organ donation, goals are set by OPOs and their governing bodies, and discussed with and adopted by the hospitals in their service areas. These goals are set with the intention of maximizing organ donation performance and improving organ donation processes and protocols.

To be successful, organ donation processes and protocols are implemented both within and outside of the hospital setting by champions from among OPO staff, hospital staff, and others, such as medical examiners, EMS staff, and donor families. These processes and protocols span hospital development activities, family support and bereavement care, clinical support of potential donors, and follow-up.

Hospital development focuses on building and strengthening the relationships between OPO and hospital staff. Family support and bereavement care are continuous, and focused on helping families by offering them emotional support, information, and resources needed to deal with these tragic situations. Processes and protocols related to the clinical support of potential donors include identification of potential donors, donor referrals, determination of medical suitability, obtaining consent, stabilization of donors, locating recipients, organ recovery and preservation, and, finally, transplantation. Follow-up processes include those related to OPO-hospital staff case debriefs, OPO follow-up with hospital staff regarding transplant recipients, and OPO and hospital follow-up with donor families.

Finally, OPOs and hospitals generate outcome data as a result of the implementation of these processes. Data are monitored and analyzed within the OPO and hospital settings to determine how well processes were implemented and whether goals were achieved. Results of data analysis continuously inform the organ donation process so that improvements can be made over time and organ donation goals can be modified accordingly.

I. INTRODUCTION

The shortage of donated organs and tissues for transplantation is one of the Nation’s most pressing public health issues. Despite advances in medical research and technology that facilitated nearly 23,000 organ transplants, 46,000 corneal transplants, and 173 bone marrow transplants in 2002, the gap between the supply and demand for donor organs and tissues continues to widen. The national waiting list for organs has grown to 81,000 people - with thousands more in need of tissue or corneal transplants. Every day, on average, 68 individuals receive a life-saving organ transplant while 17 individuals die waiting.

To raise awareness about organ and tissue donation as a national public health issue and increase donation rates, U.S. Secretary of Health and Human Services (HHS) Tommy G. Thompson initiated the Gift of Life Donation Initiative in April 2001. This initiative comprises several components targeting such groups as employers, the donation community (including organ and tissue procurement organizations, donor families, and related organizations), hospitals, States, departments of motor vehicles, and the public to spread the message of organ donation. Among these components are the following.

1. Workplace Partnership for Life. This component promotes Federal government collaboration with private corporations, organizations, and associations to make donation education information available to their employees. Through these partnerships, employees learn about, discuss, and make decisions concerning the donation of organs, tissues, marrow, and blood. More than 7,500 employers have accepted the Secretary’s invitation to create these partnerships.

2. Model Donor Card. HHS designed a model donor card that is consistent with laws of the 50 States and the District of Columbia. The model donor card allows individuals to indicate their desire to be a donor and designate which organs or tissue they want donated. The model donor card is currently available to the public on the Web site of HHS’ Health Resources and Services Administration (HRSA).

3. National Forum on Donor Registries. For this component, the Secretary requested the HHS Office of Inspector General (OIG) to conduct a study on existing registries and hold a national forum to examine the potential of, and guidelines for, registry development. The national forum to examine donor registries was held November 29th and 30th, 2001. The report summarizing the results of the forum and the OIG study are posted on the HRSA Web site.

4. National Gift of Life Medal. A national medal is being considered to present to donor families.

5. Driver’s Education Curriculum. HHS is developing a model curriculum to incorporate into State driver’s education programs and high school education programs.

On April 25, 2003, Secretary Thompson announced a sixth component to the Gift of Life Donation Initiative: “Organ Donation Breakthrough Collaborative.” Its purpose is to generate significant, measurable increases in organ donation by helping the national community of organ procurement organizations (OPOs) and hospitals to quickly identify, learn, adapt, replicate, and celebrate “breakthrough” practices of their colleagues that are associated with higher donation rates. Further, it is designed to enhance the understanding of existing knowledge as well as contribute new and vital information about increasing organ donation rates. In particular, its goals are to:

• Increase the average conversion rate of eligible donors from the current average of 43 percent to 75 percent in the Nation’s largest 200 hospitals;
• Increase donations by up to 1,900 donors per year;
• Increase transplantations by 6,000 per year; and
• Help save lives of thousands of people each year and prevent up to 17 deaths per day.

The Organ Donation Breakthrough Collaborative has 4 main phases: identification of breakthrough or “best” practices, learning the practices, replicating the practices, and celebrating successes. This report presents results from the first phase of the effort. Results include a set of overarching principles and best practices associated with higher rates of organ donation that were identified from site visits, in-depth face-to-face discussions, and other data collection involving selected OPOs and hospitals across the country.

On September 9th and 10th, 2003, HRSA will launch phase 2 of this effort by conducting the first in a series of 3 workshops designed to support rapid replication of breakthrough practices. These workshops will convene successful OPOs and hospitals wishing to improve their donation performance with other OPOs and hospitals to review and discuss how to apply the breakthrough practices to their own organizations. The format for the workshops is based on contemporary collaborative models of identifying and spreading improvements in health care systems. As part of phases 3 and 4, OPOs and hospitals will apply practices in their own organizations and monitor and celebrate anticipated successes.

The identification of best practices was informed by previous efforts to better understand organ donation practices and how they relate to performance. Specifically, a meeting was held in June 2001 of 20 national experts in organ donation to examine potential structural and process attributes of OPOs and hospitals that are associated with higher rates of organ donation. (See Appendix A for a list of participants.) The meeting yielded a framework for the organ donation process and a formative evaluation approach to promote future investigation of the correlates of high organ donation rates.

The body of this report is devoted to observations of best practices. Section II provides the study methodology, including site selection, data collection and synthesis, and data limitations. Section III presents the study findings, including overarching principles of the organ donation process, profiles of selected OPOs and hospitals visited, best practices, and implementation issues. Section IV presents the conclusions of the report.

II. STUDY METHODOLOGY
A qualitative case study approach was used to identify and describe best practices that are associated with higher organ donation performance. OPOs and affiliated hospitals were selected that are among the higher performers nationally based on rates of consent and organ donation in their communities. Background information was gathered on selected OPOs and hospitals, interviews were conducted with a broad range of OPO and hospital staff about factors that contribute to success in organ donation, and data and observations were synthesized and analyzed to formulate overarching principles and best practices.

A. Site Selection
Selection of OPOs and hospitals for the study started with the 300 hospitals with the highest consent rates (i.e., the number of persons for whom consent was given to donate organs as a percentage of the total number of persons eligible for organ donation). The study sample included 6 OPOs and 16 hospitals. After first choosing the OPO sample, a sample of hospitals affiliated with the selected OPOs was identified.

1. OPO Sample
According to performance data from the Organ Procurement and Transplantation Network (OPTN) January 2003 database (for the year August 2001 through July 2002), the 300 hospitals with the highest consent rates were affiliated with 51 OPOs. These 51 OPOs were ranked according to the highest consent rate of any one of their respective affiliated hospitals as well as the median consent rate among their affiliated hospitals. OPOs with fewer than 3 affiliated hospitals among the highest performing 300 hospitals were excluded.

From among the 14 OPOs with the highest consent rates and median consent rates greater than the national mean (i.e., consent rates greater than 50 percent) , a sample of 6 high performing OPOs was selected for the study. (See Appendix B for a listing of the 14 OPOs considered for the study sample.) Volume of cases, geographic variation, and unique characteristics of donation practices (e.g., hospital-based OPO, in-house coordinator staffing model) were considered in the final sample selection. The OPOs selected for analysis included:

• New England Organ Bank (NEOB), Newton, MA;
• LifeLink of Florida (LifeLink), Tampa, FL;
• University of Wisconsin Hospital & Clinics OPO (UWHC OPO), Madison, WI;
• Mid-America Transplant Services (MTS), St. Louis, MO;
• LifeGift Organ Donation Center (LifeGift), Houston, TX; and
• Donor Alliance (Donor Alliance), Denver, CO.

2. Affiliated Hospital Sample
A sample of hospitals was selected by identifying all hospitals affiliated with each of the 6 high performing OPOs and ranking them by 2 measures of hospital performance: rate of consent per eligible donor and rate of medically suitable donors per eligible donor. Two to 4 of the hospitals that ranked highest in these 2 measures were selected. (Consent and conversion rates were greater than or equal to 60 percent and 50 percent, respectively.) In selecting the hospitals, OPOs’ perceptions regarding which hospitals contributed most to their success were considered. Appendix C lists the hospitals visited.

Due to time and resource constraints, selection of sites was limited to 6 OPOs and 16 hospitals and excluded hospitals that were located more than 150 miles from their affiliated OPOs. Data were collected for community hospitals only, which thereby excluded Veteran’s Administration, Department of Defense, and Public Health Service (Indian Health Service) hospitals. Also excluded were children’s hospitals and hospitals with fewer than 150 beds, as only a small proportion of organ donations occur in these types of hospitals.

B. Data Collection and Synthesis
Invitations were extended by mail and through follow-up telephone calls, to OPO and hospital leadership to participate in the study. All of the selected OPOs and hospitals accepted.

Background information was collected from the six OPOs through a pre-site visit telephone interview process prior to visiting the OPOs and their affiliated hospitals. Supplemental data were collected on characteristics of OPO governance, staff, training and education programs, various organ donation protocols, and other OPO practices. In addition, secondary data were verified on individual hospital characteristics and services.

Throughout the site visit interviews, data were collected to identify best practices of OPOs and affiliated hospitals that lead to higher organ donation performance. A series of in-person discussions were conducted with OPO and hospital staff. OPOs and hospitals recommended key informants for these discussions. Depending on the preferences and availability of key informants at each OPO and hospital site, discussions were conducted either individually or in a group. Individual discussions ranged from 30 to 90 minutes in length; group discussions lasted as long as 2 hours.

Discussions with OPO and hospital staff did not follow a strict format. The purpose of these discussions was to determine what the informants perceived, from their various perspectives, to be the factors that contributed to the higher performance of their OPO and/or affiliated hospitals. Informants usually identified what they considered to be the several most important factors or practices associated with high performance. More extensive probing of informants’ initial observations, and inquiring about general areas of potential that they did not cite initially (which varied across informants), provided the opportunity for informants to identify other relevant characteristics.

Probes spanned such areas of organ (and in some cases tissue) donation as:

• Commitment and governance;
• Financial and budgetary issues;
• Contextual and facility characteristics;
• Staffing;
• Referral response and other practices;
• Planning, outreach, evaluation and quality improvement;
• Technological capacity and data collection; and
  Collaboration.

This study did not address organ transplantation, specific medical/clinical best practices which optimize organ preservation, or surgical techniques in organ procurement as such. However, some OPO and hospital staff noted these topics in the context of, for example, the transition from donation to procurement to transplantation, communication between donation staff and procurement teams, and the role of feedback from the transplantation process to the donation process.

Standards for answers included concrete, descriptive language; consistency; and evidence where available and relevant. Wherever possible, opinions were grounded with examples; when they were not, they were recorded as ungrounded for study purposes.

In total, 292 individuals were interviewed for this study – including OPO employees and hospital physicians, nurses, and pastoral care staff. Exhibit 1 shows the distribution of interviewees by their site and professional role.

Exhibit 1: Interviewees by OPO Affiliation

Qualitative data from on-site interviews were analyzed in a debriefing process. Internal debriefings were conducted after each site visit during which study team members reviewed site visit experiences and observations. Also, themes were raised at these debriefings that were tested during subsequent site visits. After the site visits were completed, the data were synthesized and analyzed to assemble a set of best practices associated with higher organ donation performance.

C. Data Limitations
As opposed to many other processes or interventions in health care, there is no recognized set of best practices in organ donation. Research findings have suggested specific strategies for gaining informed family consent to donate their loved ones’ organs, e.g., decoupling discussion of brain death from the request or making the request in a private setting. However, various recommended strategies in organ donation are not well substantiated in practice, have not been replicated in multiple settings, and are otherwise debated. While this study is an initial step at identifying and sharing “what works” in organ donation, it has several limitations:

• Small sample. Given the available time and resources to complete this study, only a limited number of site visits were conducted for this study. Even based upon the limited sample of OPOs and hospitals, it is apparent that organ and tissue donation practices vary widely across the country. As a result, certain best practices might not have been identified within the scope of this study. Also, certain practices considered to be “best” based on their appearance in some or all of this limited sample might not have been confirmed as such given a larger sample of observations. Similarly, some best practices among the sample of OPOs and hospitals may be artifacts or otherwise specific to those institutions, and therefore would not be applicable to other institutions.
• Selection of higher performers. Consent and conversion rates were analyzed from the OPTN database to identify OPOs and hospitals that were promising sites for studying potential best practices. These data were self-reported by OPOs and may not accurately reflect the performance of all OPOs and hospitals. Further, these data tracked only referred “eligible” potential donors as defined by HRSA, excluding non-referred eligible donors, medically suitable organ donors older than age 70, and “non-heart beating donors” (also known as “donors after cardiac death” or “asystolic donors”) and thereby may undercount OPO and hospital achievements. To address, in part, the potential limitations of the selection of OPOs and hospitals, the findings of this study are subject to a vetting process that provides for staff of other OPOs and hospitals to review, edit, and confirm the best practices identified here.
• No control group. This study did not compare the practices of higher performing OPOs and hospitals with the practices of lower performing organizations. Including such controls in this study would have enabled a more valid distinction between practices that simply co-exist with, but do not contribute to, higher performance, and those practices that exist more often in higher performing organizations and less often in lower performing organizations.
• Halo effect. The data on organ donation performance were retrospective and assessed prior to selecting OPOs and hospitals for study; therefore, performance could not have been affected by being selected for study. However, OPO and hospital staff were aware that they were participating in a study based on the higher performance of their organizations. Therefore, OPO and hospital staff may have been more likely to identify certain of their practices as being “best” than they would have had their organizations not been labeled as high performers.
• Limited perspectives. The practices that contribute to higher organ donation performance involve or affect many parties. Although information was collected about potential best practices from a wide range of OPO and hospital staff who, as a group, are very likely to be aware of most if not all potential best practices, it is possible that some best practices were overlooked by not involving other parties with perspectives not encompassed in this study. In particular, given the limited study scope, the opportunity to hear the perspectives of donor families on the organ donation process was not possible given the limited study scope.

III. STUDY FINDINGS
This section presents overarching principles of the organ donation process, profiles of the OPOs and hospitals visited, best practices, and implementation issues.

A. Overarching Principles
The process of organ donation is complex and delicate and relies on multiple parties working together toward common goals. Key informants used several analogies to describe the process: “a delicate dance,” “a well-oiled engine,” and “a fragile web of interconnecting strands.” The potential for organ donation is most often preceded by a tragic event. Parties involved in organ donation are keenly aware that families come to these situations in shock, usually having last seen their loved one under normal circumstances. Supporters of organ donation see it as an opportunity to realize something that is life-affirming from something terrible, providing a “gift of life.”

Visits to OPOs and hospitals, having critical roles in the organ donation process, revealed that there is no single best approach or “magic bullet” for success. Successful organ 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 report presents a set of common principles observed at each site that appear to contribute to success. In some instances, these principles are made explicit by certain OPOs or hospitals; in other instances, they are implicit in the orientation, organization, or actions of OPOs and hospitals. In the subsequent section, more specific practices and strategies are identified that put these principles into operation. (See Exhibit 2 for a list of overarching principles.)

Exhibit 2: Overarching Principles

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

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

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

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

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

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

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

1. Integrate Organ Donation Fully Into Routine Roles and Responsibilities.
Organ donation performance benefits from fully integrating the organ donation process into the routine roles and responsibilities of hospital staff. Some of the hospitals visited had been implementing organ donation for decades. These hospitals often are led by individuals who consider organ donation to be firmly embedded in the hospital mission and culture, and support it accordingly. These hospitals may have influential critical care physician or nurse leaders who view organ donation as part of end of life care, and they lead and teach this by example. Other hospitals visited appeared to have institutionalized organ donation practices more recently, by formalizing existing practices, strengthening their relationships with their OPO, responding to the Medicare Conditions of Participation, among others. In either case, organ donation is integrated into hospital policies and protocols, medical records systems, training, staffing, finances, data collection, and quality improvement efforts in the manner of other services. Among the many comments by hospital clinical and managerial staff on this subject were: “Organ donation is part of our daily business,” “It’s what we do,” “Organ donation is just another kind of care for patients and families,” “It’s an opportunity to change a tragic experience for families into something good,” “Organ donation is one of the patient’s and family’s many rights,” and “It’s the right thing to do.”

The sites with fully integrated organ donation processes report that they welcome the relationship with their OPOs. One of the key roles of OPOs is to work with hospital staff to establish and improve organ donation processes in a way that complements, rather than disrupts, hospital operations. Because organ donation is an infrequent event, and given the staff turnover in hospitals, regular education and communication is needed to define, refine, and implement protocols; clarify roles and responsibilities of staff; and solve problems as they arise.

• Additional evidence that hospitals adopt organ donation as routine include the following.
• A few hospitals reported that, at the request of senior hospital executives, OPO and hospital staff brief them regularly on organ donation performance.
• In some intensive care units, the nurse staffing model changes when a potential donor presents so that donor cases have a one-to-one nurse-to-patient ratio.
• Several hospitals have institutionalized organ donation through standing donation committees. These committees are forums for all hospital staff from different departments to review issues related to organ donation, set policy, address educational needs, and overcome barriers.
• Some nurse managers reported that hiring criteria include expectation of delivering high-quality end of life care, of which organ donation is a part.
• Orientation and training for new nurses also involves experiencing a donation case.

2. Set High Standards for Donation Performance to Reduce the Unacceptable Shortage of Life-Saving Organs.
Despite their high performance, the OPO leadership and management and key hospital staff strive continuously to improve. OPOs and hospitals establish clear, often “stretch” goals for their organizations and/or for individual 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. OPOs and hospitals embrace the increasing expectations for them to close the gap between organ supply and demand. They are motivated, not discouraged, by observations of decreasing donor pools and declining donor potential.

Goals or performance standards direct all levels of OPO operations. Leaders invest energy and resources into activities with the highest likelihood of achieving goals. Hiring, supervision, and recognition are linked to performance. Standards are set to increase performance in:

• Referrals of all deaths;
• Referrals of medically suitable donors;
• Number of early referrals;
• Number of family approaches;
• Rates of consent;
• Rates of donation;
• Number of organs recovered per donor;
• Number of transplants.

OPOs redefine their organizational goals on an annual basis or via longer-term strategic plans.

Organ donation is an endeavor of small numbers; any dip in performance or prolonged status quo triggers OPOs and hospitals to reassess goals and revise approaches to improve results. As one OPO leader reported, “While staff may think they are doing all they can to increase the number of donors, there is always more to be done.”

In order to realize their goals, several of the OPOs and hospitals actively experiment with new approaches to improving performance. For example, some OPOs applied practices from other industries, such as the pharmaceutical industry, to build relationships with hospitals. Both OPOs and hospitals noted their willingness to take risks, such as spending resources on a new staffing model that was unproven in their environment or experimenting with new techniques to maximize viability of donated organs. OPO governing boards and/or hospital executives in most of the sites support quality improvement efforts by OPO or hospital management toward organ donation goals.

3. Involve OPO and Hospital Staff in Ongoing Standards Setting and Redesign of Means to Achieve These Standards.
Goal-focused and innovative approaches are possible because they are informed and implemented by skilled and dedicated OPO and hospital staff. In many of the sites, discussion and monitoring of performance standards extends beyond OPO leadership. Most levels of OPO staff and hospital champions for organ donation are aware of and committed to meeting expectations for performance. They monitor their performance regularly and retool when necessary in order to improve.

OPO staff become aware of the performance expectations of their positions during the hiring process; for most OPOs, this practice appeared to be a more recent event. OPOs take special care in training and retaining staff to match skills to specific roles. While staff expectations are high, leaders and managers provide support and flexible working conditions within which staff are able to carry out their duties. Staff are given responsibility, autonomy in decision-making, opportunities to provide feedback to improve the process, and new challenges.

Opportunities to participate in setting and achieving standards include regular team meetings reviewing potential and actual donor cases, performance review discussions, and department meetings. At one OPO, organ donation performance hit a plateau and leadership consulted each member of the hospital development team about what practices were and were not contributing to performance. The results of these discussions helped to direct the leadership’s decision to adopt a more specialized staffing model.

Standards setting and redesign occurs in hospitals as well, often facilitated by OPO staff. As in other aspects of health care, hospitals perform better with clear guidelines for different aspects of the organ donation and procurement process, so that there is no confusion about roles and responsibilities. Hospitals work jointly with OPOs to develop, update and improve protocols, and ensure that staff are educated in how to follow them. Some hospitals have donation committees with which OPO staff are invited to collaborate on reviewing protocols, identifying potential problems, and implementing solutions. Hospital and OPO staff also review performance data on a regular basis in these or other meetings to assess and improve outcomes.

4. Hold OPOS, Hospitals, and Their Staff Accountable for Achieving These Standards and Recognize the Staff Accordingly.
OPOs and most hospitals visited enforce performance standards. Leaders, managers, and staff monitor OPO data to compare actual to expected performance. OPO and hospital staff identify weak points or errors in the process, plan ways to resolve these, and recognize good performance.

Most OPO leaders and managers establish clear performance benchmarks according to which staff are regularly evaluated. Such benchmarks are used to inform personnel decisions. OPO staff are often given incentives to perform well. Some OPOs set annual organizational, departmental, and individual goals and tie staff performance to compensation. Others offer staff financial incentives, such as bonuses, for meeting or exceeding monthly goals. Annual performance reviews, in addition to staff meetings throughout the year, provide forums for OPO managers and staff to review performance.

In addition to being accountable for referring 100 percent of deaths to their OPOs, hospitals review OPO data on timely referrals, family approaches, consent rates and donations regularly to determine how well they are following organ donation protocols. Some hospital staff remarked that reporting data by intensive care unit fosters a healthy competition among units within the institution. Hospitals emphasized the importance of clear communication between the OPO and the hospitals to ensure that performance expectations are clear.

Accountability among hospital staff may be driven by hospital administration, other champions for organ donation within the hospital, or OPO staff. At NEOB transplant centers in Boston, hospital administration emphasize attention towards organ donation performance measures, stimulated in part by a directive from the State Commissioner of Health to consider organ donation performance among the hospitals’ quality indicators. At other hospitals, referring physicians and nurse managers hold their staff accountable to performance.

OPOs recognize or “celebrate” organ donation successes in the hospital. If hospitals have transplant programs, they often celebrate transplant successes as well. OPOs are not punitive and do not assign blame if problems at hospitals are identified. Rather, they share responsibility with hospitals for understanding and fixing problems.

5. Establish, Maintain, and Revitalize a Network of Interpersonal Relationships and Trust Involving OPO and Hospital Staff, Donor Families, and Other Key Agents.
The organ donation process operates within, and depends upon, an array of interpersonal relationships. The OPOs visited establish, maintain, and revitalize relationships with all levels of hospital staff to facilitate organ donation. Hospital staff interact with personnel across different departments as well as administration. Both OPO and hospital staff interact with other individuals or organizations that play a role in any part of the organ donation process, including donor families, medical examiners/coroners, EMS staff, and community leaders. The critical path of organ donation is mediated, and can be slowed or stopped, by any one of a large group of agents. Relationships with all of these agents contributes to overall performance; one misstep in the process can have a negative impact on outcomes. Maintaining and forming new relationships help to identify and overcome potential problems.

Successful OPOs consistently invest in developing relationships with the hospitals in their service areas. Hospitals, and trauma centers in particular, are the sites of service where most of the potential donor cases present. While still responsive to all of the hospitals in their service area, OPOs concentrate most of their relationship-building efforts in the hospitals with the highest donor potential. The majority of hospitals cited the close relationship with their OPO as one of the major factors contributing to their higher consent and conversion rates.

Relationship-building in hospitals is traditionally known as “hospital development” in the OPO community. While some of the OPOs visited still use this term, others find that it does not adequately capture the goals they seek to achieve in hospitals. The primary goal of hospital development staff is to serve as liaisons or consultants to facilitate organ donation in hospitals. They build relationships with key hospital staff who will support the process of organ donation in their settings.

Building relationships with hospitals puts organ donation on the “radar screen” of key hospital staff when, for some, it would otherwise not be. The outcome of relationships with hospitals includes:

• Establish hospital trust in the OPO;
• Increase awareness and knowledge of the organ donation process, which increases referrals of potential cases to the OPO;
• Increase identification and pursuit of education opportunities;
• Develop policies to enhance organ donation;
• Increase access of the OPO to high-level hospital staff to gain management support of organ donation and to break down institutional or professional barriers to organ donation;
• Elevate organ donation cases to priority or emergency status in hospitals as appropriate.

Contracts between hospitals and OPOs are insufficient for facilitating successful organ donation performance. Hospitals are extremely busy, often stressed institutions facing competing demands and increasingly tight resources. OPO relationship-building activities include regular, frequent communication and networking, education, and technical assistance.

OPOs offer hospital staff a level of expertise and service that fills gaps in certain hospital resources for organ donation, e.g., for education sessions, protocols, and reporting. OPO staff establish hospital trust by example, such as real-time accessibility, task follow-through, and meeting the needs of donor families regardless of the donation outcome. Both OPO and hospital staff visited also noted the value of networking with other parties at the hospital that play a less obvious but very important role in organ donation. For example, some OPO and hospital staff interact with hospital trauma teams, flight crews, or security staff to raise their awareness of organ donation and the importance of early referrals to the OPO.

Relationships with other key agents in the donation process can facilitate positive outcomes. For example, some OPOs and hospitals noted that the time their staff members have devoted to interactions with the medical examiners or coroners has led to fewer cases in which the medical examiner/coroner has denied permission to release the potential donor’s body for organ donation. Some hospital staff noted the importance of being able to work with transplant teams. In some instances, transplant teams reportedly have arrived at the hospital only interested in procuring organs, with little apparent regard for others in the operating room. Such experiences have left negative impressions about organ donation on hospital staff, particularly nurses, which could pose a disincentive to participate in future donor cases. In contrast, hospital staff affiliated with other OPOs have remarked at the positive experience of working with transplant teams who regard themselves as guests in the donating hospitals, enhancing the flow and professional reward of the procurement process. A couple of OPOs have strategically delivered messages to transplant teams about the importance of this relationship and regard for the environments in which they are working.

Hospital and OPO staff share the role of doing their very best to make donor family experiences positive. Hospital staff develop initial relationships with potential donor families, working to save their loved one’s life as well as meet immediate family needs. Usually after brain death is declared, though sometimes before, OPOs support hospitals in providing care to families. After donation, OPO staff provide detailed feedback to donor families at several intervals as part of bereavement care through written and oral communication, remembrances, and other activities. Donor families can be valuable advocates for organ donation within their communities.

6. Collaborate to Meet the Range of Needs of Potential Donor Families and Achieve Informed Consent to Donate.
Potential donor families are typically thrust into these circumstances in shock and in great need. OPOs and hospitals reported that families, in their grief, experience heightened emotions of disbelief, anger, and sadness over the condition of their loved ones, doing their best to comprehend the clinical prognosis while facing other pressing interpersonal and logistical matters. Achieving informed consent to donate is related to an integrated OPO and hospital approach to meeting the wide range of needs of potential donor families.

Hospital staff - usually physicians and nurses - are the first to interact with and provide support to families of potential donor cases as they work to save the patient’s life. In hospitals where the social workers and/or chaplains are active members of the patient’s critical care team, they assist nurses in meeting family needs. Immediate needs include providing families with privacy, food or drink, blankets for overnight stays in the hospital waiting room, access to telephones for long-distance calling, transportation, lodging, and other needed resources. Among the OPOs visited, LifeGift was unique in that its in-house coordinators (IHCs) interacted with families as extensions of hospital nursing staff, including well before brain death. IHCs helped families address their immediate needs to relieve some of the burden on hospital staff. IHCs did not raise the matter of organ donation, however, until after brain death testing.

According to most respondents, the organ donation process works best when hospital staff call the OPO as soon as possible after the potential donor presents in the hospital. Early referrals, before brain death is determined, allow OPO staff the time to evaluate whether the patient is eligible to donate. OPO staff usually do not interact with families at this time. OPO and hospital staff do not want to introduce the possibility of organ donation to families if their loved one is not medically suitable to donate.

Early referrals allow time for hospital staff to interact with OPO staff regarding the status of brain death testing and family reaction to the situation. For eligible cases, hospital and OPO staff determine collaboratively the best time to approach the family about a request to donate as well as who should make this request.

Site visits found a range of views (including polar-opposite ones) on the assignment of responsibility to approach families regarding donation. In some OPOs, such as LifeGift, this assignment clearly belonged to OPO staff, i.e., the in-house coordinator, and hospital staff were strongly discouraged by hospital leadership and OPO staff to raise this topic with families. Indeed, in these instances, historical consent rates were shown to increase in association with the shift in this role from hospital staff to OPO staff specially trained for this purpose. In other instances, such as in Wisconsin, hospital staff are the designated requestors, while OPO staff are available to support the request by answering questions as necessary and otherwise coordinating the donation process. Clearly, both approaches work in their own contexts, which arise from professional, institutional, and community antecedents. Held in common is an emphasis on continuous family care and a sequence of events leading up to and following the request to donate involving close, well-understood, and reliable collaboration among hospital and OPO staff. What differs is the assignment of certain responsibilities to hospital staff and OPO staff, respectively, during the course of this process. Indeed, in some instances in a given hospital, these responsibilities may shift given the needs of the family and specific circumstances. Thus, rather than following a strict protocol, both the hospital and OPO staff are making decisions that are in the best interest of the family in the particular circumstances of the donation.

Preparing the family for imminent death contributes to informed decision-making and successful organ donation. Hospital personnel reported that spending the time preparing the family for the possibility of brain death facilitated the family’s understanding of their loved one’s passing and readiness to make other necessary decisions. Organ donation is often presented as one of many decisions the family needs to make at the time of death.

During the consent process, OPO staff, having been introduced to families by hospital staff and often with hospital staff present, can answer questions from family members about brain death and organ donation. In the event that families initially refuse to donate, OPO staff will seek to determine whether the family is denying the request to donate as such, or is denying the request at that time for another reason, which may justify reapproaching the family.

In a few hospitals, hospital staff provide families as many opportunities as possible to see their loved one in the intensive care unit. In this manner, families are able to witness hospital staff working aggressively to try to save their loved one’s life. Similarly, after consent, OPO staff enable families to visit patients’ rooms to have time alone with their loved ones before procurement.

As noted above, OPO and hospital approaches to bereavement or aftercare were similar across sites. Regardless of donation outcome, both OPO and hospital staff were committed to giving the family the best possible care at their time of loss.

7. Conduct Ongoing Data Collection and Feedback to Drive Decision-making Toward Performance Improvement.
All of the OPOs and hospitals visited rely on data to plan, monitor, and measure their performance. While donors per million population has been used for OPO certification, it was not reported to be a useful indicator for monitoring or setting goals for OPO or hospital performance. The key measures tracked by all OPOs and used to inform organ donation operations in hospitals include, but are not limited to, those listed below. These measures are consistent with goals set by OPOs.

• Donor potential: the number of deaths in the hospitals that, based on a set of criteria, demonstrate potential to be organ donors;
• Referrals of deaths: the rate at which all hospital deaths are referred to the OPO;
• Medical suitability: determination of medical suitability of potential donors by OPO, based on pre-determined criteria;
• Consent rate: the number of consents divided by the number of requests;
• Conversion rate: the number of actual donors divided by the number of potentially medical suitable donors;
• Organs recovered per donor: the number of organs recovered per actual donor; and
• Organs transplanted: the number of organs from an actual donor that are successfully transplanted in recipients.

All of the OPOs visited conducted regular death record reviews (involving regular review of the medical records of all their hospitals) to determine donor potential at each site. Findings informed OPO strategic planning and decisions regarding where to invest OPO resources. OPO staff conducted death record reviews more frequently at hospitals with higher donor potential, usually about 20 percent of the hospitals within OPO service areas.

OPOs collect and share summary data on death, eligibility, referral, consent, recovery, placement, and transplantation internally among staff as well as externally with key hospital staff to monitor performance and to ensure accountability. The OPOs anticipate how their actions will affect performance outcomes. Hospital staff reported that regular opportunities to share performance data raised their awareness of organ donation and reported the benefits of following protocols to maximize results.

The ability of OPOs and hospitals to employ data-driven decision-making also depends on the ability of OPOs to collect various organ donation performance data and share them with hospitals in a timely and systematic fashion. Most OPOs reported having systems in place to track, analyze, and disseminate organ performance data. More specific examples of using data to improve performance are provided in the best practice on data-driven decision-making.

B. Overview of OPO and Hospital Characteristics
The OPOs visited included 2 in the South, 3 in the Midwest (Donor Alliance in Colorado being the furthest West), and one in the Northeast. Five of the 6 OPOs in the sample are independent entities; UWHC OPO (Madison, WI) is the only hospital-based OPO. Four of the 6 OPOs have tissue donation programs in addition to their organ donation programs.

UWHC OPO is the longest-operating OPO in the sample, at 37 years. NEOB (Boston, MA) has the largest population in its service area, operating budget, and number of full-time equivalent staff, and is second to UWHC OPO in terms of years of operation. In operation for 16 years, LifeGift (Houston, TX) is the youngest OPO in the study sample. LifeLink (Tampa, FL) has the smallest population in its service area. Among the sites visited, the majority of OPO staff have more than 3 years experience at their OPOs. (Exhibit 3 shows a profile of selected characteristics of the 6 OPOs visited.)

The 6 OPOs have a total of 718 hospitals in their service areas. LifeGift has the most hospitals in its service area (187) while LifeLink has the fewest (48). NEOB has the most transplant centers (12) in its service area. All 16 hospitals visited are either Level 1 or Level 2 trauma centers, which usually see the most potential donor cases. Many of these institutions are responsible for delivering trauma services across their respective regions and routinely care for large numbers of patients with acute conditions. Of the 16 hospitals, 9 are teaching hospitals and 8 are transplant centers.

There were 4 hospitals affiliated with NEOB, all of which are large urban teaching hospitals with transplant centers, although the transplant program at the public hospital is small. Two large trauma centers were affiliated with LifeLink; one trauma center is also a transplant center.

University of Wisconsin Hospital & Clinics Organ Procurement Organization is located in the University of Wisconsin Hospital & Clinics system, a Level 1 trauma center and teaching institution. The 2 other hospitals affiliated with UWHC OPO are smaller (fewer than 300 beds) suburban hospitals.

Two hospitals affiliated with each of MTS and LifeGift were visited. All 4 of these hospitals are large (more than 600 beds) institutions in urban areas; one hospital affiliated with each of these 2 sites is a teaching hospital. The sample of hospitals affiliated with Donor Alliance included 3 hospitals, 2 of which are public. (Appendix C lists hospitals in the sample and descriptive data about each.)

The remainder of this section presents a brief summary of each OPO’s approach to organ donation.

Exhibit 3: OPO Characteristics

Notes:
* In addition to the 91 FTE staff members, NEOB has 15 per diem staff members, who are not included in the annual statistical reporting.
** Consent rates are based on March 2003 OPTN database extract (donor referral data reported by OPOs from August 2001 – July 2002).
*** Average number of organs recovered per donor data are from Scientific Registry of Transplant Recipients OPO Reports (July 1, 2001 – June 30, 2002)

C. Key Attributes of OPOs
This section profiles key attributes of the 6 OPOs visited, including their overall approach to organ donation, governance structure, staffing model, and approaches to community education and quality improvement. Even among these higher-level attributes, there is considerable variation. However, certain similarities among these and aspects of commitment to organ donation may contribute to higher performance.

New England Organ Bank (Newton, MA)
Three approaches drive the New England Organ Bank’s (NEOB) efforts to increase organ donation. NEOB attributes its higher organ donation performance to its ongoing, collaborative relationship-building with hospitals and transplant centers in the New England area, its specialized staffing model in its higher potential hospitals, and also its explicit systems approach to organ donation, which involves planning, evaluation, identification of best practices, feedback, and quality improvement in OPO operations. The following organizational characteristics facilitate NEOB’s implementation and achievement of these approaches.

NEOB has 3 main governance structures: a board of trustees, executive committee, and medical oversight board, each with multi-state representation. The board’s composition is consistent with the Centers for Medicaid and Medicare’s (CMS) regulations. In order to mitigate inherent conflicts of interest, NEOB enlarged its board to include 30 members to balance representation of the high number of transplant centers in its service area with other hospital leadership and community interests. While the board provides primary strategic oversight to the OPO, it does not micro-manage. According to NEOB leadership, the board entrusts the executive director and medical director with the management of the OPO’s organizational and clinical functions.

NEOB emphasized its devoted staff and low staff turnover as contributing factors to its higher performance. NEOB promotes a specialized, team approach to organ donation comprising 3 types of specialized staff - a donation coordinator, a family support counselor, and a hospital development coordinator - assigned to meet the needs of hospitals with the highest donor potential. NEOB management recruits candidates from various backgrounds to apply for positions. Candidates are subjected to a rigorous hiring process to ensure that staff are highly qualified and aligned with the mission of the organization. Once staff are hired, they undergo a formal training program tailored to their specialized function. Though NEOB has performance targets for staff, they are not given financial incentives to meet their targets.

NEOB reported that hospital education initiatives are important to facilitate organ donation efforts. To this end, NEOB has been expanding its hospital-based marketing campaigns in particular to promote its best practices. Included in these initiatives are new marketing materials, such as posters, newsletter articles, and script cards. Also, NEOB is working to promote organ donation in the community by working with the local media to increase awareness about organ donation through a media newsletter.

NEOB emphasized the quality improvement component of its systems approach as a major reason for its success in organ donation. To facilitate quality improvement, NEOB developed a data system that collects, monitors, and tracks, by hospital, trends related to requests, consents, organs recovered, and organs transplanted. NEOB reviews these data with hospital leadership on a monthly basis. Formalized feedback mechanisms such as weekly meetings with NEOB staff, monthly meetings with hospital staff, post-donation debriefings with all involved OPO and hospital staff, along with 2 data reporting mechanisms (quantitative and more qualitative, subjective reports) are all incorporated into quality improvement efforts. These efforts help to ensure that NEOB and its affiliated hospitals maintain their orientation to continually improving their organ donation practices.

LifeLink of Florida (Tampa, Florida)
LifeLink of Florida (LifeLink) management has adopted a business orientation to organ donation and procurement, with the goal of increasing the supply of donor organs to save lives. LifeLink attributes a variety of factors to its success, including a high degree of executive staff involvement on all referrals, a committed staff, shared capacities with the LifeLink Foundation, a service-orientated approach with hospitals and medical examiners to develop and build relationships, a collaborative relationship with Central Florida Lions Eye Bank, and an ability to respond on-site to every brain death referral.

LifeLink credits the high involvement of its executive staff throughout the donation process for some of its success. The LifeLink executive staff and medical director help to screen all referral cases, providing the vascular coordinator (analogous to the clinical coordinator and family support roles in other OPOs) with support, input, and real-time trouble-shooting during the donation process. LifeLink noted that “support and direction from the top translate into success and donor productivity.”

Another contributor to LifeLink’s performance is its team of 24 staff. To ensure that potential hires are aggressive, collaborative, assertive, and able to work under stressful conditions, LifeLink uses a lengthy “reality” interview process in which candidates meet with staff and participate in actual organ referral and donation events.

LifeLink and its staff benefit from the broad capacity of the LifeLink Foundation (Foundation). LifeLink is one of 4 OPOs under this umbrella, which share a board of governors (primary overseer of OPO operations), administrative staff, communications call center, public relations, community outreach and education, and accounting/finance capacities with the Foundation. In addition, the Foundation strategically recruits high profile members of the Tampa business and civic community to sit on the board of governors to increase awareness about organ donation. To mitigate any conflicts of interest and ensure innovation and fresh perspectives, LikeLink has incorporated a mechanism for selecting and removing board members as well as changing the composition and responsibilities of the members and committees.

LifeLink’s hospital development and medical examiner (ME) liaison staff align OPO objectives with hospital and ME needs. This service-oriented approach was reported to be a factor contributing to LifeLink’s performance. OPO staff promote organ donation and provide services, such as education about organ donation policies, to hospitals and MEs to facilitate organ donation successes. LifeLink also visits these hospitals and MEs regularly. LifeLink asserts that regular interactions allow for timely resolution of any problems and facilitate strong relationship-building.

In all of LifeLink’s hospitals, no distinction is made between organ and eye/tissue donation. LifeLink and the Central Florida Lions Eye and Tissue Bank have a collaborative relationship that enables nurses to call one number to refer potential organ and/or eye/tissue donation. According to LifeLink, coupling organ donation with eye and tissue donation, which occur at a higher frequency, increases the visibility of, and referrals for, organ donation.

LifeLink encourages hospital staff to make early referrals and OPO staff to respond to every call, even those that may have no donation potential. LifeLink views on-site response as part of its service to hospitals as well as another opportunity to achieve its hospital development goals. LifeLink evaluates every brain death, regardless of age, medical history, or social history, and makes every effort to determine if there are potential recipients for marginal organs.

LifeLink’s operations are backed by a comprehensive evaluation and quality improvement process. Starting from the point of referral for possible donation, LifeLink tracks each case through its call center system to the point of final donation outcome. Additionally, LifeLink holds weekly staff meetings to review all referrals, responses, problems, and hospital development activities. On a monthly basis, LifeLink conducts death record reviews and the executive administration reviews donor and referral data, including consent data, by hospital. On a quarterly basis, LifeLink performs a quality assurance review with hospital medical staff on donor outcomes and develops an activity report to its board of governors.

University of Wisconsin Hospital & Clinics (Madison, WI)
The University of Wisconsin Hospital & Clinics Organ Procurement Organization (UWHC OPO) is one of 9 hospital-based OPOs in the U.S. In this context, its organization and operations are driven by the transplant program at UWHC. As the only transplant center in the OPO’s service area, the UWHC transplant center receives the vast majority of organs procured by the OPO. This proximity facilitates close working relationships between UWHC’s transplant surgeons and OPO staff, contributing to its above average performance. Indeed, the executive director and medical director of the UWHC OPO are transplant surgeons at UWHC. The executive director and medical director of the OPO are both involved in screening and accepting all donor referrals.

The OPO is aggressive and focuses on pursuing the highest number of organs recovered to serve the highest number of patients waiting for transplants, while also providing rapid service to referring hospitals in its service area. UWHC has an active donation after cardiac death (DCD) program, with more than 500 non heart-beating donors since 1974. In 2001, HRSA awarded UWHC OPO a grant to investigate and improve DCD protocols. UWHC OPO is also conducting clinical research in optimization of donor management.

Sharing UWHC’s communication, administrative, and technological resources allows the OPO’s small staff to focus on organ procurement activities. The UWHC OPO staff of 12 people (10.25 FTEs) includes: an executive director, medical director, manager of clinical services, 2 surgical support staff, 4 organ procurement coordinators, 2 surgical recovery coordinators, an outreach coordinator, and a clinic assistant. In the last 3 years, UWHC OPO implemented a formal hospital development program in order to receive accreditation of the Association of Organ Procurement Organizations (AOPO).

The hospitals in UWHC OPO’s service area report having long ago incorporated organ donation identification, referral, and consent protocols into their routine hospital operations. The UWHC OPO views hospital staff as an extension of OPO staff, contributing to the achievement of OPO goals. The OPO staff provides the guidance and support for the physicians, nurses, and pastoral care staff in their service area to participate in the entire organ donation process.

Hospital staff are the primary requestors in UWHC OPO’s service area and OPO staff are actively involved in educating these individuals on the various aspects of the organ donation process. The OPO conducts a designated requestor training program that is mandatory for the physicians, nurses, and pastoral care staff who are requestors. The OPO also conducts other ongoing training and case reviews at hospitals to educate nurses and other hospital staff about making referrals and other aspects of organ donation such as donor management. UWHC OPO also hosts a biennial symposium on organ donation and transplantation, which is a 2-day program of educational sessions for health care providers addressing key issues in organ donation and transplantation, including the challenges facing organ donation and transplantation, the consent process, and current advances in the field of transplantation.

UWHC OPO is committed to providing ongoing hospital and community education on the importance of organ donation and transplantation. Community education events include presentations at local civic and charitable groups, high schools, and organ donation displays in hospitals, at sporting events, as well as at various other community events. These educational outreach efforts contributed to a high-level of awareness of donation and increased buy-in of organ donation in both hospitals and the community at large. Hospitals also develop their own relationships with donor families beyond UWHC OPO by hosting annual picnics and dinners for families.

UWHC OPO integrates quality improvement mechanisms into its functions. After every organ donation case, UWHC OPO staff regularly follow up with hospital staff through phone calls and in-person meetings to discuss the case and address any hospital staff concerns or problems that might have arisen. In addition, OPO staff regularly select and present case studies of missed referrals or actual organ donation cases to hospital nursing staff in order to address their questions and improve the process at their hospitals.

Mid-America Transplant Services (St. Louis, MO)
Mid-America Transplant Services (MTS) focuses on providing high-quality professional services to the hospitals in its service area, concentrating its resources in its high donation potential hospitals. MTS staff described their strong relationships with referring physicians as a contributing factor to their high performance. In addition, MTS has a specialized and tenured staff that coordinates all aspects of the organ procurement process from the time of referral to the placement of organs. MTS reports that all levels of its staff employ data-driven decision-making and direct their efforts towards constantly increasing the number of organ donors. MTS also provides financial incentives to staff who meet their performance targets.

MTS’ mission is to serve its region by encouraging and facilitating organ and tissue donation and assuring the fair allocation of procured organs and tissues. It is governed by a 30-member board of directors that includes physicians, hospital administrators, business leaders, and donor family representatives from its service area. Board members are appointed by a nominating committee of the MTS board. MTS board members serve an unlimited term of office. MTS expects them to serve as champions in overcoming barriers to organ donation, if needed. The board meets 3 times per year, and has an executive committee and a medical affairs committee.

The OPO’s 75 employees comprise hospital development staff, clinical staff, and dedicated family support staff. More than half of the staff members have been with MTS for at least 3 years, and MTS management staff have an average of more than 11 years of experience. MTS attributes its high staff retention to several factors. MTS staff members have very specialized roles in the organ procurement process, assigned according to their professional backgrounds and strengths. MTS gives staff members the flexibility to work from home. The 2 MTS operating rooms relieve hospitals of maintaining donors in their beds and of disrupting their operating room schedules for procuring organs. In addition, the on-site operating rooms also provide a setting for clinical staff to learn new skills and develop professionally.

MTS works closely with the 4 transplant centers in its service area, and maintains a high level of awareness among the medical staff at all of its hospitals. The OPO hospital development staff focus on maintaining high visibility in their high potential hospitals as well as building very strong relationships with their referring physicians and other referring staff. MTS achieves this by providing a broad range of educational programs and services regarding donation and transplantation for physicians, nurses, and pastoral care staff at hospital meetings and in social settings. MTS’ hospital development staff also conduct death record reviews to explore ways to improve their hospitals’ donation performance.

With its own tissue bank, MTS works with hospitals to implement specific systems for requesting organ and tissue donations and the recovery process within each hospital. MTS seeks to improve these systems via feedback from surveys that it administers to hospital staff every few years.

While not a major focus of its investment in improving organ donation, MTS seeks to educate the community by organizing special events and presentations and seeking newspaper and radio coverage. MTS leadership noted that promotion of the State donor registry had contributed positively to organ donation performance. According to MTS, mailings to area businesses have encouraged participation in the HHS Workplace Partnership for Life Initiative and the State donor registry.

MTS constantly strives to improve organ donation in its community. Toward achieving its goals, MTS has begun several new initiatives. The OPO is focusing on using organ donor registries in the 3 States in its service area to improve consent and conversion rates. MTS’ hospital development staff conducts death record reviews to explore ways to improve their performance. MTS recently started a nurse advocate program in which it gives key nurses at its high potential hospitals special training intended to accelerate the referral process. MTS is working to expand its pool of non-heart beating donors. To date, 7 hospitals in the MTS service area have approved DCD protocols.

LifeGift Organ Donation Center (Houston, TX)
LifeGift Organ Donation Center (LifeGift) attributes much of its high performance, including a 15 percent increase in recovered organs during fiscal year 2001, to maximizing and concentrating its resources in hospitals with high potential for donation and procurement. Known as the “Core Concept,” the LifeGift philosophy addresses a variety of areas, including turning potential donors previously considered unsuitable into actual donors, maximizing non-heart beating donors, improving consent rates, minimizing lost recoveries, and improving organ yield. Toward that end, in 1996, LifeGift introduced its in-house coordinator (IHC) approach by placing 2 full-time nurses in Houston’s 2 Level 1 trauma centers.

LifeGift’s leadership, particularly its president and CEO, attribute much of its higher performance to the Core Concept. LifeGift seeks to create an environment that promotes innovation, dedication, independence, and accountability among its staff.

The Core Concept also entails strong, transparent hospital partnerships. The IHC program, in which OPO staff are fully integrated into hospital operations, fosters these relationships. By “being there,” as opposed to “going there,” these coordinators are part of the hospital fabric. In addition to high visibility, this role allows a ready means for continuous education of the hospital staff, early referral (a 99 percent referral rate in 2002) and identification of potential donors, and immediate problem-solving.

LifeGift has 3 main governance structures: a management team that is responsible for overseeing the OPO’s 3 regions, a board of directors, and the LifeGift Endowment. Of the 3, the 18-member board of directors serves as the primary oversight body. The board has 4 committees: 1) executive committee, 2) medical advisory committee, 3) finance committee, and 4) benefits committee. LifeGift also has 7 medical directors placed among its 3 regions.

LifeGift reports devoting fewer resources to community outreach and education because the OPO leadership has not seen evidence of a relationship between these activities and increased organ donation rates. The OPO does use volunteers to conduct education programs in the community to heighten public awareness about organ donation.

LifeGift’s quality improvement strategy includes a weekly conference call among regional leadership to discuss current and planned activities and to review organ donation performance. LifeGift indicates that these standing weekly meetings stimulate competition among the regions. At the hospital level, the IHCs meet regularly with medical staff to present organ donation performance statistics and review cases. These regular presentations also serve as learning opportunities for hospital staff. Within the OPO, organ procurement staff meet weekly to review the events of the previous week on a case-by-case basis and to discuss other matters pertaining to performance.

Donor Alliance (Denver, CO)
Role specialization and a collaborative approach to donation highlight Donor Alliance’s strategy for maximizing organ donors. Faced with data indicating decreasing donor potential in the region in 2000, OPO leadership restructured staff within the OPO and created 4 specialized staffing tracks in the organ donation process. The new position of family support coordinator facilitates consents and increases family support throughout the donation process. The 4 family support coordinators generally have non-clinical backgrounds, though they received extensive training in medical suitability of organ donors. OPO leadership also split the duties surrounding organ procurement into 2 roles. Organ placement specialists focus on organ placement, and organ recovery coordinators focus on the clinical management of the donor. Apparently unique to Donor Alliance is the role of organ recovery specialist. This person is a non-M.D. surgeon with extensive training and experience in organ recovery. With this devoted specialist on staff, Donor Alliance is able to avoid delays due to scheduling conflicts among hospital surgeons and otherwise streamline procurement, which may contribute to organ viability.

Donor Alliance places great emphasis on hospital development. Six full-time personnel, known as donation consultants, act as liaisons to the 100 hospitals within the OPO service area. These personnel are responsible for professional education, facilitating early referral, data collection and monitoring, and feedback. Donation consultants also work with coroners, medical examiners, and funeral directors throughout the community. In those regions where there is no dedicated family support coordinator, the donation consultant is involved in the consent process.

Donor Alliance conducts community education through an extensive public relations program. The cornerstone of this outreach is promotion of the Colorado Organ and Tissue Donation Registry. Instituted by the Colorado legislature in October 2001, the donation registry enables Donor Alliance to eliminate the traditional practice of seeking permission from next-of-kin before recovering organs from donors. The Colorado Donor Registry is considered an advance directive and is irrevocable. The registry is updated every 24-hours by the State department of motor vehicles (DMV). Donor Alliance anticipates that a similar donor registry will be in place in Wyoming by July 2003.

Donor Alliance has a 25-member, community-based board of directors that meets 5 times per year. According to OPO leadership, the board provides oversight and has allowed considerable latitude for innovation and risk-taking in recent years. In addition to the full board, several committees meet on a regular basis, including the executive, finance, medical advisory (tissue), medical advisory (organ), ethics, professional development, and nominating committees. Two medical directors are dedicated to organ and tissue procurement, respectively. With the board’s approval, Donor Alliance implemented a staff performance appraisal system 2 years ago that ties performance relative to organizational, departmental, and individual goals to compensation.

D. Best Practices
The best practices described in this section refer to actions of OPOs and hospitals that appear to be associated with higher organ donation performance and are capable of being replicated in other OPOs and hospitals. The individual overarching principles cited above may be supported or enhanced by more than one best practice. Consistent with the scope of this study, these best practices do not address organ transplantation. Also, while some best practices have implications for donor management prior to transplantation (e.g., timing of referral, efforts to remain apprised of new organ preservation techniques), this study did not address specific medical/clinical best practices, which optimize organ preservation or surgical techniques in organ procurement.

OPOs and hospitals visited embraced the idea of identifying and sharing best practices. It is widely regarded that all parties stand to benefit from improved performance by others, and the higher performing OPOs and hospitals uniformly recognize that continuous improvement is necessary to maintain, let alone improve, performance. Among these best practices, some were explicitly identified by one or more OPOs and hospitals; others surfaced through further investigation or emerged from observations across sites. In some instances, OPOs and hospitals observed before-and-after differences in organ donation performance upon instituting certain practices. However, given the case study approach involving assessment of practices in a limited set of higher-performing sites, it is not appropriate to attribute strict cause-and-effect relationships between these practices and higher organ donation performance.

Most of these practices appear to have evolved over time, including via trial and error. Some OPOs have sought to replicate practices from peers but needed to adjust them to work in their own environments. As noted above, multiple agents and interventions can affect the critical path of organ donation, so that an otherwise well-planned process can be sidetracked by one or a small number of inappropriate actions or decisions. (See Exhibit 4 for a depiction of the process of organ donation.) As such, some best practices may not translate into improved performance unless they are implemented together.

While OPOs and hospitals share many of these practices, they are not all implemented in the same way or by the same staff. The context in which OPOs and hospitals operate can influence their implementation strategy, as can the governance structure, or past experiences. A description of each practice and the specific strategies and examples used to achieve each practice are provided. (See Exhibit 5 for a summary of best practices and strategies.)

Exhibit 5: Summary of Best Practices and Strategies
Best Practices Strategies
1: Orient organizational mission and goals toward increasing organ donation.

• Orient operations towards outcomes rather than processes
• Make organ donation into an expected, routine process of the organization
• Apply business principles to operations

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

• Restructure staff to achieve donation goals
• Implement or plan to implement innovative applications of information technology
• Remain apprised of new interventions through professional consortia and clinical research
• Be more aggressive in donor management and pursue marginal donors and/or non-heart beating donors

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

• Use various practices to identify and recruit staff
• Offer adequate orientation and training
• Create a culture of collaboration and autonomy
• Offer flexible work environments and other benefits
• Provide opportunities for professional growth and development

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

• Comprise boards to promote collaboration and mitigate conflicts

5: Specialize roles to maximize performance.

• Assign staff to specific roles according to professional strengths

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

• Develop and adapt organ donation process by assessing staffing
• Use plans and data collection to facilitate the tailored approach
• Minimize any burden that the organ donation process places on hospitals

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

• Dedicate a position to hospital development
• Accept OPO staff in hospitals and on intensive care units
• Maintain high visibility and continuity
• Maximize availability and accessibility

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.

• Invite hospital personnel to serve on the OPO board
• Target hospital executives and other hospital leaders
• Identify key referring physicians and nurses

9: All aboard: secure and maintain buy-in at all levels of hospital staff and across departments/functions that affect organ donation. • Make OPO resources known to hospitals

• Build trust and respect of all hospital staff
• Reinforce the donation message among all levels of hospital staff
• Consistently show appreciation to hospital staff for their efforts
• Celebrate successes and communicate them internally or externally

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

• Target education to referring staff
• Provide opportunities for hospital staff to seek education on a regular basis and in multiple ways
• Provide incentives
• Tailor education to accommodate hospital staff’s skills, preferences and needs

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

• Promote State registries, if applicable
• Raise awareness and provide opportunities for advanced discussions of organ donation
• Target public outreach efforts to specific ethnic groups
• Never lose an opportunity to make a positive, lasting, and communicable impression on donor families and others in the community

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

• Teach certain clinical triggers
• Dispel the many myths surrounding organ donation
• Have a “go to” person that is responsible for organ donation on units
• Be positive, never punitive

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

• Start early to understand family dynamics, monitor status, and support family needs
• Work as an OPO-hospital team to determine the right person(s) to raise donation and make the request
• Ask at the right time
• Ask in the right way
• Reapproach if needed
• Prepare to adapt to particular family needs or requests to facilitate organ donation

14. Use data to drive decision-making.

• Conduct regular death record reviews in all hospitals to determine those with the highest donor potential
• Focus more resources on hospitals with the highest donor potential
• Regularly collect, monitor, and share referral, consent, and other organ donation data to improve organ donation performance
• Survey hospital staff to identify areas for improvement

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

• Hold regular OPO review sessions to debrief activities, discuss lessons learned, discard practices that are no longer working, and learn from peers
• Follow up and provide feedback to hospital staff after each organ donation case, including on the process as well as the outcome
• Provide feedback to hospital staff about organ and tissue placement and transplant recipients
• Follow up with donor families after donation
• Resolve problems in the organ donation process immediately

Best Practice 1: Orient organizational mission and goals toward increasing organ donation.
The missions and goals of all of the OPOs studied directed the actions of leaders and managers to increasing organ donation. Hospitals, particularly management staff and the intensive care and other unit staff most involved in organ donation, have integrated organ donation into their broader health care missions and specific performance goals. OPO and hospital leaders set, hold themselves and their staff accountable to, and continuously refine or reset their goals to improve organ donation performance. Most of the OPO leaders reported that they invest resources only in activities that are known, or are expected, to result in higher organ donation performance. Resources are withdrawn from activities that do not contribute to donation. Hospital leaders emphasized the importance of making organ donation an expected, routine process of high-quality hospital care.

OPOs demonstrate goal-focused leadership and management by orienting their operations toward outcomes rather than processes. Critical to orienting the organization to outcomes is placing less emphasis on process measures, such as counting interactions, events, mailings, among other activities. While most OPOs continued to monitor these activities, they monitor progress based upon direct measures of donation. The OPOs integrated outcome measures into all facets of OPO operations. For example, OPOs set annual outcomes targets to which their staff are held accountable. They regularly track performance, and use data systems to track results at the staff member and organizational levels. Examples of OPO orientation to organ donation performance include the following.

• LifeGift’s Core Concept directs OPO staff to invest in hospitals with high donation potential in order to: turn unsuitable donors into suitable donors; improve consent rates; increase organ yields per donor; identify DCD donors; and minimize any lost recoveries. LifeGift invests less in public education efforts because it cannot trace achievement of outcomes back to these activities.
• At NEOB, MTS, LifeLink, LifeGift, and Donor Alliance, OPO leadership sets performance targets for their staff (e.g., number of consents per year). In some cases, OPOs provide financial incentives for achieving these targets.

Hospitals make organ donation an expected, routine process of the organization. Many hospitals have a pro-donation environment that is conducive to organ donation. Though OPOs help to maintain and, to some degree, cultivate this pro-donation environment, much of this orientation stems from hospital staff viewing organ donation as an expectation of the organization or of their particular position. In this context, organ donation is viewed no differently than any other service the hospital provides and “is never really assumed otherwise.” Similar to other hospital services, organ donation is viewed as a “social good, ” “the right thing to do,” and congruent with the hospital’s mission and goals of caring for patients and their families. “It’s an opportunity to change a tragic experience for families into something good.” Hospitals foster the pro-donation orientation by promoting education, drafting policies, and holding the organization and its staff accountable for organ donation performance. Examples include the following.

• Staff of one Boston hospital noted that organ donation is something that cannot be compromised; “Let’s make a deal is not applicable when it comes to organ donation.” Hospital staff view organ donation “as the right thing to do” and not as a financial liability.
• At another Boston hospital, staff noted that they view “organ donation as a value “ that supports the hospital’s overall mission.
• Staff of one of LifeLink’s hospitals noted that its pro-donation culture comes from the top-down and is infused throughout the organization because “the passion for organ donation is role-modeled” by the executive staff.
• In a UWHC hospital, the pro-donation culture is fueled and further enhanced by the community’s strong commitment to organ donation. Given the hospital’s large medical transplant center status, many community members and hospital staff have personal connections to donation and transplant recipients. This personal connection fosters hospital and community affinity to the organ donation process.
• One Denver hospital espouses a philosophy of patient advocacy in which organ donation is one of the patient’s many rights. This supports a pro-donation culture that contributes to organ donation.

The application of business principles focuses attention on organ donation performance. OPOs noted that the traditional medical model of having transplant centers and surgeons manage the organ donation process is less likely to be productive, given insufficient managerial and business expertise and the potential for conflicts of interest. Instead, some OPOs noted the importance of viewing organ donation as a resource-driven enterprise that applies a business orientation to achieve the organizational goal of increasing organ donation. Several senior hospital administrators of transplant centers noted the linkage of organ donation performance and the success of their transplant services. Among the business principles identified by OPOs are: developing strategic plans; implementing the most efficient and effective practices; viewing good relationships as a function of customer service; hiring, allocating, and rewarding staff based on clear performance goals; and investing in innovation. Examples include the following.

• To realize economies of scale and improved organ donation performance, LifeLink established a “one-stop shop” that houses a transplant institute with transplant surgeons, medical histocompatibility lab, and patient care center providing medical and ancillary services that result in increased patient satisfaction and care.
• LifeLink approaches referrals with a customer service orientation. In order to serve the “customer” making the referral, LifeLink streamlined its referral process. This OPO worked with its affiliated tissue and eye bank to combine various referral pathways into one so that the referring customer only has to call one number regardless of donation type (eye/tissue/organ). By integrating the various referral processes, LifeLink improved relationships with nurses making referrals and diminished the possibility of conflict or confusion between eye/tissue banks and the OPO in responding to a referral. LifeLink and the eye bank shared the costs of developing the referral software and staffing the call-center.
• Four of the 6 CEOs or executive directors of the OPOs visited have hospital administration experience or business training. As a group, they stressed that, historically, many OPOs have had institutional, professional, social, or political goals that are not necessarily aligned with increasing organ donation. Reorienting OPO operations to achieve that production goal enables application of business principles that have been effective in other industries.
• MTS begins each year with a new set of goal-focused initiatives. This year’s efforts include improving conversion rates, studying ways to expand referrals, instituting standing clinical orders for potential donors, and pursuing more non-heart beating donors. MTS is also focusing its outreach efforts on promoting the State donor registry.
• Some senior hospital administrators of transplant centers reported reviewing their hospitals’ organ donation data regularly, along with data from other hospital services. They noted the importance of organ donation performance on transplant success.

Best Practice 2: Do not be satisfied with the status quo; innovate and experiment continuously.
Across the sites, OPO and hospital leaders and managers demonstrate a pursuit for excellence, insisting that there is always room for improvement. These leaders concur that maintaining the status quo in the evolving health care and socioeconomic environment would not only halt their advancement, but would be regressive. One OPO leader stated, “Anytime you get comfortable, you’re dead.” Leaders also emphasized shrinking donor pools, requiring them “to do more with less.” As a result, leaders of the high–performing OPOs expressed a willingness to innovate and take informed risks to improve organ donation performance. Some OPOs and hospitals utilized innovation to break out of a consent and conversion rate plateau, while others innovated to staunch falling outcomes, initiate earlier referrals, and maximize organ viability and yield through improved clinical donor management.

OPOs have restructured staff.

• In 1996, LifeGift implemented an in-house coordinator (IHC) program at 2 Level I trauma centers in Houston. LifeGift made this change because it determined that working from within, rather than from outside of, hospitals with high organ donor potential yields more donations. Originally nurses, the IHCs were trained as organ procurement coordinators and each was assigned to one hospital. Their duties include all those activities that are normally performed in the course of providing service to a donor hospital, with the additional requirement that they are based in the hospital. This on-site presence allows for daily interaction with hospital staff, higher visibility, earlier potential donor identification, and earlier opportunities to establish relationships with potential donor families. Since its introduction at the 2 Level 1 trauma centers, LifeGift Organ Donation Center achieved higher consent rates (48 percent pre-IHC vs. 68 percent post-IHC), increased referrals (257 pre-IHC vs. 408 post-IHC), and increased organ donors (56 pre-IHC vs. 79 post-IHC).
• Recognizing the importance of meeting needs of potential donor families, Donor Alliance of Denver attributes some of its recent successes to the family support coordinator role, introduced in 2000. Four trained staff members facilitate the consent process by focusing solely on the family, while the functions of clinical donor management, organ placement, and organ procurement are assigned to separate job categories. OPO leadership instituted this new model, based on the one in place at South Carolina Organ Procurement Organization (SCOPA). In order to “break the old culture of doing things,” Denver leadership sent staff out-of-state to SCOPA for training as family support coordinators. MTS also has staff devoted exclusively to family support.
• Several OPOs (in coordination with hospitals in some instances) have implemented or are planning innovative applications of information technology to facilitate early referrals or improve other aspects of organ donation.
• LifeLink of Florida developed an automated calling system to expedite the referral process. MTS and UWHC OPO have an automated calling service, as well. LifeLink reported the following advantages and impact on performance.
  • Now that referrals are logged into the computer system, there is better maintenance of information that would otherwise be lost or less accessible in paperwork;
  • The user-friendly system guides the operator and enables easier, more efficient use of the calling system;
  • Decreased risk of inefficient, protracted referrals;
  • Shortened response time because vascular coordinators are involved earlier in the process. The call center has prompts to call the vascular coordinator on call within 5 minutes; otherwise, the referral is shifted to the next vascular coordinator on the call list.
• NEOB is developing an intranet that will enable staff to write reports in the field, making information more accessible to both OPO and hospital staff.
• MTS is working with the information systems department of one of its hospitals to see if it can make better use of hospital data for organ donation purposes. It is exploring whether it can retrieve electronic profiles on potential donors from the hospital data base in close to real time.
• LifeGift is seeking to increase the utility of its 24-hour call center by exploring the possibility of having the call center facilitate organ placement in addition to referrals.

OPOs and transplant centers seek to remain apprised of new interventions to increase organ donor recovery and outcomes through participation in professional consortia and clinical research.

• NEOB is involved in several regional organ consortia, made up of representatives from transplant programs in the New England region, that develop uniform protocols, discuss the science of innovative organ recovery, and act as a forum for the discussion of organ donation, procurement and best practices in transplantation.
• UWHC OPO is actively involved in research in machine preservation, UW (Belzer) solution, multi-organ recovery techniques, and immunosuppression to optimize organ recovery. It also introduced anesthesiologists at some of their hospitals to T4 (thyroxine) treatment to increase organ viability.

Some OPOs and hospitals are more aggressive in donor management and pursuing more marginal donor cases, and the majority of OPOs are pursuing donation after cardiac death cases in their affiliated hospitals.

• UWHC OPO reported that it accepts more marginal (extended criteria) donors than other OPOs. It also attempts to recover from every possible donor even if the donor is unstable.
• MTS increased the age threshold for kidney donors and accepts kidneys from older donors.
• All but one of the OPOs visited developed donation after cardiac death protocols and shepherded them through many of their regional hospitals and their respective care units.

Best Practice 3: Strive to recruit and retain highly motivated and skilled staff.
All of the OPOs and some of the hospital managers attribute much of their high performance to highly motivated and skilled staff with tenure in the organization. OPOs seek to hire and retain staff that are, or can become, passionate about organ donation, who build and maintain expertise in their areas of responsibility, and are willing to extend beyond routine levels of effort to achieve goals. Hospital managers reported that long-standing nurses in intensive care units serve as mentors on organ donation to nursing peers.

Leaders and managers within OPOs noted that staff continuity is one of an OPO’s greatest assets. Highly competent and experienced staff are more likely to sustain the requisite network of relationships for successful organ donation. Organ procurement staff have, historically, experienced high turnover rates, given the long and unpredictable hours and often physically and emotionally draining nature of the work. In many OPOs, individual staff have had a range of responsibilities, contributing to the hours and stress of the job. OPOs must expend resources and effort recruiting and retaining staff in a tight labor market, particularly for nurses, that offers less stressful positions, more predictable hours, and comparable or better pay. OPOs described the various approaches they are taking to ensure staff satisfaction and retention.

OPOs use various practices to identify and recruit staff. Depending on the position, these OPOs recruit from a variety of sectors in and beyond health care, spanning medical care, emergency medicine, mental health, the military, pharmaceutical industry, public relations, and marketing, and put selected candidates through a process of rigorous interviews.

• NEOB managers receive training in and apply an “experiential approach” to hiring. OPO leadership and frontline staff conduct one-on-one interviews with candidates, during which they pose a typical OPO situation (involving, e.g., a highly stressful case involving the need to manage a complex process or influence a decision without being in a position of authority), and ask how candidates have handled similar situations in their past. Managers reported that this technique reveals the extent to which candidates have the necessary practical experience and style to be successful.
• LifeLink looks for candidates who are aggressive, socially aware and sensitive, collaborative, assertive, and work well in stressful environments. LifeLink has a lengthy “reality” interview process that involves meeting with 2 of LifeLink’s frontline staff, experiencing an actual referral/donation event, and then bringing the candidate back to interview with the executive OPO staff. LifeLink found that it must interview approximately 5 candidates to hire one, and that only one of 3 hires stays longer than one year.

In some instances, OPOs have recruited through their ongoing working relationships. A few OPOs reported having hired staff who had worked as nurses at an area hospital and become familiar with the OPO and organ donation prior to inquiring about a position with the OPO.

Staff need adequate orientation and training. Most of these OPOs provide new hires with extensive orientation, including general sessions and those tailored to specific roles. OPOs noted that, depending on the position, it takes staff between 6 months and 2 years to reach proficiency. OPOs support highly motivated staff by offering continuous training opportunities. Staff reported that exposure to regular training helps them develop and hone their skills, and increases job satisfaction.

• NEOB developed an extensive orientation program with corresponding checklists to document coverage of certain content. New staff receive training on organizational roles and responsibilities, administrative services, and human resource policies. New hires participate in a training curriculum tailored specifically to their respective roles as donation coordinator, family support counselor, or hospital development coordinator. NEOB also requires that staff participate in a quality assurance orientation.
• MTS provides its new hires with a comprehensive 9 month orientation and ongoing staff training thereafter. Orientation includes training on MTS’ various roles in the organ donation process, MTS hospital development structure and services, and the continuous quality improvement process at MTS. MTS immerses new staff members in the organ donation process immediately. For example, new family support staff are called onto every referral during their first 9 months so that they can gain as much exposure to the consent process as possible and learn techniques from different staff members.
• Donor Alliance guides its new hires through an orientation process that includes the observation of many of the events in the organ donation process. For instance, hospital development orientees are required to participate in several tours of relevant sites (transplant centers, regional STATLINE offices) and to observe the referral, approach/ consent, and donor management phases.
• LifeLink found it takes 3 to 6 months of training before a vascular coordinator is ready to act without assistance. Until then, new vascular coordinators accompany experienced ones on every referral call.

OPOs create a professional culture that encourages both collaboration and autonomy. OPO leaders foster collaboration and teamwork, but also give their highly qualified staff opportunities to make independent decisions. Collaboration occurs formally, with supervisors or in team meetings, or informally. Leaders and managers provide direction and encouragement, solicit staff feedback, and solve problems jointly with staff. OPO staff report that managers’ trust in their ability to make autonomous decisions toward achieving organizational goals contributes to job satisfaction.

• NEOB provides staff “room to do their job” by vesting staff with decision-making authority within their respective roles in the organ donation process.
• LifeGift provides its staff with decision-making authority on organ donation matters. For example, a regional director at LifeGift noted that OPO leadership encourages staff “…to find out what works best for our region.”
• Though staff have different roles, UWHC OPO staff work as a team and are held accountable for their results as a team. To contribute to teamwork and camaraderie, UWHC OPO holds social functions outside of the work, and staff members report meeting socially on their own.

Staff members value, and report performing better in, flexible work environments, and appreciate other benefits.

OPOs report providing staff with flexible work environments and other incentives to ensure employee satisfaction. Examples include the following.

• Several OPOs, including MTS, allow their on-call clinical coordinators to be on call from home. MTS implemented this policy in response to requests from clinical staff. MTS clinical staff are required to come into the office only on the days of their standing weekly meetings. In addition, staff make themselves available to cover for their colleagues in the event that one of them needs additional time to recover from a particularly stressful case the night before.
• Besides their employee assistance programs, a few OPOs reported making available certain other forms of support as needed. NEOB gives staff the opportunity to meet with a psychologist once a month individually or in a group, at no cost to staff. LifeGift’s in-house coordinators started their own optional support group during which they can discuss issues that are directly or indirectly related to their jobs. The OPO provides food for these meetings.
• LifeLink has hired a company to benchmark its salaries against the market for similarly qualified staff. LifeLink reports that it pays 100 percent of staff health insurance premiums, and provides a competitive pension plan.
• As noted above, several OPOs, including MTS, LifeLink, LifeGift, and Donor Alliance, provide financial incentives for meeting individual and organizational targets.

Given the physical and emotional stress that can attend organ donation, hospital management also noted the importance of providing nurses who participate in organ donation cases with some relief in their work schedules. For example, one of LifeLink’s hospitals allowed nurses the time to follow their organ donation cases through procurement. To make this possible, unit managers shuffled shifts and fellow staff nurses assumed more responsibilities on the unit. This relief provided nurses with closure at a time of loss and increased the likelihood of their participating in donor cases in the future. This provision also was noted at one of UWHC OPO’s hospitals.

OPOs provide staff with continued opportunities for professional growth and development in an effort to attract and retain qualified staff and minimize turnover. OPOs indicate that the people they tend to hire seek to learn more, improve their qualifications, and increase their opportunities for advancement.

• MTS employees are encouraged to publish their research and give presentations at area hospitals.
• NEOB provides a variety of opportunities and outlets for its staff to conduct research studies, write and publish research papers, and take relevant classes at local universities.
• MTS provided training for its clinical staff in continuing the donor management process into the operating room therefore negating the need for the anesthesiologist during organ recovery. Clinical staff expressed gratitude for the new challenge and professional development opportunity.
• At Donor Alliance, family support coordinators received training in the determination of medical suitability. This training provides the coordinators with the ability to assess brain death status, review medical and social histories, and be more responsive to questions from family members.

Best Practice 4: Appoint members to OPO board who can help achieve organ donation goals.
In all OPO sites, OPO boards or advisory structures were designed to advance the interests of the OPO. Common themes among the boards included a professionally diverse composition and equal representation of organ donation and transplantation interests. Some OPOs use their governing boards strategically to gain hospital and community buy-in to organ donation as, in the words of one OPO leader, a “sacred public trust.”

Some OPO governing boards are comprised to promote collaboration and mitigate conflicts of interest.

• Both NEOB and LifeGift serve a large number of transplant centers and have representatives from each center on their board, in compliance with Federal regulations. Both OPOs chose to maintain fairly large boards that are not dominated by transplant centers, which they report to be highly competitive. As such, these OPO boards include a complement of members from large non-transplant hospitals. Some OPO leaders remarked that having a wider representation on their boards broadens input and tends to balance potential biases.
• MTS strategically appoints top officials from high donor potential hospitals to its board. With this greater interest in the welfare of the OPO, these individuals are more likely to make organ donation an institutional priority, and to respond and take more informed action when barriers to organ donation arise at their hospitals. The board also has a mixture of neurosurgeons, intensivists, a medical examiner, and community representation (including a donor family representative, attorney, and bank executive). Citing the value of continuity, this OPO sets no term limits for its board members.
• Donor Alliance reported that when it replaced its transplant surgeon medical director with a non-transplant surgeon 3 years ago, it broadened board perspectives of OPO operations.
• Community members are recruited to sit on LifeLink’s board. Among its board members is the editor of a leading local newspaper, representatives from such companies as a major bank, a major department store, and a local professional athlete. LifeLink reports that this distribution of board members promotes collaboration, increases community support, and mitigates conflict of interest.

Effective boards organize to reflect their corporate structures and achieve their organizational missions. LifeLink has 3 governing boards, one each for its Foundation, Transplant Institute (a 501(c)(3) subsidiary of the Foundation’s board that focuses primarily on the management of physicians and patient care), and Legacy Fund, which is charged with fundraising for LifeLink. The LifeLink Foundation has 4 OPOs under its management, each with an advisory board that reports to the Foundation’s board. LifeLink makes it clear that it expects board members to be committed to promoting donation in the community. It involves board members in community events and engages them with organ donor families and recipients. LifeLink reports that its board structure (with the Foundation’s board as the primary oversight body) improves its organ donation performance, because it helps to provide LifeLink with community buy-in, resources, and the infrastructure necessary to achieve its goals in multiple regions.

Best Practice 5: Specialize roles to maximize performance.
Alternate staffing models were observed among the 6 OPOs visited. Most of the OPOs adopted a specialized staffing model in which certain personnel are responsible for specific aspects of the organ donation process. One of the OPOs in the sample implemented a general staffing model; LifeGift supports an in-house coordinator model in which one person, a nurse, is responsible for practically all aspects of organ donation and consent. Both approaches were perceived by respondents in the sites where they were implemented as contributors to higher than average performance. The former reportedly reduces staff burnout and turnover, allowing staff to deepen their expertise in one or 2 areas of organ donation. The latter appears to promote the earliest possible referrals from the hospital to the OPO because coordinators are on the hospital premises. In addition, in-house coordinators are resources to hospital staff and potential donor families, even prior to brain death.

While this best practice addresses OPO staff specialization as a contributor to high performance, it is not meant to discount the general staffing model that is effective. Role specialization exists in hospitals. Physicians, nurses, and, often, social workers and chaplains make up a multidisciplinary patient care team, each playing a role in the organ donation process. For example, the family support role is often assumed by social workers, chaplains, or staff nurses prior to brain death declaration.

The majority of OPOs visited attributed part of their higher performance to their specialized OPO staffing models. These staffing models were prompted, in large measure, by the need to reduce staff burnout and turnover. These OPOs moved away from the traditional model of having organ procurement coordinators being responsible for all events in the organ donation process (e.g., response to hospital referrals, family consents, clinical management of donors, recovery and placement of organs) to a model in which designated experts assumed specific roles in the process.

Most OPOs delineated the necessary roles in 3 categories, i.e., persons responsible for: supporting families through the organ donation process, including asking families for consent; developing and maintaining relationships with hospital staff, including identifying champions for organ donation and educating hospital staff; and clinical aspects of organ donation, e.g., donor management, organ recovery, and organ placement. Each category of personnel requires a certain mix of skills. OPO managers expressed largely consistent opinions regarding optimal skills for the various roles, as follows.

1. Clinical coordinator: clinical/technical experience in critical care or trauma settings; experience managing complicated, high stress events; ability to be flexible and work with people. Effective clinical coordinators often come from backgrounds as critical care nurses, emergency medical technicians, physician assistants, and medics.

2. Family support: therapy or counseling experience, highly empathetic and compassionate, ability to connect with people of different backgrounds. Effective family support staff often come from backgrounds in social work, social service, advocacy, mental health or counseling, and pastoral care.

3. Hospital relations: experience in business development or marketing, account management/development experience, sales expertise. Effective hospital relations staff have come from diverse backgrounds, including public relations, pharmaceutical sales, nursing, social work, biological sciences, and other positions in organ procurement.

OPOs reported that role specialization affects organ donation processes in several ways. Job satisfaction and tenure with the OPO increased as staff have more time to specialize and increase proficiency. Two OPO managers noted that the involvement of more highly specialized staff encourages hospital staff to turn to the OPO for expertise in organ donation situations. Several hospital staff confirmed that they trust expert OPO staff to assist them in the care of donors and donor families. Hospital staff expressed that they value working with familiar, experienced OPO staff, as it improves communication between hospital and OPO staff and supports improved organ donation performance. As noted by one OPO manager, role specialization, particularly for family support staff, benefits donors and their families most. Although combining these roles in a single staff position can be successful, separating the clinical care coordinator role from that of the family support role enables both to be devoted to what can be highly demanding tasks. Further, it enables people with appropriate backgrounds (e.g., clinical care and social work, respectively) to adapt and apply these appropriately.

OPOs and hospitals assign staff to specific roles according to professional strengths.

• Many of the OPOs reported having “designated requestors” at their hospitals. OPOs provided specialized designated requestor training to physicians, nurses, social workers, and pastoral care staff in their hospitals to increase their ability to make compassionate and effective organ and tissue requests. In St. Louis, pastoral care staff are the designated requestors for tissue. The hospital staff in UWHC OPO’s service area are the designated requestors for both organs and tissue.
• MTS divided its employees into 3 categories: clinical staff, family support staff, and hospital development staff. While hospital development staff had specific assignments, family support and clinical staff were on call. MTS established further specialized roles for more complex donor cases, such as child donors. MTS sends 2 clinical coordinators instead of one to the hospitals to expedite the organ procurement and placement process; one coordinator manages donors and organ recovery while the other is responsible for placement.
• LifeLink’s “Liaison Program” created 2 roles: the vascular coordinator (analogous to the clinical coordinator and family support roles) and hospital development role. LifeLink had determined that assigning both functions to individual staff persons resulted in their working excessive hours over extended time periods (i.e., before, during, and after donation) and increasing staff burnout. According to LifeLink, the clinical role specialization resulted in improved screening for medical suitability, increased consents, and better clinical management. Upon this staffing change, vascular donors increased from 63 to 96 and bone donors increased from 107 to 138 between 1989 to 1992. Creating the hospital development role resulted in more interactions with hospitals and was associated with a 100 percent improvement in referrals during the same period.
• NEOB assigns a team consisting of a hospital development coordinator, family support counselor, and donation coordinator to each of its high and mid-potential hospitals. This approach allowed each staff person to develop an understanding of hospital dynamics; in addition, staff performance benefited from the team interaction. Staff reported that the team approach provided better coordination across the events in the organ donation process, ongoing support to donor families that freed hospital staff to manage the donor and/or see other patients, and facilitated hospital relationship-building.

The specialized staffing model is often not fully implemented in outlying areas. Most OPOs assign a hospital development person to hospitals in outlying areas and provide on-call clinical coordinators who may also assume the family support role.

Best Practice 6: Tailor or adapt the organ donation process to complementary strengths of OPO and individual hospitals.
The high performing OPOs visited tailor the organ donation process to the complementary strengths of OPOs and individual hospitals. Implicit in this practice is that a “one size fits all” approach is not necessary. Instead, OPOs work with hospitals, leveraging existing hospital resources and capacities to complement OPO strengths to create an integrated approach to organ donation. The particular tailored approach notwithstanding, all are subject to high performance standards, ongoing monitoring, and adaptation to achieve and exceed these standards. Several ways in which OPOs and hospitals have tailored the organ donation process to their complementary strengths are as follows.

OPOs and hospitals develop and adapt their organ donation process by assessing staffing in the context of the roles or functions required for high performance. The organ donation process requires that specific roles, e.g., family support and clinical management of the donor, be carried out effectively. Whether these roles are assumed by OPO staff or hospital staff is less important than whether they are conducted in a manner that optimizes organ procurement in a particular hospital environment. Through the development of their hospital plans and other means, OPOs work with hospital staff to assess how critical care is delivered at each hospital and determine who is best qualified to assume the necessary, complementary roles in the organ donation process. OPOs target their training and education sessions according to hospital staffing models, as well. Examples include the following.

• In many hospitals, the social work department is an essential component of the critical care team. Hospital nurses often page social workers to assist with family care for every trauma case. Recognizing the important role social workers play in the care for the potential donor patient and family, OPOs educate social workers to serve as a referral source of potential donors, if appropriate. Even though some of these OPOs have their own family support staff, the OPO does not assume or usurp the social workers’ role of supporting the family. Instead, OPO staff work with social work and hospital staff to bolster family support.
• UWHC OPO tailors its referral and consent process to capitalize on the strengths of hospital staff. The hospital staff in UWHC OPO’s service area have considerable experience making referrals and obtaining consents from families at consistently high levels. Recognizing this, UWHC OPO does not take the lead in obtaining consent, which is done by nurses and physicians, but serves to support the medical staff during the organ donation and recovery process. The OPO also provides hospital staff with continuing education sessions on requesting and related aspects of organ donation. This approach supports, rather than replaces, the longstanding institutional and professional commitment to organ donation in the UWHC system, and the extensive experience of requesting nurses and physicians with organ donation.

OPOs use plans and data collection to facilitate the tailored approach. OPOs develop hospital plans and profiles to document individual hospital characteristics and tailor hospital development approaches accordingly.

• As required of other OPOs, NEOB develops hospital plans annually for each hospital in its service area. This OPO establishes clear objectives for staff to achieve at each hospital, implements actions pursuant to established objectives, and tracks hospital performance relative to objectives. OPO staff also conduct a strengths, weaknesses, opportunities, and threats (SWOT) analysis of organ donation within its hospitals. Strengths may include organ donation experience of the neuro-intensive care unit (NICU), surgical intensive care unit (SICU), and pediatric intensive care unit (PICU); presence of a routine referral mechanism; strong support from nurse managers; and existing relationships with several committees. Weaknesses may include having less organ donation experience in other hospital units that see fewer potential donors, such as the medical intensive care unit (MICU) and critical care unit (CCU) staff. OPO staff modify their actions according to this analysis.
• LifeLink identifies hospital needs by developing a hospital profile for every hospital in its service area. The profile characterizes each hospital’s system, including the nature of relationships with the medical examiner, EMS staff, and other key agents. The profile lists the recommended names of hospital staff with whom the OPO should work, which serves as a useful resource to new staff in the event of turnover. Staff use and update the profiles in real-time.

Part of the tailored approach is to minimize any burden that the organ donation process places on hospitals. OPOs and hospitals express the importance of minimizing the burden that organ donation can place on hospitals. Hospital staff are more receptive to making referrals and participating in the process when it is apparent that the OPO consistently seeks to accommodate hospitals.

• Several high potential hospitals affiliated with OPOs in the sample reported that organ donation had increased the burden on already busy operating room (OR) staff and space. OPOs took action in different ways. MTS built 2 OPO-site ORs that relieved hospital resources. Other OPOs contracted with independent anesthesiologists and surgeons to assist hospital staff with the procurement of organs, and developed independent contractor relationships with hospital OR nurses to be on call for organ procurement during off-hours.
• Recognizing that donor management is a resource-intensive process, several hospitals noted that the OPO donor management protocols minimize the burden placed on their nursing staff. OPO clinical coordinators direct all aspects of donor management with clear clinical orders and processes. Physician staff affiliated with NEOB remarked that nurses appear to be more willing to participate in donor management cases knowing that the OPO directs the care of the donor, enabling nurses to follow orders. Medical staff perceive OPO staff as being a net benefit to their work. In addition, some nurses emphasized that having qualified NEOB family support staff on-site enabled them to serve other patients and their families.
• OPO staff endeavor to schedule education, training, and debriefing sessions at times and places that are most convenient for hospital staff. OPO staff routinely schedule these sessions at times “when staff will be hungry,” early in the morning or over lunch breaks, and bring more than enough food to serve all attendees. Donor case debriefing sessions are most effective if scheduled soon after the event. OPO managers typically try to schedule these post-donation debriefings on the critical care units to minimize disruption of patient care responsibilities.
• UWHC OPO’s rapid recovery model involves the immediate mobilization of the surgical recovery team to recover organs as quickly as possible, thereby minimizing the burden on hospitals.
• MTS hospital development staff and hospital staff at several affiliated hospitals have implemented a system that both streamlines the death record review process and reduces the burden on hospital staff to pull charts. In this system, hospital staff allow MTS staff to access records on a daily basis before they are filed.

Best Practice 7: Be there: integrate OPO staff into the fabric of high potential hospitals.
All of the OPOs and hospitals emphasized the importance of integrating OPO staff into the institutional fabric of high potential hospitals. As hospital staff become more familiar with OPO staff, they become more cognizant of the organ donation process. Among the benefits of this practice include strengthening and revitalizing the network of relationships upon which organ donation depends, raising awareness of organ donation within the hospital institution, increasing the likelihood of earlier referrals to the OPO, and facilitating real-time problem solving. OPO staff become enmeshed in the fabric of high potential hospitals in such ways as the following.

OPOs dedicate a position or part of a position to hospital development. All of the OPOs visited had departments and staff dedicated to hospital development activities. Their function is to develop and sustain relationships with hospital administration and staff to advance organ donation. Most often, hospital development personnel were assigned to specific hospitals and worked independently or as part of a team of OPO staff. At LifeGift, hospital development responsibilities were assumed by the in-house coordinator. While hospital development responsibilities are shared among all of its staff, UWHC OPO hired one staff position dedicated to hospital development and is looking to hire an additional hospital development staff person to implement a more formal hospital development program.

One OPO shared the impact of instituting a formal hospital development program. LifeLink initiated a liaison program in 1989, creating the hospital development liaison position to focus solely on building relationships in hospitals. As noted above, LifeLink recruits hospital development coordinators from either public relations or marketing backgrounds. LifeLink reports that, during the period 1989 to 1992, the number of visits with hospitals rose from 571 to 3,238 and the number of referrals increased from 379 to 2,154.

Accept OPO staff in hospitals and on intensive care units. In order for OPO staff to work productively in hospital settings, it is essential that they be welcomed and accommodated by hospital staff, as described in the following examples. (Strategies associated with Best Practice 9: All aboard: secure and maintain buy-in, include examples of how OPOs secured hospital buy-in.)

• In Houston, 2 hospitals accommodate LifeGift’s in-house coordinators. Hospital administrators ensure that IHCs have office space and hospital identification badges. On the units, hospital staff willingly give the IHC desk space, phones, and private rooms for family approaches.
• Three Boston hospitals offered NEOB staff office space. One of these hospitals provides office space in its transplant center, while another provides office space in the SICU.
• One hospital in MTS’ service area and all NEOB affiliated hospitals in the sample provide OPO staff with hospital badges.
• Hospitals make their medical records available to OPOs to perform death record reviews.
• Several hospitals invite OPO staff to standing meetings to deliver organ donation education and share data on performance.

OPOs stressed that, while it is important to be integrated into the fabric of the hospital organization, it is still necessary to recognize and respect that OPO staff are guests in hospitals. OPO staff are made aware of the importance of not over-stepping their boundaries as they team with hospital staff in organ donation.

Hospitals remarked that the high visibility and continuity of OPO staff contributed to their organ donation performance. OPOs made a concerted effort to maintain high visibility in hospitals. Some hospital staff reported that OPO staff are so familiar that they are frequently mistaken for hospital staff. Among the means cited for increasing the presence of OPO staff in hospitals are securing office space in hospitals, conducting regular rounds in high potential intensive care units, and participating in standing hospital meetings. Hospital staff remarked that, “They are here all of the time.” and “It’s abnormal when they are not on the scene.” OPOs add further to their presence and organ donation awareness through their services, including conducting education and training sessions, providing educational materials, and conducting and participating in social functions and public awareness events. Specific examples of OPO visibility in hospitals and its effect on performance include the following.

• All 6 OPOs and hospital respondents described the value of making regular rounds. One NEOB hospital development coordinator noted that making rounds to high potential units heightens organ donation awareness among hospital staff and increases staff compliance with organ donation protocols. When nurses see her, “they will automatically look at the white board to see if any patients look like potential organ donors.”
• By design, LifeGift’s in-house coordinators are highly visible within hospitals. They are the most likely OPO personnel to identify potential donor cases early; they raise hospital staff awareness of patients who appear to be progressing toward brain death and may qualify as donors.
• MTS distributes pens, notepads, and mugs with the MTS hotline number on them. These aids are intended to support the MTS presence in the hospital and serve as reminders for staff to contact the OPO when the OPO staff are not present in the hospital.
• LifeLink’s visibility in hospitals is enhanced by its coupling of organ donation with the more frequent eye donation process (such as through use of a shared call-in number). Likewise, Donor Alliance of Denver reported that it uses its close relationship with the Rocky Mountain Eye Bank to keep organ donation at the forefront of the minds of hospital staff.
• At one Denver hospital, a Donor Alliance donation consultant maintains and updates a donation “fact of the week” posted on the trauma services department office door. For instance, during the site visit, the message was about the current enrollment in the Colorado Donor Registry.

Staff continuity also contributes to being part of the hospital fabric. Hospital leadership and staff remarked how easy it is to communicate and work with the OPO staff whom they have known for years. Trust and a professional, sometimes personal, rapport develop between OPO and hospital staff. Staff of one Boston hospital noted that the OPO presence in the hospital is a routine and welcome occurrence, and notice when their OPO liaison is not around.

When turnover occurs, OPOs work hard to enact a smooth transition, so that relationships with hospitals are not jeopardized. For instance, NEOB assigns a team of 3 people to their high potential hospitals not only to ensure adequate coverage but to serve as a hedge against turnover. When OPO staff turnover does occur, the departing team member introduces the new team member to the hospital staff to demonstrate continuity and communicate their verification of the new OPO staff.

OPO staff seek to maximize their availability and accessibility at all times to hospital staff. OPO staff use cell phones, pagers, and beepers to maintain real-time communication with hospital staff. Having office space at hospitals also facilitates a quick response time for hospital staff. Real-time access to OPO staff increases hospital and OPO staff ability to troubleshoot or break down any barriers to donation, thereby increasing organ donation performance, developing trust that OPO staff will respond to any hospital calls, facilitating future referrals to OPOs, and demonstrating OPO dedication and accountability to hospital staff.

Best Practice 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.
Hospitals and OPO staff interviewed almost universally stressed the importance of having organ donation champions at hospitals. The organ donation champion serves as an advocate, a liaison between the OPO and hospital, and a facilitator of the organ donation process in the hospital. Organ donation champions can range from executive to unit-level medical or administrative staff; many hospitals had champions at different levels of staff and departments. Typically, these champions are leaders at their respective levels or units, including hospital managers or chiefs of surgery known throughout their institutions or charge nurses within particular units.

OPO staff, primarily hospital development personnel, identify and support organ donation champions on an ongoing basis. Some champions come into hospitals with a pro-donation stance, having had a personal experience with donation or having always considered donation to be a part of their job. OPO staff formalize and maintain relationships between these individuals. OPO staff cultivate relationships with other champions who may have less experience with the process but come to see organ donation as part of fulfilling the hospital’s mission. Some of the characteristics attributed to champions include: respect among peers, commitment to organ donation, source of leadership, decision-making authority within the institution or a unit, and availability and willingness to resolve barriers to organ donation, especially in real-time. Organ donation champions arise or are designated in various ways, such as the following.

OPOs can invite hospital personnel who are champions to serve on the OPO board. A few OPO leaders strategically select influential, potentially pro-donation hospital personnel to serve on their boards. While these OPO leaders do not necessarily expect a lot of time from board members, they do expect them to be champions for organ donation and accessible to the OPO for immediate as well as longer-term needs for facilitating organ donation. OPO leaders note that they are careful not to abuse access to board members. MTS has a board retreat every 2 years that is used to get members “hooked” onto the OPO’s mission and commit to helping the OPO solve problems. This 2-to-3 day event is held out of town and is open to spouses. The retreat gives the board a chance to bond and offers learning opportunities.

OPOs and other influential leaders can target hospital executives or chiefs of staff as potential champions. OPO leadership or hospital development personnel as well as health care leaders outside of the OPO have played a role in identifying executive-level champions for organ donation within hospitals. While high-level executives may delegate responsibilities, their participation demonstrates to staff an institutional commitment to make organ donation a priority. Some OPO leaders noted that it may be difficult to start at the top in larger, high profile hospital institutions where senior executives are difficult to access. Others preferred high-level physician champions for their credibility among clinical staff.

• In Boston, former Public Health Commissioner Howard Koh met with all of the CEOs of transplant centers in Massachusetts and NEOB in 2000 to promote organ donation as a public health initiative. Commissioner Koh invited each CEO to make organ donation a priority, designate a high-level liaison between NEOB and their institution to facilitate organ donation, and participate in periodic meetings to review each hospital’s organ donation outcomes. All of the hospitals in the sample were participants in the “Koh initiative,” which had the following reported effects.
  • CEOs of all of the hospitals designated high-level champions, e.g., a chief medical officer, vice president, or associate chief nurse, to which NEOB had direct access.
  • One hospital that considered itself pro-donation before the initiative saw an increase in its referral rates in units with lower donor potential.
  • Several hospitals increased monitoring of organ donation performance.
  • In 2 hospitals, high-level champions were able to elevate organ donation to emergency status, permitting access to additional staff resources when needed.
  • High-level champions at 2 hospitals were instrumental in overcoming barriers to approving the donation after cardiac death policy.
• LifeLink developed a relationship with the senior vice president (VP) of patient care services at one of its hospitals. LifeLink noted that the senior VP holds staff accountable for organ donation performance by requesting regular data reports. LifeLink meets with the high-level champion on a regular basis to review and discuss any problems. The champion troubleshoots and facilitates the organ donation process by contacting the managers of the units that tend to miss potential referrals to discuss how to improve performance.
• Leadership at several hospitals considers organ donation as one of the many inviolable rights accorded to patients. This message was emphasized in interviews with a nurse administrator who is willing to bring this to the direct attention of staff who may be interfering with the process.

OPOs identify organ donation champions through the relationships they develop with referring physicians and nurses. OPOs identified and engaged unit-level physicians, surgeons, intensivists, nurse managers, staff nurses, social workers, and chaplains to promote and facilitate the organ donation process.

• MTS identifies high-level physicians, especially trauma surgeons and critical care and neurology intensivists, to be organ donation champions. By engaging these high-level physicians, MTS seeks to influence mid-level physicians/residents, resulting in higher referrals and potential donors. As one MTS manager stated, “If you secure doctors of high stature, it will facilitate mid-level doctor support.”
• LifeGift’s in-house coordinator in one of Houston’s higher potential hospitals identifies staff nurse champions of organ donation. LifeGift cultivates relationships with these nurses, intending to create a trickle-down effect among nursing staff in that more senior nurses teach student nurses about organ donation referral and guidelines. Nurses learn to call the OPO for a potential referral, considering this as “just another consult.” At another hospital, LifeGift staff seek to identify potential champions as a part of meeting with all new hospital staff and conducting one-on-one education.
• Six years ago, Donor Alliance invited a staff nurse from one of its hospital’s surgical intensive care units (who had a personal experience with organ donation) to join its board. Well before her board appointment, she had been instrumental in “creating a milieu where donation is honored and supported” within the hospital. Asserting that organ donation begins in the field, she was instrumental in arranging for the EMS personnel to observe an organ procurement in the OR to raise their awareness of organ donation.
• At one hospital within the Donor Alliance service area, a donor resource team (chaired until recently by the current director of cardiac/critical care service and a former Donor Alliance board member) champions organ donation. In collaboration with a Donor Alliance donation consultant, this team meets regularly to review data, air disputes, and design hospital-wide policies. Members of this team reported that they serve as a “committee of ears,” providing continuity and reducing fragmentation in the hospital.

Identifying and supporting organ donation champions at various hospital levels and engaging them to strengthen the organ donation process and overcome real-time barriers improves organ donation performance. As recommended by a hospital executive, peer-to-peer communication is as a potential strategy for identifying and supporting organ donation champions in hospitals.

Best Practice 9: All aboard: secure and maintain buy-in at all levels of hospital staff and across departments/functions that affect organ donation.
OPO and hospital personnel do not rely on champions alone to achieve high levels of performance. Given the range of participants and functions involved in organ donation, including many that can serve as barriers as well as facilitators of the process, it is necessary to secure and maintain buy-in at all levels of relevant hospital staff and across all relevant hospital departments. Buy-in, i.e., an identification with and commitment to organ donation, supports the integration of organ donation into routine patterns of care. It can be promulgated from the top down as well as across hospital units and departments.

Among the diverse methods for supporting buy-in are the following.

OPOs make their resources known to hospitals. Hospital buy-in is strongly encouraged by offering needed services to hospitals. Resources that OPOs can offer include providing education, awareness events, requestor training, personnel, and technical assistance for policy development and fulfilling regulatory requirements.

• Nurses at hospitals affiliated with NEOB and MTS expressed appreciation for the family support service offered by these OPOs. These nurses noted that the most difficult aspect of organ donor cases is supporting the family because it is emotionally stressful and very time consuming. Aside from relieving them to care for other patients, knowing that the OPO can provide support services to the donor family actually facilitates the nurses’ awareness and support of organ donation in their units.
• OPOs with tissue programs seek out hospital staff to serve as tissue donation requestors. In the hospitals visited, tissue requesting is conducted by nurses, social workers, and chaplains. OPO staff provide formal training and recertification sessions to designated tissue requestors. While these individuals do not usually make requests for organ donation, their training and accomplishments contribute to an increased level of donation awareness within their hospitals.
• Several hospitals, including high donor potential hospitals, remarked that their OPO hospital development contact assists them with writing their organ donation audit reports for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
• Sample hospitals in Denver were able to use OPO data during recent evaluations by the American College of Surgeons for accreditation as a Level I Trauma hospital.

OPOs invest in building the trust and respect of all hospital staff. Many hospitals remarked that they welcome OPO staff, not only because of the skill and services they bring to the process, but because they are trustworthy and mindful of hospital staff responsibilities and needs. Hospital staff observed that OPO staff are mutually committed to the well-being of patients and their families regardless of progression to brain death or the outcome of requests for consent; bring expertise to the organ donation process; follow-through when interacting with hospital staff; and try to solve problems at the source before going to superiors.

• Several hospitals emphasized that nurses trust and respect OPO staff because they are not solely focused on “procuring organs” but on supporting families to come an informed decision that is right for them.
• In the event of a problem, such as a missed referral, LifeLink staff routinely discuss this first with the person responsible before raising it with superiors. This provides staff with an opportunity to explain any extraordinary circumstances that might have prevented the referral and to work with OPO staff to remedy the situation for the future. This approach fosters trust and mutual respect between OPO and hospital staff.
• Staff of one hospital affiliated with LifeLink noted that LifeLink staff attend hospital trauma rounds and provide feedback about placement of organs, and that this interaction helps to develop rapport and trust. This contributes to the willingness of hospital staff to identify and refer potential donors to LifeLink.

OPOs and hospitals secure buy-in by reinforcing the donation message among all levels of hospital staff via donation events, social outings, and other activities.

• MTS invites physicians, residents, and nurses involved in organ donation at their affiliated hospitals to St. Louis Cardinals baseball games, hockey games, annual dinners and other outings to maintain buy-in, strengthen relationships, and recognize high performance. Some of the events are entirely social in nature, while others include formal presentations on aspects of organ donation or new research.
• One hospital in UWHC OPO’s service area hosts an annual donor picnic that is attended by hundreds of individuals in the community. This event, hosted by the hospital (though also attended by OPO staff) raises community awareness and contributes to the strong public buy-in of organ donation. In addition, hospitals in UWHC OPO’s service area also hold annual dinners and other events for donor families.

OPOs consistently show appreciation to hospital staff for their efforts. Shows of appreciation by OPOs range from providing food for staff (done by all OPOs), to hosting dinners, to naming hospital staff in newsletters and other notices about organ donation activity. Once a year, MTS hospital development staff visit high-referring ICUs with dinner and provide an update on organ donation performance. To show its appreciation for a physician’s timely response to a request to perform a key test during the middle of the night, MTS sent the physician a box of his favorite cigars with a personal note of thanks.

Some OPOs and hospitals jointly celebrate successes and communicate them internally or externally, fostering support for organ donation. Some OPOs present organ donation successes in reports to hospitals or via a formal plaque or certificate. OPOs and hospitals engage local media to increase awareness within the community and within hospitals of successful transplantations. While transplant centers appeared to consistently promote their successes within the community, some hospitals were more willing than others to disseminate their organ donation successes outside of individual hospital units.

• OPO staff provide plaques and other awards to individual hospital units in a few hospitals affiliated with LifeLink and Donor Alliance. These forms of recognition serve not only to recognize the unit’s success and dedication to organ donation, but as another reminder to refer potential donors.
• Several high potential hospitals of many OPOs publish organ donation stories in their hospital newsletters, highlighting recent organ donation successes.
• UWHC OPO decorates a “memorial” wall with names of donors and recipients for public viewing.
• Local media published a story of a successful organ transplantation that, according to medical staff at an NEOB-affiliated hospital, promoted organ donation within the hospital and throughout the greater community.

Best Practice 10: Educate constantly; tailor and accommodate education to staff needs, requests, and constraints.
While not the first thing that OPO staff mentioned as the reason for their successful organ donation performance, most hospitals noted the important role that repeated education plays in maintaining or increasing organ donation consent and conversion rates. Among its many benefits, education:

• Increases familiarity of hospital staff with the organ donation process and the benefits of organ donation. “Education gets and keeps donation on staff radar screens;”
• Helps to eliminate myths or misconceptions about organ and tissue donation that may prevent staff from participating in a donor case;
• Informs hospital staff of their important role in the organ donation process, including consistently identifying and referring potential donors to the OPO as soon as possible, communicating the potential donor’s clinical status to families, and supporting donor management and procurement;
• Lowers barriers to the organ donation process;
• Assists staff with compliance with Federal regulations that require hospitals to report all deaths to the OPO, ensure that only trained requestors approach families, and provide OPOs with access to conduct death record reviews. (In the case of the 3 OPOs in the sample that oversee tissue donation, OPOs train hospital staff to be designated tissue requestors.)

Educational interactions addressed 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, among others. As noted by LifeLink, the goals of brain death education for nurses and doctors include increasing nursing staff awareness of the signs of pending brain death and improving medical staff ability to communicate brain death status to potential donor families so that messages are consistent and clear.

OPOs and hospitals target education to referring staff to raise awareness and solve problems. OPOs and hospital nurse managers noted that they target education to appropriate audiences, such as hospital staff working in the units that see potential donors (e.g., NICU, SICU, CCU, and MICU). ICU staff are most likely to encounter potential donors, and targeting education to this group affects referral rates and facilitates problem identification and solving, according to OPO and hospital staff. Instances of this type of education are the following.

• MTS specifically targets education to referring physicians, raising their awareness of organ donation and likelihood of calling MTS in the event of a potential donor.
• At one of its hospitals, NEOB offered more education sessions to the medical ICU staff than staff in other critical care units because this group was less experienced with organ donation.
• LifeLink learned that declaring brain death was a rate-limiting step in the referral process. In addition, the medical staff did not clearly convey to potential donor families the status of patients. To facilitate organ donation, LifeLink developed a brain death curriculum for nurses and physicians.

Hospitals seek education on a regular basis and in multiple ways. Repeated education is needed to maintain awareness and proficiency amidst staff turnover in hospitals and rotating resident staff in teaching institutions. In addition, organ donation is an infrequent event in hospitals; therefore, repeated education is needed to remind staff of policies and procedures and roles to maintain awareness of organ donation. OPOs deliver education in multiple ways: group sessions, one-on-one informal discussions, manuals, rounds, newsletters, letters, social settings, among others. OPOs and hospitals commented that multiple means of education facilitate learning and interest in organ donation efforts.

• Most OPOs hold monthly (and/or other periodic) in-service training sessions for hospital staff at their high potential hospitals. In-services for the SICU residents at one of NEOB’s hospitals are scheduled for the first Thursday of every month so staff can plan in advance to attend.
• The majority of hospitals invite OPOs to conduct a session on organ donation in their new staff orientations for nurses. In addition, several hospitals pair new nurses with preceptors to educate them about organ donation. MTS provides quarterly presentations for new hires. At one of the hospitals in UWHC OPO’s service area, organ donation appears on the new staff orientation checklist as a matter that must be reviewed with new hires. NEOB and Donor Alliance hospitals incorporated organ donation into some of their hospitals’ critical care nurse orientation programs.
• The biennial symposium on organ donation and transplantation hosted by UWHC OPO provides a 2 day program of educational sessions for health providers, addressing key issues including the challenges and trends of the consent process, and current advances in the field of transplantation. Over the last 10 years, hundreds of health care providers in UWHC OPO’s service area have attended and hospital staff have commented that the symposium has a great impact on raising nursing staff awareness.
• A high potential hospital in NEOB’s service area simulated an organ donation case during one of its rounds to educate staff about the donation and transplantation process. Increased familiarity among hospital staff reportedly improves organ donation performance. The same hospital plans to simulate another case related to donation after cardiac death.

OPOs provide incentives to participate in educational sessions in hospitals. Incentives offered by OPOs range from providing meals to continuing education units to grants. Coupling education with incentives results in higher attendance and enthusiasm to participate.

• Hospital staff consistently remarked about the food OPOs provided during in-services and other interactions. NEOB provides food at grand rounds at one of its hospitals when making an organ donation presentation. In Denver, departments take turns putting in their requests for “theme meals” that are provided by Donor Alliance staff at their regular presentations. MTS staff cater to specific food preferences of hospital staff to show them that the OPO appreciates their efforts in identifying and maintaining donors.
• LifeLink works with one of its hospitals to incorporate organ donation into the hospital’s continuing education seminars, for which staff receive class contact hours.
• UWHC OPO provides educational grants to nurses for receiving further training in organ donation by attending seminars, workshops, courses, and the Transplant Games, i.e., the “Olympics” for transplant recipients.

OPOs tailor education to accommodate hospital staff’s schedules, preferences, and needs. OPOs seek to smoothly integrate education into the hospital environment with minimal intrusion. All OPOs mentioned that they conduct educational sessions at times that are convenient for hospital staff.

• LifeLink determined that, contrary to agreed-upon procedures, physicians at one of its high potential hospitals were still approaching families about organ donation and making requests for consent. LifeLink increased its education in this hospital to reinforce understanding that OPO requests lead to better donation outcomes.
• Because hospital staff members are increasingly accustomed to evidence-based practice, LifeGift tailors its teaching and in-service approach to include data and graphics to support practice.
• LifeLink recruits a high-level physician, preferably a neurologist, to deliver its brain death education lecture during the hospital’s new house staff orientation session.

Best Practice 11: Design, implement, and monitor public education and outreach efforts to achieve informed consent and other donation goals.
OPO staff described a range of education and outreach efforts, as well as a range of opinions regarding their effectiveness. While most OPO leaders expressed confidence in the utility of these efforts, some indicated that they have detected no cause and effect relationship between these efforts and organ donation performance, and therefore have diminished them. Most OPO leaders concur that education and outreach efforts should be monitored for their impact on organ donation, and revised accordingly.

OPO public education and outreach efforts focus on increasing community awareness of organ donation and transplantation, with the ultimate goal of increasing organ donation. Some OPO and hospital staff believe that prior education about organ donation has helped to attain higher consent rates. These staff note that, given the difficulty of making decisions under tragic circumstances, families may be more likely to decline donation if it is the first time they are exposed to the concept. Staff report that increasing organ donation awareness within the community prompts families to have conversations about organ donation. This may have a positive impact on the willingness of families to consent to donate and even to raise the topic before hospital or OPO staff would raise it.

OPOs reported a variety of venues through which they deliver public education and outreach messages, including television, radio, and newspaper ads, mailings and newsletters, as well as at schools, civic clubs, and other community locations. In many of their public outreach campaigns, OPOs highlight the personal impact of organ donation by inviting transplant recipients and donor families to describe the benefits of organ donation. Some transplant centers reported investing in public education efforts, such as celebrating transplantation successes or promoting living donor programs.

In the limited sample, hospital staff tended to indicate more often than OPO staff that public education contributed to higher performance. Most OPO leaders reported investing minimal resources in this area since it was difficult to measure the impact on improved consent rates or other donation outcomes. OPOs that do invest any substantial resources in public education and awareness tend to focus these on specific areas with proven or highly likely success. They described public education as a best practice only when it had a specific purpose and yielded measurable increases in consent rates. The following strategies were reported by OPOs and hospitals as yielding higher performance.

OPOs in States with registries promote them.

• MTS invests resources to promote its State organ donor registry. Also, MTS reports some benefits for informed decision-making by families by sharing registry information with families when it is available for potential donors. In June 2002, MTS communication center staff began sharing registry information with hospital staff in real time. In the first 7 months of operation, there was a 30 percent decrease in the number of families declining donation; 52 families presented with registry information were positively influenced by it, resulting in 43 donors. MTS also printed the State donor registry form in the St. Louis Post-Dispatch, resulting in enrollment of 627 people on the donor registry.
• Similar to MTS, Donor Alliance also values its investment in promoting the State organ donor registry. The registry lists everyone who has indicated their wish to be an organ and tissue donor through the DMV on their driver’s license or identification card. It also helps to ensure that a person’s wish to be a donor is known since, in many cases, a license or State identification card is not available at the time of death. Staff reported many instances in which family members showed relief upon learning that their loved one was on the registry, removing the need for one more family decision during a time of stress. Donor Alliance promotes the registry through various media, including radio and television commercials, print ads and posters on buses, and tracks the campaign’s effectiveness by monitoring web site activity. In January and February of 2003, more than 35,000 people visited the registry web site and received information about organ and tissue donation.

Some OPO and hospital staff believe that increased awareness and advanced discussions of organ donation contribute to increased consent rates.

• UWHC OPO and its hospital staff reported raising awareness in the community by promoting advanced directives at community civic club presentations. At these presentations, OPO and hospital staff distributed “Share Your Decision, Share your Life” packets from Rotary International to attendees. These packets include organ donation commitment forms and tools to communicate organ/tissue donation preferences to local hospitals, family members, and friends. Hospital staff reported that these interactions and materials about advance directives make organ donation decisions easier for families and have contributed to higher consent rates.
• Some hospitals in UWHC OPO’s service area conduct advance care planning with patients and families upon admission to the hospital. Hospital personnel proceed through a form of “end of life decisions,” which includes questions regarding organ donation and preferences regarding which organs and tissues may be donated. The form becomes a part of the patient’s medical record, making the decision about organ donation easier for families. While not every patient who enters the hospital completes this form (trauma cases typically do not), hospital staff reported a greater likelihood that a family member has been exposed to the subject of organ donation after having gone through the process of completing the form for another person. Hospital staff reported that this leads to more families raising the subject of organ donation to hospital staff.

Some OPO staff suggest that the degree to which public education and outreach affect organ donation consent rates varies by community. They note that community characteristics such as population size, racial and ethnic make-up, income level, education level, and other factors may affect the impact of public education and awareness on achieving increased consent rates.

Some OPOs target public outreach efforts to specific ethnic groups.

• Upon analyzing regional and national data, OPOs observe ethnic differences in organ donation behavior. In an effort to realize some of the untapped potential in certain groups, LifeLink uses materials developed by the Coalition on Donation that are written in different languages to target these ethnic groups. In addition, billboards are reported to have been particularly successful in Puerto Rico.
• LifeGift worked to enhance its community partnerships through the African-American Clergy Outreach Program. This program sought to garner support for organ donation by spreading the word through church leaders.
• In the past year, Donor Alliance targeted the African-American community through a series of television and radio commercials. It also tailored messages to the Hispanic community by developing a brochure written in Spanish that was distributed at Cinco de Mayo events.

Never lose an opportunity to make a positive, lasting, and communicable impression on donor families and others in the community.

In contrast to the lack of agreement regarding broad public awareness campaigns, all OPOs and hospitals concurred that actual donation experiences present important opportunities to inform families and, indirectly, their networks of contacts, about the benefits of donation. Some hospital staff noted the importance of making the organ donation experience a positive one for donor families. Donor families share their organ donation experiences with their communities and can thus influence the community’s perception of organ donation. Some hospital staff reported that the awareness generated by donor families’ positive experiences with organ donation at their hospitals leads to increased consent rates.

• Some hospital OR staff in Wisconsin reported that they make an extra effort to interact with each donor family after their loved one’s organs have been procured, assuring them that the donor was treated with dignity and respect during the procurement process. OR staff noted the importance of this communication with the donor family, since it may be the last impression with which they leave the hospital and can significantly affect their perception of organ donation and how they share their experience with the community.
• As noted in more detail below, OPOs provide certain anonymous follow-up information and expressions of gratitude to donor families regarding the placement of their loved ones’ organs.

Best Practice 12: Referral: anticipate, don’t hesitate, call early, even when in doubt.
One of the most important messages that OPOs convey in education sessions and via regular contacts with hospital staff is to call in referrals as early as possible to facilitate consent and organ recovery. Among the hospitals visited, there was a common willingness to make early referrals to the OPO and to consult its experts regarding potential donations. OPO personnel have cultivated this inclination by teaching the early signs of brain death and emphasizing the importance of not waiting until brain death declaration to place a call to the OPO. Instead, OPOs encouraged hospital personnel to anticipate the event and recognize the signs and symptoms of a patient who appears to be on the pathway toward brain death.

This practice of early referral has penetrated into emergency room settings, where one physician remarked that he is “already thinking about organ donation” upon the arrival of certain types of patients. At another hospital, the awareness of the potential for brain death in certain patients and consideration of calling the OPO has extended to EMS technicians in the field, who recounted how they provided life support to a patient whom they knew had virtually no chance of survival, but who appeared to be a potential organ donor. As a result of experience as well as ongoing education by OPOs, intensive and critical care and trauma staff expressed such messages as “Call early, even when in doubt,” “The sooner the better,” “Better safe than sorry,” and “Consult the experts (i.e., OPO) when in doubt.”

One means that OPO and hospital staff use for delivering the message of early referrals is to teach hospital staff certain “clinical triggers.”

• Brain death identification is a crucial juncture in the critical pathway of organ donation. Recognizing the importance of determining brain death in a timely manner, LifeLink developed a brain death curriculum for nurses and physicians and provides it as a service to its affiliated hospitals.
• Many hospital personnel rely on clinical triggers, e.g., neural insult, Glasgow Coma Scale (GCS) of less than 4 or 5, and patient on a ventilator.
• LifeGift’s in-house coordinators routinely distribute pen lights as a reminder to call LifeGift when pupils are fully dilated.
• One Florida physician now notifies LifeLink after the first brain death test. Prior to brain death education by the OPO, this physician would wait until after the second brain death test to make the referral.

OPOs work to dispel the many myths surrounding organ donation. Even though a call has been placed to the OPO, treatment and care for the patient are not compromised. OPO staff do not “hover” waiting for organs but do discretely monitor the patient’s condition. In most instances, no OPO staff approach families until brain death has been declared and an appropriate introduction of the subject has been made. For example, NEOB stresses to hospital staff that when a referral is made, NEOB interaction with hospital staff is limited to reviewing the chart to see if the patient is a possible candidate for donation. If the patient is not a candidate, NEOB thanks hospital staff for the referral. If the patient is a candidate, NEOB works with hospital staff and will approach only when medical staff permits. Some hospital staff reportedly became more at ease making referrals to OPOs after learning about how the body is treated during donation and that open casket funerals are still options for families.

Some hospitals have found that it is helpful to have a “go to” person who is knowledgeable about donation in the unit, and new staff can easily consult with this person when they are unsure or uneasy about making a referral. This “go to” person is often a nurse and has sometimes been identified by OPO staff as an organ donation champion. Aside from their commitment to and experience with organ donation, such nurses already may be involved in providing end of life care of which organ donation is a part. One hospital identifies these nurse champions and assigns only these nurses to potential donor cases. The relationship between physicians and nurses can influence the timeliness of referral. In some hospitals, nurses are responsible for making referrals, while in others, the decision to place the initial call is more likely to rest in the physician’s hands.

UWHC and LifeLink are among the OPOs that involve executive staff members on all referrals. OPO coordinators view this involvement as an added support, while hospitals appreciate the capacity for real-time troubleshooting to facilitate the organ donation process.

Even when referred patients do not progress to brain death or otherwise do not qualify for organ donation, OPO response to a referral is always positive, never punitive.

• UWHC OPO experienced several cases where hospital staff did not call because the patient’s heart might not be suitable, even though the other organs were. The OPO addressed these types of issues in their training, especially among new staff unfamiliar with organ donation.
• Some nurses in UWHC OPO’s service area hospitals reported that they frequently call the OPO to notify them that there might be a potential donor; this helps them determine early on whether or not the patient is even a candidate for donation.
• Nurses who had prior experiences with Donor Alliance expressed an eagerness to “get them (the OPO) involved as early as possible,” and welcomed their expertise in clinical case management.
• Staff at hospitals within LifeLink’s service area remarked that “There is no such thing as a bad referral” and “There is no downside to calling” the OPO.
• In one SICU within NEOB’s service area, medical staff noted that everyone in the unit is able and willing to call NEOB, even when in doubt. They attributed this to NEOB’s constant feedback and positive reinforcement for making the call. NEOB always thanks staff for making a referral regardless of patient’s medical suitability.

Hospitals perceived the early call as relieving the burden of making decisions about a patient’s medical suitability. The call also triggers the arrival of additional staff resources at the hospital, which can relieve some burden of patient care, family care, and ultimately donor management. Other positive outcomes attributable to an early referral included more time for the OPO to establish a relationship with the family and hospital staff, and more time for monitoring the patient for medical suitability.

Best Practice 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.
Obtaining consent can be an intricate process that is highly dependent on the cooperation and skills of OPO staff, physicians, nurses, pastoral care staff, and social workers. The roles in the consent process are largely consistent across high performing sites; however, they may be carried out by different combinations of staff. Interacting with a potential donor family to achieve an informed consent to organ donation usually entails a particular sequence of time-sensitive events and carefully conveyed communications, all within a context of trust. The staff that are involved in managing these events and communications vary among OPOs and their affiliated hospitals. Of course, those involved in the consent process must be able to adapt to a range of circumstances and dynamics, including situations in which families raise the issue of donation themselves prior to OPO or hospital staff.

OPOs and hospitals start early to understand family dynamics, monitor status, and support family needs. The organ donation process is highly time-sensitive. After brain death is declared, there is only a small window of time to secure consent. OPO and hospital staff involved in the consent process reported the importance of “setting the stage” for consent well ahead of the declaration of brain death or withdrawal of support (in the cases of non-heart-beating donors). OPO and hospital staff emphasized the importance of establishing a strong relationship with the donor family and earning and maintaining their trust in achieving informed consent to donate. Though OPOs had slightly different approaches to connecting with donor families, all approaches involved becoming familiar with family dynamics and establishing a relationship with the key family decision-makers.

Staff involved in the consent process establish relationships with families and earn their trust by providing them support throughout their time in the hospital. Family support involves, for example, being present during physician conversations, helping families understand the clinical aspects of their loved one’s condition, bringing the family food and blankets, listening to their stories, and helping them with funeral planning and other logistical matters. OPO staff, physicians, and nurses concur that providing this type of family support is essential for securing family trust and increasing the likelihood of their giving consent to donate.

Physician attitudes and actions early in the treatment of a patient are extremely important in establishing the trust of a family. All interviewees noted the importance of ensuring that the potential donor family knows that the medical staff has done everything possible to save their loved one’s life and provide for their comfort as much as possible. Examples of how OPOs and hospitals conduct this process include the following.

• Some hospitals reported that assigning experienced organ donation nurse champions to potential donor patients helps to secure the family’s trust and set the stage for obtaining consent. Nurses who are knowledgeable about donation and who are skilled and experienced in working with families can lay the foundation for the request, whether by themselves or other staff. Some hospitals reported not assigning nurses who were not strongly supportive of donation to potential donors so as not to put them in an uncomfortable situation that might also jeopardize the opportunity for a consent.
• Most OPO family support staff reported the importance of gaining early information from nursing staff, social workers, and/or pastoral care staff regarding the family dynamics of potential donors. Due in part to OPO education, hospital staff reported paying special attention to family dynamics and relaying this information to OPO requestors or keeping it in mind when approaching families themselves for consent. This type of “surveillance” information was reported to be extremely useful in tailoring approaches to families for consent.
• One pediatric intensivist in Colorado explained how he serves as the bridge to organ donation when there is no hope for the patient’s survival. It is this physician’s preference to introduce the subject of organ donation to the family and then introduce OPO staff. He believes that the family’s trust in him will positively influence the organ donation process.
• In St. Louis, it was reported that families establish closer bonds with intensivists who tend to spend more time with the patients than neurosurgeons. The intensivists prepare the families for the pending brain deaths of their loved ones.
• All OPO staff and hospital staff involved in the consent process noted the importance of supporting the family throughout their experience, regardless of their decision to donate. If a family is not able to donate for a specific reason, they still can share the perceptions of the OPO and the organ donation process with their community. Therefore, it is important to make this experience a positive one for them regardless of their decision.

OPOs work as a team with hospital staff to determine the right person(s) to raise donation and make the request. All interviewees involved in the consent process noted the importance of the OPO and hospital staff working as a team when preparing families for the prospect of organ donation and making the actual request. OPO and hospital staff noted the importance of working collaboratively in front of donor families in securing their trust.

Interviewees concurred that the requestor should be an individual with the strongest connection or bond with the family, whether it be an OPO family support staff member, physician, nurse, chaplain, social worker or other person that has a relationship with the family. In addition, this must be a person who is highly familiar with organ donation and has a history of achieving families’ consent to donate. Four of the 6 OPOs visited have dedicated family support staff who are the preferred requestors, based largely on their demonstrated ability to achieve high consent rates. Although OPO family support personnel make the request in many of the sites visited, hospital personnel often are the first to raise the topic of organ donation to the family and then introduce the OPO family support person who proceeds with the consent process.

In several instances, the family support and requestor role is taken on by hospital staff, including by attending physicians (especially intensivists), nurses, chaplains, and others. In other cases, OPO staff, nurses, and chaplains approached families as a team when they judged that this approach would be beneficial in securing a consent. Some OPO and hospital staff reported taking the donor family’s race or ethnicity and language into account when deciding who should make the request. Most staff who offered an opinion on this matter concurred that bilingual requestors are preferred (or that a trusted staff person who speaks the same language be present) when English is not the first language, even when family members speak English as a second language. Several OPOs in urban areas noted that matching same race requestors was beneficial within the African-American population. However, other OPO and hospital staff reported this to be less important for securing consent. As noted above, while the individuals making the request were different from site to site, they were consistently the ones who had established the strongest rapport with the family.

The following represent some strategies used by OPOs and hospitals for determining who should request.

• LifeGift, LifeLink, and NEOB reported higher consent rates when OPO family support staff were the requestors. Hospital staff in their service areas came to concur with this, and generally comply with instructions to defer the request to the OPO staff.
• MTS has found that higher consent rates are achieved when MTS family support staff make the request. However, requests are occasionally made by physicians (especially intensivists) when the opportunity arises. The subject is generally introduced by the physician after the first brain death exam. Nurses, pastoral care staff, and MTS family support staff are usually present at this declaration. The physician usually then defers to the OPO to discuss organ donation further with families. Using a team approach, MTS family support staff work together with the nurses, doctors, chaplains, and social workers. Pastoral care staff are certified requestors and are the official requestors for tissue donation.
• Hospital staff in UWHC OPO’s service area are responsible for obtaining consent. The OPO provides training and certification for certain individuals at hospitals to become designated requestors. These individuals usually are key referring physicians, ICU and trauma nurses, pastoral care staff, or social workers. They often work together when approaching families. Every hospital in the service area has a slightly different arrangement regarding designated requestors. For UWHC OPO’s hospitals, the person with the strongest bond with families is usually an ICU staff nurse. Often, the physician raises the subject after announcing the results of the first brain death exam, or asks the nurse to mention it to the family. OPO and hospital staff report that physicians are also successful requestors in this community, and that there is no perceived conflict of interest in the roles of doing the best to save patients’ lives and then inquiring about donation. Staff emphasize that families welcome an opportunity to realize some good from their loss, and that they trust these hospital staff members to help make this transition.
• Donor Alliance has 2 bilingual family support personnel. Staff there emphasized how the ability to communicate with the family in their language facilitated and expedited establishing a trusting relationship.
• MTS found matching same race requestors for African-American families to be extremely successful. For MTS, this practice caused their consent rate in this population to increase from 19 to 50 percent over 10 years.

It is critical to ask at the right time. Timing is critical to securing consent. Interviewees noted the importance of addressing all of the family’s needs and establishing the family’s trust before any discussion of donation. They also emphasized the importance of not rushing a family through their grief; this may include maintaining care for the patient in a manner that allows the family needed time with their loved one. Interviewees noted that inquiring about donation too early could be damaging and lead families to decline donation.

Three of the 6 OPO sites reported decoupling of discussions of brain death and organ donation. Half of the OPOs did not view this decoupling of messages as necessary. One OPO cited recent research on the topic; another OPO noted that decoupling is a preferred policy but not mandatory. The requestors at these sites attempt to prepare the family as early as possible as appropriate for potential brain death and the possibility of organ donation, in case the need for these discussions arise.

In some cases involving the prolonged demise of a patient, OPO or hospital staff have considered it appropriate to raise the subject of donation even before the results of the first brain death exam, since the family has had more time to face the seriousness of their loved one’s condition. There was no general consensus on this approach and it seemed to often depend on physician preferences and the specific family or other circumstances. However, decoupling was consistently reported for cases of donation after cardiac death (DCD). Decoupling of withdrawal of care and organ donation discussion for cases of DCD was viewed as essential by all OPO and hospital staff. Some of the strategies used by OPOs include the following.

• MTS family support staff and other hospital requestors generally do not discuss donation until the family understands the clinical aspects of their loved one’s condition. MTS usually waits until after the physician has announced the results of the first brain death exam and after the family has had time to deal with the news before bringing up the subject of organ donation. MTS has found that routine decoupling of messages is not necessary; instead, they seek to determine when the family appears to be prepared to consider donation.
• In Wisconsin, designated requestors reported pursuing donation when they see an opportunity to raise it. While it is typically brought up after the results of the first brain death exam, some nurses use their judgment to gauge the situation and may bring up the topic before the first brain death exam. OPO and hospital staff in this and other service areas reported that families increasingly are raising the subject of donation prior to hospital staff.

Requesters are trained to ask in the right way. All OPOs reported some type of mandatory training for requestors. This includes careful consideration of the timing of the request, usually once a family accepts the declaration of brain death or decision to withdraw care. OPO requestors reported that it is important to frame the discussion in terms of presenting them with the information and “giving them the opportunity to donate” rather than forcing a “yes” or “no” answer.

Requestors noted that it is necessary to approach the family in a caring, compassionate, and understanding manner. They should never underestimate how difficult a decision this is for families. Requestors must first help families perceive the actual physiological state of their loved one. Organ donation should be discussed very carefully, taking the family’s feelings and emotional state into account as well as family dynamics and other factors. Some requestors reported presenting the donation request as a personal story, giving examples of transplant recipients or asking families what they think their loved one would have wanted. Requestors must also be able to provide the family with information about the donation process. Requestors also need to support the family throughout the entire decision-making process.

• All OPOs reported providing training programs for individuals who wish to be designated requestors. Training involves role-playing so that requestors will have the opportunity to practice choosing their words, demeanor, etc.
• Requestors must be mindful of matters of culture, race, ethnicity, language, and religion. Chaplains at one hospital affiliated with MTS produce information packets on religious aspects of donation to answer potential donor families’ concerns.

Reapproach if needed. All interviewees involved in obtaining consent cited the appropriateness of reapproaching families under certain circumstances.

• MTS only reapproaches if there is a reason to think that it will make a difference. If the family seems to be basing its decision not to donate on inaccurate information or assumptions or unfounded fears, MTS family support staff try to address these matters, and then reapproach. If the family appears to need more time to grieve before facing the prospect of donation, staff will reapproach after an appropriate interval. However, if the family is adamantly against donation for specific personal or other reasons, then MTS will not reapproach.
• UWHC OPO only reapproaches if staff believe the family is basing its decision not to donate on inaccurate information. For example, some families believe, inaccurately, that the organ procurement is done without respect or regard for the integrity of the body, and that it will not be possible to have an open casket at the funeral.
• LifeLink staff reapproach families if the first response is negative, to ensure that the family based its decision on the correct information. If a family’s decision not to donate appears to be based on incorrect assumptions or myths about donation, LifeLink will reapproach the family with appropriate information to support a more informed decision.

OPO and hospital staff should be prepared to adapt to particular family needs or requests to facilitate organ donation.

• In one case, the mother of a potential donor would only agree to donation if she could be present in the operating room during the organ procurement. Although this was contrary to usual hospital policy, OPO and hospital staff arranged to allow this, resulting in obtaining a consent that they would not have gotten otherwise.
• In another case, an OPO and its affiliated hospital obtained permission from the hospital’s legal department to perform a DCD donation without a formally accepted policy (the policy was in draft form) to accommodate a family’s wish to donate their loved one’s organs.

Best Practice 14: Use data to drive decision-making.
All of the OPOs and most hospitals cited the importance of data-driven decision-making to improve organ donation and focus their resources appropriately. By regularly collecting and reviewing data on the organ donation process and performance, including conducting surveys at hospitals to identify areas of improvement, OPOs and hospitals enhance their decision-making and strategic planning. Using data to inform decisions helps OPOs and hospitals to maximize referrals, consents, and donors in their service areas. Approaches to data-driven decision-making were quite consistent across the sample.

OPOs conduct regular death record reviews (DRR) in all hospitals to identify those with the highest donor potential and determine ways to increase donations. All of the OPOs reported conducting regular reviews of all death records in order to identify the hospitals in their service areas with greatest donor potential. Some OPOs reported conducting DRR on a monthly basis, while others did so daily.

Most of the OPOs noted that they use regular DRR to investigate how to expand donations through identification of missed referrals. OPOs compare all referrals received to all reported hospital deaths to ensure that all potential donors are identified. Data on missed referrals are collected and used to inform referral education sessions for hospital staff.

OPOs focus more resources on hospitals with the highest donor potential. OPOs reported using DRR data to categorize their hospitals into different groups or “tiers” based on their organ donation potential, which they use to determine where to focus their resources. All OPOs reported using this “tiered” approach under the presumption of an “80/20 rule,” i.e., that 80 percent of their donor potential exists in 20 percent of the hospitals in their service areas. Most OPOs reported focusing their resources, including staff, education sessions, and outreach and relationship-building efforts, on their high donor potential hospitals. For example, MTS focuses most of its resources on the top 12 (out of 112) hospitals that account for 60 percent of its donor potential. MTS hospital development staff are allocated equally among these 12 hospitals so that each staff member can focus time and effort on one high donor potential hospital.

OPOs regularly collect, monitor, and share referral, consent, and other organ donation data to improve organ donation performance. Most OPOs reported producing hospital-level reports to influence improved organ donation performance at hospitals. OPOs tailor these reports to individual hospital preferences to facilitate hospital quality improvement. OPOs also review data trends by hospital to compliment successes and suggest areas for improvement. OPOs that also run tissue programs reported both organ and tissue donation outcomes to hospitals.

• Some hospital respondents reported “friendly competition” among transplant centers and hospitals as a motivator to improve organ donation performance. In one Boston hospital, OPO liaisons provided data by critical care unit, which hospital staff posted to foster friendly competition. Similarly, MTS publishes hospital-level data in its Request Line newsletter, enabling nursing staff to compare referral and donation statistics among competing hospitals. Nurses reported that this sense of competition led to improvements in referrals and consents.
• LifeLink provides monthly organ donation data reports to the hospitals visited. Nursing directors, striving for 100 percent referral rates, review these data reports regularly. If they identify missed referrals, they follow up with the nurse who missed the referral, as required by one of the hospital’s senior administrators.
• When reviewing their organ and tissue donation data, administrators at one UWHC OPO-affiliated hospital noticed that while their performance in organ donation was above average, their tissue donation performance was poor. They conducted an informal survey at their hospital to determine the cause of their poor tissue donation performance and found that it was due to a lack of education among physicians and nurses regarding identifying potential tissue donors. Therefore, they instituted more training for their physicians and nurses in order to increase their performance in this area.

Some OPOs survey hospital staff to identify areas for improvement. About half of the OPOs noted the importance of surveying hospital physicians and nurses in order to identify areas requiring change to improve performance. For example, MTS hired an independent firm to conduct a formal customer satisfaction survey of physicians and nurses in hospitals every few years to identify areas for improvement. In the survey, hospital staff identified many areas for improvement, including: increasing public awareness, respecting the physician-patient family relationship, timely assessment of donor suitability and medical management, the request process, emotional aspects of dealing with families and tragic deaths, personal visits by MTS coordinators, feedback on outcomes, communication with physicians, protocols for DCD, updates and training, and successful harvest of organs suitable for transplant. MTS staff used these survey results and recommendations to alter and improve services to its hospitals.

Best Practice 15: Follow up in a timely and systematic manner. Don’t let any issues fester.
All of the OPOs and hospitals reported the importance of conducting timely internal and external review of cases. OPO staff reported that follow-up usually involved giving positive, constructive feedback as well as identifying and solving problems in the donation process. OPO staff, physicians, and nurses affirmed that timely and systematic feedback was crucial to increasing awareness and improving organ donation processes at hospitals, thereby maximizing the number of early referrals and actual donors at hospitals. Immediate problem solving was another contributor to success. Several respondents noted 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. OPOs and hospitals conduct follow-up both formally and informally, using a variety of techniques outlined below.

OPOs hold regular review sessions to debrief activities, discuss lessons learned, discard practices that are no longer working, and learn from peers. Staff at all of the OPOs stated the importance of holding regular meetings to review events and pointed out that this type of debriefing was extremely important in troubleshooting and improving organ donation processes at their hospitals. During these reviews, corrective feedback is not punitive but instead leads to further collaboration and brainstorming on ways to the achieve improvements. Most OPOs reported holding meetings on a weekly basis, both within role specialization and across role specializations in order to keep all staff up-to-date and informed.

• MTS holds weekly meetings that are attended by all OPO staff, including family support staff, hospital development staff, and clinical coordinators, to review events of the previous week. OPO staff noted that these meetings were essential to effective trouble-shooting.
• LifeLink also reported holding “Monday meetings” at which they review each referral from the previous week. These meetings are attended by all OPO staff, regardless of their involvement in a case. OPO staff review cases in their entirety and any problems related to a case are discussed and pursued by the hospital development coordinator within 24 hours of identification.
• LifeGift’s organ donation coordinators reported meeting weekly to discuss the prior week’s events, with the purpose of dissecting successes and failures and developing solutions as needed. Staff reported that debriefing discussions during these “week in review” meetings are conducted in a non-threatening manner and help staff identify areas for improvement.

At affiliated hospitals, OPOs follow up and provide feedback to staff on the process and outcomes of each organ donation case. The staff of all of the OPOs as well as physicians and nurses asserted the value of following up with hospitals after each organ donation case. OPO staff noted the importance of 2 components of follow-up: debriefing with hospital staff involved in the case about the process and notifying hospital staff about the placement of organs and the transplant recipients.

All of the OPOs cited some type of debriefing with hospital staff on each organ donation case. This follow-up is either formal or informal and is arranged to avoid conflicts with hospital staff schedules. Feedback drives improvement in donation performance and is never punitive. Physicians and nurses in particular reported using this feedback and sharing it with staff at organ donation meetings or other multidisciplinary committee meetings in order to aid in problem solving. Hospital staff also reported that timely feedback is important, finding that, months after a case, information becomes stale and the opportunity for problem solving is lost. Many nurses reported that the ability to access OPO staff easily for feedback on an ad hoc basis was extremely useful and increased their willingness to refer cases to the OPO.

• MTS and UWHC OPO staff reported touching base via phone or in person with hospital staff to follow up on every case and to identify any areas of the process that could have gone more smoothly.
• NEOB and Donor Alliance reported trying to schedule post-donation conferences/ debriefs with all hospital staff directly involved in a case. Soon after the event, OPOs gather all hospital staff involved in the process to debrief on what went right and areas for improvement. Post-donation conferences are usually conducted in the ICU to accommodate busy hospital staff. Other sites debrief informally.
• OPOs, including NEOB, LifeGift, and UWHC OPO, reported conducting regular case reviews where donation cases are reviewed with hospital staff for education purposes.

OPOs give feedback to hospital staff regarding organ placement and transplant recipients. OPOs send personalized letters of thanks to all hospital staff involved in a donation and inform them about the people who benefited from their efforts. Although these letters do not mention names of recipients, they do provide some descriptive information about the people who received organs and tissues and how their lives have changed. OPOs reported reviewing medical charts to ensure that every single person involved in the case receives a letter, no matter how small their role. Sometimes hospital staff also receive letters of thanks from the transplant recipients. These letters are usually posted in highly visible places in the units.

All hospital staff reported that this communication is valued and influences organ donation performance, starting with early referrals. Many staff see letters as providing a positive outcome after having lost a patient. Letters increase medical staff awareness of organ donation, validate their important role in the process, and allow them to celebrate the success of their participation. Some staff reported that “It is one of the most satisfying parts of my job.”

OPOs follow up with donor families after donation. Many OPO and nursing staff reported some type of follow-up with donor families. All OPOs reported communicating with donor families through phone calls and letters following various lengths of time after donation in order to reconnect and contribute to making the donation experience a positive one. Donor families share their organ donation experiences with the community through word-of-mouth and can be valuable advocates for donation in public awareness campaigns.

• LifeLink calls the donor family the morning after donation and sends a thank you letter one month following the patient’s death. At 2 months, LifeLink sends the family a medallion, and at 6 months, surveys the family about their satisfaction with the experience. At the one-year anniversary of the donor’s death, the family receives another card.
• Some OPOs and hospitals also reported holding annual remembrance services for donor families. Nurses reported that these services are greatly appreciated by donor families and encourage their own participation in donation.

Staff at all of the OPOs and hospitals emphasized the importance of immediately resolving problems in the organ donation process. OPO and hospital staff reported that once a problem is identified, the parties involved need to take immediate action by communicating, planning, and acting on a solution. Because the success of the organ donation process hinges on key relationships among referring physicians and nurses and OPO staff, it is imperative that the strength of these relationships is not jeopardized. Physicians and staff noted that they valued the prompt action from OPO staff in response to problems.

• In one instance, a key referring physicians at an OPO’s high potential hospital was offended by the contents of an organ donation-related publication and notified the OPO that he was no longer going to make an effort to make referrals to the OPO. The OPO’s executive director immediately called the physician to resolve the misunderstanding and restore his confidence in the OPO. Resolving this situation was imperative since this individual was one of their top referring physicians and had great influence over other physicians and nurses at the hospital.
• The OPO liaison at one hospital wrote a letter of complaint to the OPO’s executive director after one of the surgical residents on the organ procurement team sent by the OPO reportedly treated the hospital’s OR staff with a lack of respect. The executive director took this feedback very seriously and warned his surgical staff that this behavior would not be tolerated and disciplinary action would be taken if this were repeated in the future. The hospital was pleased with how the OPO responded to this incident, and no further problems have been reported with recovery teams.
• When one OPO switched to the STATLINE answering service for calling in referrals, there were initial problems in getting the system to operate properly. One physician called in a referral and waited an hour for a response. He notified the executive director that the response time was unacceptable, and the OPO responded and resolved the problem immediately.

E. Implementation Considerations
OPOs and hospitals must consider many implementation challenges as they move to replicate best practices. These issues are organized into 2 main categories: barriers and facilitators. Many of these are introduced or otherwise discussed in the context of best practices. The strategies employed to realize best practices can help to overcome these barriers, and can be more readily implemented by the facilitators.

1. Barriers

1. In a subset of hospitals, the process of organ donation was fully ingrained in the hospital culture, sometimes for 2 or 3 decades. In others, both OPOs and hospital champions were still working together to overcome hospital resistance to organ donation. Potential barriers that were noted include the following.

• Some hospitals and physicians do not perceive organ donation efforts to be a part of the hospital’s primary business or routine. Some hospital administrators and physicians reported a feeling of being “overextended” with primary patient care responsibilities and noted that competing demands on providers’ time may prevent them from making organ donation a priority.
• Some physicians find it burdensome to make the telephone call to the OPO for every death, particularly when it is apparent to them that the patient involved is not an organ donation candidate.
• Some respondents noted the perception that an early call to the OPO could mean that medical staff are not doing their best to save a patient’s life. They expressed concern that early calls to an OPO might be viewed as unethical and may be interpreted incorrectly by families. For these reasons, some individuals reported being reluctant to contact the OPO “too early.”
• In the past, prior to implementation of the Medicare Conditions of Participation, hospital staff were usually the personnel responsible for approaching families about donation. For some nurses and physicians, making the transition from asking to not asking was a difficult one, requiring education and other interventions by the OPO.
• Hospital staff articulated the important role they play in doing everything in their power to save patients’ lives. Several physicians reported difficulty in making the transition from trying to save a patient’s life to trying to maintain the donor in order to save lives of other patients. These physicians, particularly neurosurgeons, view brain death as a failure and as an event that marks “the end of treatment” for a patient. These perceptions make it difficult for physicians to plan the patient’s trajectory of care beyond the declaration of brain death, in preparation for possible organ donation.
• Some hospitals are under financial and capacity constraints, with tight margins and overcrowded emergency departments. Hospital executives may assume that supporting organ donation could subtract further from their bottom line, as a result of donors occupying beds, using critical care, and operating room resources.

2. The lack of agreement on declaration of brain death can be a barrier to organ donation. While some hospitals have strict clinical criteria and protocols in place for declaring brain death, others do not. The lack of clear criteria and protocols for declaration of brain death can cause delays that lead to the decreased viability of organs.

3. Growing medical liability premiums for neurosurgeons can also be a barrier to donation. One neurosurgeon reported that the support of organ donation could be perceived as unethical for his specialty. As noted above, some neurosurgeons report that brain death constitutes a failure of their professional efforts.

4. Potential or perceived conflicts of interest arise in pursuit of organ donation and transplantation goals. Some hospital administrators, neurosurgeons, and transplant surgeons indicate that there could be a perceived conflict of interest in the pursuit of saving lives and procuring organs, especially at transplant centers.

2. Facilitators

1. Donor registries can function as advanced directives. Hospital staff in States with organ donor registries reported the benefits of organ donor registries, especially if they act as advanced directives. Donor registries may remove the decision-making burden from the family. In addition, hospital staff reported that donor registries appear to increase the likelihood of families discussing organ donation issues in advance of a potential organ donation situation. This may increase family awareness and knowledge, and the probability that they will be more amenable to donation should the circumstance arise.

2. Tissue donation can complement and improve organ donation. OPO leadership reported multiple benefits of pursuing tissue donation. They reported that the higher frequency of tissue donation seems to: raise awareness in hospitals of donation, in general, and give OPO staff more opportunities to interact with hospital staff. OPOs that manage tissue donation are able to offer a streamlined process for hospital personnel whereby they only have to contact one organization, the OPO, for both organ and tissue related matters. Revenues from tissue donation are often used to support other OPO activities, including those that promote organ donation.

3. Living donation programs contribute to other donation efforts. Living donation programs have been growing across the U.S. For example, in the past several years, laparoscopic surgery has made kidney removal a much less invasive procedure with a significantly shorter recovery time; as a result, more people are choosing to become living donors. Living organ donation programs, including altruistic non-directed donation, help in increasing awareness and community support of organ donation. Along with transplant recipients, living donors can be persuasive advocates for organ donation.

4. Proximity of transplantation programs may encourage organ donation. While some hospital staff perceive involvement in both organ donation and transplantation efforts as a potential conflict of interest, others view proximity to transplant recipients as an opportunity to heighten the immediacy of need for organ donation, increasing staff awareness and support of organ donation in the hospital.

IV. CONCLUSIONS
Site visits to 6 OPOs and 16 hospitals revealed 7 overarching principles and 15 best practices and accompanying strategies that appear to be associated with high organ donation performance. Many of these principles and best practices are interrelated, and many of the strategies and examples gleaned from the OPOs and hospitals support more than one principle or best practice. A noteworthy example is the OPO practice of providing letters of thanks to hospital staff following a donation, which is consistent with principles and best practices concerning recognizing and celebrating success, providing timely and systematic feedback, maintaining buy-in, and maintaining a network of interpersonal relationships.

Best practices can be viewed in the context of a systems approach to organ donation, as illustrated in Exhibit 6. Some OPOs and hospitals explicitly manage organ donation using a systems approach. Others implement various of its components. In this systems approach to organ donation, goals are set by OPOs and their governing bodies, and discussed with and adopted by the hospitals in their service areas. These goals are set with the intention of maximizing organ donation performance and improving organ donation processes and protocols.

To be successful, organ donation processes and protocols are implemented both within and outside of the hospital setting by champions from among OPO staff, hospital staff, and others, such as medical examiners, EMS staff, and donor families. These processes and protocols span hospital development activities, family support and bereavement care, clinical support of potential donors, and follow-up.

Hospital development focuses on building and strengthening the relationships between OPO and hospital staff. Family support and bereavement care are continuous, and focused on helping families by offering them emotional support, information, and resources needed to deal with these tragic situations. Processes and protocols related to the clinical support of potential donors include identification of potential donors, donor referrals, determination of medical suitability, obtaining consent, stabilization of donors, locating recipients, organ recovery and preservation, and, finally, transplantation. Follow-up processes include those related to OPO-hospital staff case debriefs, OPO follow-up with hospital staff regarding transplant recipients, and OPO and hospital follow-up with donor families.

Finally, OPOs and hospitals generate outcome data as a result of the implementation of these processes. Data are monitored and analyzed within the OPO and hospital settings to determine how well processes were implemented and whether goals were achieved. Results of data analysis continuously inform the organ donation process so that improvements can be made over time and organ donation goals can be modified accordingly.

APPENDICES

Appendix A: Expert Panelists

The following 20 participants attended a meeting in June 2001, sponsored by HHS/HRSA/OSP/DoT, to examine potential structural and process attributes of OPOs and hospitals that are associated with higher rates of donation.

Teresa Beigay
Doctoral Student
Health Policy and Management
University of Pittsburgh
Pittsburgh, PA

Howard Degenholtz, Ph.D.
Assistant Professor
University of Pittsburgh
Center for Bioethics and Health Law
Pittsburgh, PA

Francis L. Delmonico, M.D.
Professor of Surgery
Amer. Society Of Transplantation (AST)
Harvard Med. Sch., Dir, Renal Transp., Mass. Gen. Hosp.
Boston, MA

Beth Fetter
Manager, Organ Procurement
Translife
Orlando, FL

Mary Ganikos
Chief, Education Branch
HRSA/DoT
Rockville, MD

Julie Gassaway, RN, MSN
Project Director
Inst. for Clinical Outcomes Resrch.
Severna Park, MD

Pat Giordano
Executive Director
Texas Organ Sharing Alliance
San Antonio, TX

David Howard, Ph.D.
Assistant Professor of Health Economics
Depart.of Hlth Policy & Mgmt., Rollins Sch. of Public Hlth
Emory University
Atlanta, GA

Dixon Kaufman, M.D.
Amer, Soc. Of Transplant Surgeons (ASTS)
Northwestern Univ. Div. of Transp.
Chicago, IL

Gene Knott, Ph.D.
University of Rhode Island
Peacedale, RI

Ellen Kulik
National Donor Family Council
Skaneateles, NY

Kathleen Lohr, Ph.D.
Chief Scientist
Statistics, Health, & Social Policy Unit, Research Triangle Inst.
Research Triangle Park, NC

Virginia McBride
Education Branch
HRSA/DoT
Rockville, MD

Karl McCleary, Ph.D.
Assisant Professor of Health
Policy and Administration
The Pennsylvania State University
University Park, PA

Martha McKinney, Ph.D.
Community Health Solutions, Inc.
Richmond, KY

Robert Metzger, M.D.
Council on Organ Availability
TransLife
Orlando, FL

Patrice Miles
Executive Director
National Minority Organ and Tissue
Transplant Education Program
Washington, DC

Richard Millspaugh
Chaplain
Boone Hospital Center
Columbia, MO

Esther Padilla
California Transplant Donor Network
Fresno, CA

Sheldon Zink, Ph.D.
Director of the Program for Transplant Policy and Ethics
Senior Fellow
Center for Bioethics
University of Pennsylvania
Philadelphia, PA

Appendix B: OPOs Considered for Inclusion in the Study
Fourteen OPOs were considered for inclusion in the study (see below). These OPOs had among the highest consent rates and median consents rates that were greater than the national mean (i.e., consent rates greater than 50 percent). The final sample of 6 OPOs was selected from this list of 14 based on volume of cases, geographic variation, and other unique characteristics (e.g., hospital-based OPO, in-house coordinator staffing model).

WISE
Wisconsin Donor Network
Milwaukee,WI

WIUW
University of Wisconsin Hospital & Clinics Organ Procurement Organization
Madison, WI

CADN
California Transplant Donor Network
Oakland, CA

FLWC
LifeLink of Florida
Tampa, FL

MWOB
Midwest Transplant Network
Westwood,KS

TXGC
LifeGift Organ Donation Center
Houston, TX

CORS
Donor Alliance Inc.
Denver, CO

IAOP
Iowa Donor Network
Iowa City, IA

MIOP
Transplantation Society of Michigan, now Gift of Life Michigan
Ann Arbor, MI

CAOP
OneLegacy
Los Angeles, CA

MAOB
New England Organ Bank
Newton, MA

FLFH
TransLife /Florida Hospital
Orlando, FL

MNOP
LifeSource Upper Midwest Organ Procurement Organization
St. Paul, MN

MOMA Mid-America Transplant Services
St. Louis, MO

Appendix C: Hospital Sample and Characteristics
Site visits were made to the following hospitals, listed by the OPO with which they are affiliated:

• New England Organ Bank (Newton, MA)
  • Beth Israel Deaconess Hospital (Boston)
  • Boston Medical Center (Boston)
  • Brigham Women's Hospital (Boston)
  • Massachusetts General Hospital (Boston)
• LifeLink of Florida (Tampa, FL)
  • Lakeland Regional Medical Center (Lakeland)
  • Tampa General Hospital (Tampa)
• University of Wisconsin Hospital & Clinics Organ Procurement Organization (Madison, WI)
  • Gundersen Lutheran Hospital (Lacrosse)
  • Theda Clark Regional Medical Center (Neenah)
  • University of Wisconsin Hospital & Clinics (Madison)
• Mid-America Transplant Services (St. Louis, MO)
  • Barnes-Jewish Hospital (St. Louis)
  • St. John’s Mercy Medical Center (St. Louis)
• LifeGift Organ Donation Center (Houston, TX)
  • Ben Taub General Hospital (Houston)
  • Memorial Herman Hospital (Houston)
• Donor Alliance (Denver, CO)
  • Denver Health Medical Center (Denver)
  • Memorial Hospital (Colorado Springs)
  • St. Anthony Central Hospital (Denver)

Tables C1 – C5 that follow present characteristics of each hospital in the sample.

Appendix Table C-2:  Selected LifeLink Hospital Characteristics

Appendix Table C-3:  Selected UWHC Hospital Characteristics

Appendix Table C-4:  Selected MTS Hospital Characteristics

Acknowledgements
This report was prepared for the Health Resources and Services Administration, U.S. Department of Health and Human Services, by Clifford Goodman, Christina Worrall, Umi Chong, Sophie Kallinis, and Margaret Rockwood of The Lewin Group. The Project Officer was Virginia McBride of the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA), Office of Special Programs (OSP), Division of Transplantation (DoT). Frank Zampiello of Quality Reality Checks accompanied The Lewin Group in the data collection that informed this report. Other HRSA contributors include: Secretary Tommy G. Thompson and staff of HRSA/OSP/DoT, including Joyce Somsak, Dennis Wagner, Rich Durbin, Mary Ganikos, and Lorah Tidwell. The following OPOs and their affiliated hospitals were included in the study:

• New England Organ Bank (Newton, MA) and: Beth Israel Deaconess Hospital, Boston Medical Center, Brigham Women's Hospital, Massachusetts General Hospital (all Boston)
• LifeLink of Florida (Tampa, FL) and: Lakeland Regional Medical Center (Lakeland), Tampa General Hospital (Tampa)
• University of Wisconsin Hospital & Clinics Organ Procurement Organization (Madison, WI) and: Gundersen Lutheran Hospital (Lacrosse), Theda Clark Regional Medical Center (Neenah), University of Wisconsin Hospital & Clinics (Madison)
• Mid-America Transplant Services (St. Louis, MO) and: Barnes-Jewish Hospital (St. Louis), St. John’s Mercy Medical Center (St. Louis)
• LifeGift Organ Donation Center (Houston, TX) and: Ben Taub General Hospital (Houston), Memorial Herman Hospital (Houston)
• Donor Alliance (Denver, CO) and: Denver Health Medical Center (Denver), Memorial Hospital (Colorado Springs), St. Anthony Central Hospital (Denver)