JCAHO Commitment to Organ Donation (pdf) - UW Health
JCAHO Commitment to Organ Donation (pdf) - UW Health
JCAHO Commitment to Organ Donation (pdf) - UW Health
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University of Wisconsin<strong>Organ</strong> Procurement <strong>Organ</strong>izationJoint Commission Initiatives<strong>to</strong> Increase <strong>Organ</strong> <strong>Donation</strong>April 27, 2005Charles A. Mowll, FACHE, FHFMAJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izationsJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations1
Hospitals FaceMany Seemingly InsolvableChallenges…• Preventing Sentinel Events• Infection control/iatrogenic injuries• Staffing shortages• Payment shortages• Emergency Department overcrowding• Hospital-physician relations• Operating at peek capacityJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations2
• Increasing organ donationThis challengeis solvable!Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations3
87,6136,00017Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations4
Patients on the Waiting List for Life1995-2004More than Doubled in 10 Years!KidneyAll199529,603 41,203199632,955 46,961199736,480 53,167199840,288 60,381199944,010 67,224200047,758 74,078200150,803 79,524200253,643 80,790200356,665 83,731200460,986 87,613Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations5
Transplants Performed1995-200439 Percent Increase in 10 Years1995 19,3891996 19,7481997 20,3031998 21,5131999 22,0102000 23,2372001 24,2152002 24,9082003 25,4672004 26,984Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations6
<strong>Organ</strong> <strong>Donation</strong>Supply & Demand: Disequilibrium• Increased demand for organs is far outstripping the supply of suitable organs• Ratio: 2.5 <strong>to</strong> 1• We need <strong>to</strong> reduce demand andincrease supplyJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations7
Goals:1. Continuously Exceed75% Conversion Rate2. Narrow (significantly) theorgan donation gap3. Save lives!Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations8
Opportunities <strong>to</strong> Improve<strong>Organ</strong> <strong>Donation</strong> Rates• ~ 12,000 (11,953 year-end 2/29/04) potentialhospital deceased donors a year• Actual donors 5,964 for year-end 2/29/04 (50%conversion rate)• Deceased organ donation +4.8% in 2003• 39 percent of the families of potential organdonors refuse <strong>to</strong> consent <strong>to</strong> organ donation (NEJM8/14/03)• 16 percent of families were never asked(NEJM 8/14/03)Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations9
Opportunities <strong>to</strong> Improve<strong>Organ</strong> <strong>Donation</strong> Rates• Average Wait Time = 230 days (heart) <strong>to</strong>1263 days (kidney)• Clear disparities (34% on Waiting Listracial/ethnic minorities)• 90% of eligible donors found in 846hospitals• <strong>Organ</strong> donation yield 3.6/8Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations10
DCD/2004An Opportunity <strong>to</strong> Increase <strong>Donation</strong>• <strong>Donation</strong> after Cardiac Deathrepresented 3.2% (711) of transplantsfrom deceased donors in 2004 1• (SCD) Standard Criteria Donors –• (ECD) Expanded Criteria transplants -DCD transplants –DCD/ECD transplants –Total18,2232,9577118424,975 1Source: 1) Scientific Registry of Transplant RecipientsJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations11
DCD/2004An Opportunity <strong>to</strong> Increase <strong>Donation</strong>• Increases in non-traditional donor sources 2 :– ECD kidney donors +8% 2003– DCD donors +43% (189 <strong>to</strong> 271) in 2003• <strong>Donation</strong> After Cardiac Death, A Reference Guide (UNOS,HRSA)• National Consensus Meeting Philadelphia, April 7-8, 2005• 52% of DCDs in 6 OPOs 1Sources: 1) Scientific Registry of Transplant Recipients2) Delmonico et al, AJT, 2005Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations12
Making <strong>Organ</strong> <strong>Donation</strong> a Priority SavesLivesHHS Secretary Mike Leavitt (March 2005):• 2004 a new national record for organ transplants(26,984)• <strong>Donation</strong> up 11% in 2004• Largest increase in 10 years• Deceased donor transplants rose by 1,368 <strong>to</strong>10,018 (2003 <strong>to</strong> 2004)• Living donor transplant grew 2.3% <strong>to</strong> 6,966 (+154over 2003)Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations13
HRSA<strong>Organ</strong> <strong>Donation</strong>Breakthrough Collaborative• Collaborative 1 hospitals (97) – increasedconversion rate 48% <strong>to</strong> 65%• Collaborative 2 hospitals (138) – increasedconversion rate 45% <strong>to</strong> 52%• Collaborative 1 hospitals: 16% increase inorgan donors in 2004• All other hospitals: 9% increase in organdonorsJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations14
Joint Commission<strong>Organ</strong> <strong>Donation</strong> Initiatives:1. Enhancing standards expectations2. National symposium – March 2004& Fall 2004 (November 17, 2004)3. Public Policy Initiative –Recommendations/Actions4. Publishing Best Practices [(630) 792-5424]5. Identify appropriate performance measures(seek NQF endorsement)6. Inform the survey process (PFP, tracers, probes)7. Recognize hospital success (Quality Check )Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations15
Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations16
Strategies for Narrowingthe <strong>Organ</strong> <strong>Donation</strong> Gap-- A Call <strong>to</strong> Action -- --• Providers• <strong>Organ</strong> Procurement<strong>Organ</strong>izations• Government agencies(state & federal)• Joint Commission• Researchers• Congress• Academia• Purchasers• Insurance/payersJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations17
Strategies for Narrowingthe <strong>Organ</strong> <strong>Donation</strong> Gap-- Equity Issues --• Ethnic/racial minorities• Reduce disparities• Compliance assessmentdisabled• Equalize access• Living donor registry• Living donor advocacy• Adopt safe practices• Standardize suitability• Study cause of disparities• Create immunosuppressivedrug benefits• Living donor insurance• Leave policies• Educate caregivers re:disabilitiesJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations18
Strategies for Narrowingthe <strong>Organ</strong> <strong>Donation</strong> Gap-- Cultural Issues --• Educate staff• Focus resources• Follow the leaders• In-house coordina<strong>to</strong>rs• Ethnically likereques<strong>to</strong>rs• Make it a priority• Optimize Hospital-OPO relationship• CMS – pay for costs• Improve conversionrate• Performance measureset• Pay-for-performanceJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations19
Strategies for Narrowingthe <strong>Organ</strong> <strong>Donation</strong> Gap-- Alternative Approaches --• Enforce UAGA – nofamily consent needed• Implement DCDpro<strong>to</strong>cols• <strong>Health</strong>promotion/diseaseprevention programs• Promote living donorexchanges• 11 states need <strong>to</strong> adoptUAGA• State donor registries• R&D projects i.e.,public education• New technologies <strong>to</strong>reduce organ rejection• Improve immunosuppresivetherapyJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations20
Current StandardLD.3.110The hospital implements policiesand procedures developed with themedical staff’s participation forprocuring and donating organs andother tissues.Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations21
Elements of Performance forLD.3.1101. If the hospital procures human organs, it hasan agreement with the appropriate organprocurement organization (OPO) and followsits rules and regulations.2. The hospital’s policies and proceduresidentify the OPO with which it is affiliated.Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations22
Elements of Performance forLD.3.1103. The hospital has an agreement with at least onetissue bank and at least one eye bank (as long asthe process does not interfere with organprocurement) <strong>to</strong> cooperate in retrieving,processing, preserving, s<strong>to</strong>ring, and distributingtissues and eyes.4. The hospital notifies the OPO in a timelymanner of patients who have died or whosedeath is imminent.Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations23
Elements of Performance forLD.3.1105. In Department of Defense hospitals, VeteransAffairs medical centers, and other federallyadministered health care agencies, thisnotification is done according <strong>to</strong> proceduresapproved by the respective agency.6. The OPO determines medical suitability fororgan donation and, in the absence ofalternative arrangements by the hospital, fortissue and eye donation.Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations24
Elements of Performance forLD.3.1107. The hospital has procedures, developed incollaboration with the designated OPO, fornotifying the family of each potential donorof the option <strong>to</strong> donate—or decline <strong>to</strong>donate—organs, tissues, or eyes.8. This notification is made by an organprocurement representative or the hospital’sdesignated requester.Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations25
Elements of Performance forLD.3.1109. Written documentation by the hospital’sdesignated requester shows that the patien<strong>to</strong>r family accepts or declines the opportunityfor the patient <strong>to</strong> become an organ or tissuedonor.10. The hospital’s staff exercises discretion andsensitivity <strong>to</strong> the circumstances, beliefs, anddesires of the families of potential donors.Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations26
Elements of Performance forLD.3.11011. The hospital maintains records of potential donors whosenames have been sent <strong>to</strong> the OPO and tissue and eye banks.12. The hospital works with the OPO and tissue and eye banksas follows:• In reviewing death records <strong>to</strong> improve identification ofpotential donors• To maintain potential donors while the necessary testingand placement of potential donated organ tissues, andeyes takes place• In educating staff about donation issuesJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations27
<strong>Organ</strong> Procurement EffectivenessStandard PI.1.10, EP 29• PI.1.10 – the organization collects data <strong>to</strong>moni<strong>to</strong>r its performanceEP 29 – The organization collects andanalyzes conversion rate data <strong>to</strong> moni<strong>to</strong>rorgan procurement effectiveness and, whenpossible, takes steps <strong>to</strong> improve theconversion rate.Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations28
PotentialPerformance Measures• Conversion Rateorgan donorseligible donors• Medical Examiner Denials(number/month)• Referral Rate (percent of imminent deathsreferred <strong>to</strong> OPO)• Timely Notification (percent referredwithin 1 hour of clinical trigger)Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations29
Protecting Living DonorsChallenging set of issues confronting thecare giving team when caring for a livingdonor:• Clinical care provided• Psychosocial needs• Patient rights• Financial concerns• Ethical issuesJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations30
2004: organs donated by a livingdonor hit a record high6,966Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations31
Protecting Living Donors1. Ensuring that the same level of careis provided as other patients receive(staffing levels for transplant units)2. Assessing psychosocial needs of thepatient3. Respecting patients’ rights, cultural& linguistic needs, informed consentJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations32
Protecting Living Donors4. Universal Pro<strong>to</strong>col for PreventingWrong Site, Wrong Procedure,Wrong Patient Surgery5. Family support systems6. Blood type matching(Jessica Santillan)Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations33
Protecting Living Donors7. Preparing for complications (1/3liver donors suffer a medicalcomplication)8. Medical leave policies--job at risk?9. Insurance consequences—preexistingcondition10. Adhere <strong>to</strong> clinical guidelinesJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations34
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Contributing fac<strong>to</strong>rs<strong>to</strong> Best PracticesC Success1. Champion for the cause!2. <strong>Commitment</strong> of leadership3. Culture of priority for organ donation4. Collaborative effort (staff & OPO)5. Communicate rapidly (call within 1 hour)6. Clinical trigger for call <strong>to</strong> OPO7. Conversion rate improvement8. Counsel potential donor families9. Clarify proceduresJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations37
The Scientific Registryof Transplant Recipients (SRTR)• www.ustransplant.org• Table 3A – measures of donation rates by hospital• Actual donors ÷ eligible donors (observed rate)• Expected rate – based on hospitals of similar size,MSA, Case Mix Index, ICU beds, trauma centerdesignation, presence of neurosurgery unit• University Renal Research and EducationAssociation (for HRSA DoT)Joint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations38
Look for:“The <strong>Organ</strong> Shortage Continues”(OPTN)• Your Hospital’s Conversion Rate• State & National comparisons• Waiting List for Life• HRSA Goal: 75% Conversion Rate• Transplants PerformedJoint Commission on Accreditation of <strong>Health</strong>care <strong>Organ</strong>izations39
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