Organ Donation Opportunities for Action (2006) / Chapter Skim
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4 Systems To Support Organ Donation
4 Systems To Support Organ Donation
Pages 93-126
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From page 93... ...
Although any hospital may have a patient who is a potential organ donor, specialized hospitals that treat many patients with traumatic injuries and other serious conditions (particularly those that can result in neurologic determination of death) are the ones that, to date, have been most likely to have potential organ donors in their patient populations.
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From page 94... ...
This chapter focuses on the clinical systems issues that are specific to the organ donation process. It is important to note, however, that an equitable allocation system and ongoing attention to the recipient are vital to maintaining the value of the donated organ and sustaining the integrity of the entire organ transplantation system (Box 4-1)
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From page 95... ...
extended the benefits to lifetime coverage of immunosuppressive medications; however, this full coverage applies to only a fraction of total transplant recipients. Private insurers offer some patient assistance programs to provide medications to patients who lack Medicare coverage or the ability to pay, but these programs are highly individualized to specific insurance companies.
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From page 96... ...
Under the existing legal and ethical framework of deceased organ donation in the United States, organ donation must not cause or hasten death (the dead donor rule) and the individual's wishes regarding donation must be honored.
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From page 97... ...
The financing of organ transplantation largely occurs through the health insurance costs paid by Medicare or private insurers. In 2004, private insurance was the primary payment source for 47.9 percent of transplant recipients, with 39.3 percent having Medicare as the primary source, and 9.0 percent using Medicaid (HRSA and SRTR, 2006)
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From page 98... ...
The heterogeneity of OPOs is evident in the range of donation rates. The Scientific Registry of Transplant Recipients calculates observed donation rates (calculated as the number of actual donors per the number of individuals eligible for donation)
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From page 99... ...
The condi tions of participation for OPOs and transplant centers are in the process of being revised to address requirements of the Organ Procurement Organization Certifica tion Act of 2000. The proposed rules increase the recertification cycle from 2 to 4 years and establish multiple outcome and process performance measures, includ ing changes in measurements of donor potential by replacing the current use of population data with data based on hospital referral calls to OPOs.
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From page 100... ...
Variations among OPOs and among transplant centers are being addressed through quality improvement processes and practices through the Organ Donation and Transplantation Breakthrough Collaboratives, which are described below. According to the best estimates, approximately 200 of the nation's hospitals host half of the nation's eligible donors (HRSA, 2005a)
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From page 101... ...
One potential gap in the current system is that the referrals most often involve patients whose deaths are imminent as determined by neurologic criteria and do not often include deaths determined by circulatory criteria (Bernat et al., 2006) (Chapter 5)
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From page 102... ...
, the collaboratives attempt to increase rates of organ donation by encouraging hospitals and OPOs to use methods of continuous quality improvement to enhance the process of deceased organ donation. The process of identifying and referring potential donors, requesting donation, recovering the organs, and ensuring that they are successfully transplanted is complex.
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From page 103... ...
, a nonprofit organization that is a leader in promoting the application of quality improvement methods to healthcare systems. IHI developed the Breakthrough Collaborative model, which brings healthcare organizations together to identify, learn, adapt, replicate, and celebrate breakthrough practices that can help them achieve specific improvement goals (IHI, 2003)
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From page 104... ...
Because not all eligible donors are identified as such and the reliability of the classification of potential donors as "eligible" and "ineligible" is unknown, the level of the conversion rates should be interpreted cautiously. However, differential trends in conversion rates across collaborative and control hospitals provide evidence of the impact of the Breakthrough Collaboratives on donation rates (Figure 4-1)
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From page 105... ...
. 800 700 600 donors of 500 number 400 the 300 in 200 Increase 100 0 1990 1992 1994 1996 1998 2000 2002 2004 2006 Year FIGURE 4-2 Annual increase in the number of deceased organ donors.
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From page 106... ...
Sustaining the quality improvement efforts is critically important. The Breakthrough Collaboratives have been instrumental in enhancing the coordination, processes, and practices within hospitals and OPOs as well as among all of the relevant organizations and individuals.
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From page 107... ...
This is particularly true when families are reapproached after they initially declined the opportunity to donate. In addition, further research is needed on family responses to this approach, its impact on donation rates, and its consistency with key ethical principles, such as the ones presented in this report.
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From page 108... ...
Requesters The early and consistent involvement of staff members with the family increases organ donation rates when it is coupled with effective communication. In a small study of a single hospital in Texas, the use of early notification and an in-house coordinator was associated with an increase in donation rates from 45 to 74 percent (Shafer et al., 1997)
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From page 109... ...
For example, Life Gift in Houston, Texas, has OPO staff working as in-house coordinators in the core hospitals with maximum donor potential. An OPO covering a wide geographic area works closely with the hospital staff who often talk with the families about organ donation.
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From page 110... ...
In institutions with palliative care programs, natural collaborations may develop among palliative care providers, critical care professionals, and OPO staff that provide the families of potential organ donors with the needed services. Some data suggest that the rates of donation by members of minority groups can be increased through the use of ethnically sensitive in-house coordinators or like-to-like requesters (Kappel et al., 1993; Gentry et al., 1997; Shafer et al., 1997)
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From page 111... ...
; interpersonal, relational, and communication skills; and decision-making and organizational skills. Although the provision of quality end-of-life care is improving across the country, concurrent improvements in organ donation processes and end-of-life practices and processes are needed to create the trustworthiness necessary to improve donation rates.
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From page 112... ...
Healthcare organizations demonstrate competence trustworthiness by putting into place integrated systems with clinical, educational, and administrative infrastructures that enable healthcare professionals to practice in accord with these competencies and achieve the outcomes that the process was designed to reach. Interdisciplinary teams of healthcare professionals and OPO staff who work collaboratively must be able to design systems to promote organ recovery that are flexible; that are aligned with the systems, structures, and cultures of their institutions; and that are effective.
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From page 113... ...
Sustain Continuous Quality Improvement As described above, the Breakthrough Collaboratives focus specifically on improving the current system for obtaining and transplanting organs. However, the goal of a collaborative is not merely to achieve the specific breakthrough improvement around which it is organized.
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From page 114... ...
should ensure that quality improvement efforts are recognized as part of normal organizational healthcare operations and should reimburse accordingly. It would also be desirable to provide some ongoing funding for technical assistance and the ongoing interaction of organizations around the use of quality improvement methods to improve the organ donation process.
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From page 115... ...
Quality improvement processes and practices need to be implemented in tandem with efforts to enhance organ donation rates. Further, there is still much to be learned about how to develop and follow through on advance care directives.
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From page 116... ...
To isolate organ donation from the broader context of end-of-life care has the potential to ultimately undermine the effectiveness of efforts to increase donation rates. Emphasis on Patient and Family Relationships An end-of-life care framework acknowledges that care is for the patient and his or her family and continues through the patient's death and the family's bereavement.
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From page 117... ...
. Recently, models of training in the organ donation process have highlighted the importance of an interdisciplinary team that includes OPO staff and that closely collaborates with OPO staff.
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From page 118... ...
. Building on the successes of the Organ Donation Breakthrough Collaboratives and HRSA's demonstration projects, national initiatives for interdisciplinary training and models of collaboration should continue to be supported and expanded.
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From page 119... ...
The Organ Donation Breakthrough Collaboratives are working to galvanize the efforts of hospitals and OPOs to develop and implement continuous quality improvement methods and thereby create changes in policies, practices, and structures. Future support for continuous quality improvement efforts is critical to the progress of organ donation efforts.
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From page 120... ...
. AOPO (Association of Organ Procurement Organizations)
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From page 121... ...
1999. Comparison of consent rates between hospital-based designated requestors and organ procurement coordinators.
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From page 122... ...
Under review. Evaluation of a nationwide quality improvement initiative to increase organ donation rates.
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From page 123... ...
1999. Continuous Quality Improvement in Health Care: Theory, Implementation, and Applications, 2nd ed.
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From page 124... ...
2005. National Reports: National Sum mary by OPO by Table, Table 3 (Measures of Donation Rates)
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From page 125... ...
2004. Cost-effectiveness of extending Medicare coverage of immunosuppressive medications to the life of a kidney transplant.
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