The Forward Focus Journey at MCHS - Eau Claire

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The Forward Focus Journey atMCHS - Eau Claire

• Anna Sylla, RN-BSN

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MCHS-EC Forward Focus Team Team Luther

• Anna Sylla, RN Co-Lead
• Susan Allen, UW OTD Co-Lead
• Dr. Donn Dexter-Faculty Member
• Kelly Buchholtz, RN
• Damian Budzinski, RN
• Amy Williams, RN
• Beth Swope, RN
• Rachel Fish, RN
• Aimee Wollman, Chaplain

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The Beginning of Our Journey

• Selecting Our Team
• Multi-Disciplinary
• Understanding of the Organ Donation Process
• Time Commitment
• Engaged
• Prep Work
• Meetings with Administration and Department
  Directors
• Analyzed the Current State of the 11 Steps in the
  Organ Donation Process (Family Support Donor
  Management, Referral, Patient Monitoring,
  Eligibility, Consent, Data, Donor Evaluation,
  Organ Placement, Allocation, Recovery, Post
  Case Follow-up)
• Who ? What ? How ? Hooray or Headache
• Developed a Plan for the Journey to Increase the
  Number of Organs Transplanted at MCHS-EC
• An Opportunity for Expanding Our Current RN Donor
  Coordinator Team
• An Opportunity to Improve the Referral Process

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The Journeys Progress

• PDSA 1 An Opportunity for Expanding Our Current
  RN Organ Donor Coordinator Team
• The MCHS-EC Physician Donor Support Team
• Group of physicians engaged in organ donation
• Collaborate with the RN coordinator and UW OTD to
  determine medical eligibility for organ donation
• Support the RN coordinator with the consent
  process by being present in the room for medical
  questions from family or by taking an active role
  in the donation approach when needed
• Assist with provider to provider communication
  when providers from other departments are
  involved with the donation to support the
  process, answer questions, and offer
  clarification when needed. (Cardiology,
  Pulmonology, Neurosurgery, etc)
• PDSA 2 An Opportunity to Improve our Referral
  Rate on Patients Who Meet Clinical Triggers After
  the Admission Date
• Primarily cardiac/post-code patients (initially
  non-neuro patients) with anoxic injuries
  related to the cardiac event
• Addition of a RN clinical trigger order to the
  hypothermic protocol
• Addition to the CCU lead RN daily check list to
  confirm a referral has been made on patients who
  meet clinical triggers

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Team Luthers Forward Focus Journey
Accomplisments

• PDSA 1 The MCHS-EC Physician Donor Support Team
• Started with 2 physicians
• Utilizing case scenarios, including members of
  the MCHS-EC patient advisory board and a donor
  mom for testing our 1st PDSA 
• Making a bold request and in return received the
  consent of 4 additional physicians for the
  physician coordinator team (4 general surgeons, 1
  Neurologist, and 1 Pulmonologist/Intensivist)
• Involving a member of the provider organ donor
  support team in 90 of donation approaches since
  March 2012
• PDSA 2
• Approval of adding an RN order to the hypothermic
  protocol
• Increased CCU staff awareness of non-neuro
  patients who may potentially meet clinical
  triggers
• Data collection from first month shows successful
  test (and no additional missed referrals)
• Other
• Recovered 21 organs from 6 donors since March
  2012 (OTPD of 3.5) improved the RN donor
  coordinator checklists
• Total immersion in quality improvement
• Collaboration with 9 hospitals who all have the
  same goal and are aiming for the same results
• Unveiling of the MCHS-EC Organ Donor Remembrance
  Wall

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The Future of Team Luthers Forward Focus
Journey

• Designator Requestor Train 4 of the 6 Physicians
  on the Physician Donor Support Team (2 are
  currently DR trained).
• Review the Physician Donor Support Role with
  Every Donor Case During the After Action Reviews.
• Continue with the PDSA Steps for the Missed
  Referral PDSA by Conducting Monthly Audits and
  Reviewing This Data.
• Meet on a Regular Basis to Continue our Journey
  of Sustaining the Energy and Forward Focus
  Movement to Continue Improving Our Organ Donation
  Process and Results.