Welcome to Your DSA Action Team Meeting. November 30, 2011

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1 Welcome to Your DSA Action Team Meeting November 30, 2011

2 Who s on the Call?

3 Questions??? Use the Q & A panel displayed on your screen Type your question in at the very bottom portion of the Q & A panel. Time permitting, questions will be repeated and answered at the end of the hour.

4 Why We re Talking Today Create a robust and efficient group to be in action for making changes that will result in improvements in organ, tissue and eye donation and transplantation.

5 Agenda DSA Data Review How Do We Improve Our Timely Referral Rate? Where Are They??? Access to current references and education programs on My Donation Resource Connect to Purpose Meeting Evaluation/Questions/Wrap-up

6 2011 LifeSource DSA Activity Dashboard Measurement Targets Jan Feb Mar Apr May Jun Jul Aug Sep Oct YTD GROWTH PILLAR # Organs Transplanted (deceased local donor) # Organ Donors (all) # Donors after Cardiac Death (DCD) Conversion Rate (All Organ Donors/Possible Organ Donors) 80% 100% 67% 68% 86% 85% 80% 61% 83% 100% 90% (prelim) 80% Organs Transplanted Per Donor (overall) Timely Vented Referral Rate (within 1 hour of meeting triggers) # tissue donors # Donor Designation Increases in LifeSource DSA 90% ,000 68% 66% 72% 84% 86% 69% 75% 73% 66% 60% 71% ,641 25,015 29,188 quarterly 62,844 Green = Goal Met; Yellow = Nearing Goal; Red = Improvement Needed

7 Timely Referrals Why We Care

8 Rapid, Early Referral & Linkage Start Early: Organ Donation Breakthrough Collaborative Hospital and OPO communicate early; establish protocols to ensure early identification and timely referral of potential donors

9 CMS Condition of Participation Interpretive Guidelines Timely notification means a hospital must contact the OPO by telephone as soon as possible after an individual has died, has been placed on a ventilator due to a severe brain injury, or who has been declared brain dead (ideally within one hour).

10 Organ Recovery Agreement with LifeSource Timely Notification means notification of an imminent death to LifeSource within one hour of the patient meeting the clinical trigger criteria for imminent death. Notification to LifeSource shall be made prior to the withdrawal of any life-sustaining therapies. With respect to cardiac death, timely notification means notification to LifeSource within one hour of cardiac death.

11 LifeSource DSA Data Account Name 2010 Timely Referral Rate 2011 Q3 Timely Referral Rate 2010 Potential Donors 2010 Conversion Rate Abbott Northwestern Hospital 67% 75% 8 88% Altru Health System 100% 92% 2 50% Avera McKennan Hospital & University Health Center 84% 82% 9 78% Children's Hospitals and Clinics-Minneapolis 77% 80% 2 100% Children's Hospitals and Clinics-Saint Paul 63% 67% 2 100% Essentia Health Saint Mary's Medical Center (Duluth) 86% 94% 4 100% Fairview Southdale Hospital 61% 62% 5 80% Hennepin County Medical Center 74% 77% 21 81% Mayo Clinic - Saint Marys Hospital 79% 70% 19 89% Medcenter One Health System 86% 89% 3 33% Mercy Hospital (Coon Rapids) 69% 64% 4 100% Methodist Hospital-Saint Louis Park 75% 70% North Memorial Health Care 58% 68% 18 67% Rapid City Regional Hospital 84% 63% 6 67% Regions Hospital 62% 76% 21 76% Saint Alexius Medical Center 88% 93% Saint Cloud Hospital 61% 62% 10 80% Saint Joseph's Hospital (St. Paul) 63% 88% 3 33% Saint Luke's Hospital (Duluth) 94% 100% 4 100% Sanford Health (Fargo) 95% 100% 10 80%

12 Timely Referral & Conversion GOAL: > 90% of Referrals are Timely 5 Hospitals Meet the Goal LifeSource DSA = 79% Timely Conversion = 91% Altru, Essentia Saint Marys, Saint Alexius, Saint Luke s, Sanford Health (Fargo)

13 Sanford Health Fargo Donation Referral Call Timeliness Peggy Hill House Administrator Lead and Donor Council Chair

14 Rice Memorial Hospital

15 Jessica Vagle MA APRN CNS-BS FNP-BC Director of Adult & Care Management Karen Deisting LPN Care Management Quality Abstractor

16 Who are we? Located 2 hours west of the Twin Cities Largest City owned Hospital in Minnesota 99 Beds Life Source customer Donor Referrals from OR, ESD, ICCU & Adult Health Care Why are we speaking to you today? Demonstrated improvement in call timeliness to the Donor Referral Center

17 Donor Referral Center called within 60 minutes of death Rate Improvement: % % % % (thru 3rd quarter)

18 The Staff Nurses own the process! Life Source encourages us to do better! Form was recreated Combined with Pronouncement Of Death the nurses do on the forms top section. Donation is not discussed with the family prior to calling the Referral Center. Referral Center Call within 60 minutes of the death of ALL 100% of patients. Created a time entry on the form.

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20 The key to our success! Process: Every case is reviewed with an Audit Form we created which mirrors the actual form by our Abstractor Karen. It is identified on the audit form what the error was The audit form is sent to both the individual and the Director for follow up Follow up is one on one and educational in nature BOTTOM LINE Staff don t like to get the audit slips!

21 My Donation Resource Kathy Hicks, MPH Education Coordinator

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44 On-line Donation Resources

45 Connect to Purpose Bill Carlson, LifeSource Volunteer and Heart Recipient

46 A Gift to Bill s Donor Family on Veteran s Day

47 Polling

48 Questions and Answers

49 Next Meeting February 29, :00-1:00 PM Thank you and talk with you then!