The Forward Focus Journey at MCHS - Eau Claire

1. The Forward Focus Journey atMCHS - Eau Claire Anna Sylla, RN-BSN

2. 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

3. 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

4. The Journey’s 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

5. Team Luther’s 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

6. The Future of Team Luther’s 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.