Managing Resistance and Conflict: Through Partnering Transplant Donation

1. Managing Resistance and Conflict: Through PartneringTransplant Donation Sheldon Teperman, MD, FACS Associate Professor of Surgery The Albert Einstein College of Medicine Director of Trauma and Surgical Critical Care Jacobi Medical Center Bronx, NY

2. Disclaimers/ Disclosures/ Thanks • NYODN –Helped me get out here • Thanks to them-Helen Irving-Mike Goldstein and Trevor Cork • Warm thank you to Organ Donation and Transplant Alliance. • All case study identifiers are completely changed • Stories are totally true, just you cant go back and figure out which pt. it was.

3. Disclaimers/ Disclosures/ Thanks I am not a transplant surgeon and your world is outside of the scope of my daily practice The work we have done in partnering may, or may not be applicable in every setting and in every donor hospital

4. X Managing Resistance and Conflict:Through PartneringTransplant Donation Sheldon Teperman, MD, FACS Associate Professor of Surgery The Albert Einstein College of Medicine Director of Trauma and Surgical Critical Care Jacobi Medical Center Bronx, NY

5. NYODN Designated Service Area (DSA)* • Second largest OPO in the United States • One of 4 OPOs in New York State • 13 million population • Nearly 100 hospitals • 10 Transplant Centers • Average organs transplanted per donor is 2.68 New York State New York Organ Donor Network (NYODN) Service Area * Slide Courtesy of NYODN

6. Transplant Programs (Hospitals)* *Slide courtesy of NYODN

7. Jacobi Medical Center -Northeast Bronx New York City

8. Jacobi-Trauma Registry-Patterns of Injury 20% penetrating-80% Blunt

9. Disclaimers/ Disclosures/ Thanks • I am not a transplant surgeon and your world is outside of the scope of my daily practice • The Work we have done in partnering may, or may not be applicable in every setting and in every donor hospital • Ours is an Urban Trauma Center /Urban Violence • Socio-Economic , Educational and Cultural Barriers

10. I'm not going to tell the story the way it happened," narrates Finn (Hawke), the central character, at the beginning. "I'm going to tell it the way I remember it." * *Great Expectations- Adaptation of Charles Dickens Novel- Film version 1988

11. About as Low as it gets!

12. Getting Better!

13. Awesome!

14. Still on Track

15. How did we go from here to here?

16. Death in the Cath Lab Case actually happened- many of the details are changed- Some issues are exaggerated to highlight the point- No offense is meant. This happened at least six years ago 39 Y.O. female suffers a massive head injury and is declared brain dead, but is hemodynamically unstable and requires significant pressors The bedside transplant coordinator has a box to check. Her protocol tells her to obtain a Cath.

17. Death in the Cath Lab Does not check with OPO MD or the unit’s Critical Care attending “Order’s the Cath” Cardiology attending “does the right thing” and OK’s the Cath No optimization prior to transport Donor arrests “en route” all organs lost!

18. Death in the Cath Lab- Lessons learned • OPO ( ‘then’ not terribly concerned) • Trauma Center and SICU staff very concerned! • What are your concerns? • Mindless, check list driven protocol • No senior medical control or oversight • No protocols in place to prevent a dangerous and unnecessary transport.

19. The Next time Trauma Center goes to block a seemingly unnecessary test. OPO MD Calls the TC COO and ….Asks for …

20. Low Point

21. Case Study-ExperimentationChange in Protocol 55 Y.O. woman declared brain dead after MVC. Roughly early last decade Pt has poor P/F ratio-lungs failing Experimental (inflatable) vest is brought into the facility and placed on Pt’s. chest No protocol provided to host hospital, no evidence of FDA approval , no prior notification or discussion with host hospital Host hospital surgeon accused by OPO representative of being immoral, not caring about the donation process and being a “murderer”

22. Case Study-ExperimentationChange in Protocol Hospital and OPO now spend too much time talking about removing that individual ( which eventually happens) No one ever talks about the “Vest”, the protocol and its efficacy Sometime thereafter, an unrelated protocol change involving new and extensive blood “draws” are put into place…with no notification

23. Low Point Clearly the relationship is broken Its neither benefitting our Pt.'s or either organization Radical change and some form of new leadership is called for

24. Low Point- time for a change • New CEO and the Medical Director- • Deconstruct the relationship • Throw out things not working • Emphasize things that do. • Reality check of where does the resentment/conflict come from? • Born is the “Jacobi Protocol”

25. Finances Trauma Center and its finance Dept. cannot gets its act together in charging a donor management fee Then OPO CEO says, “You should do this out of the goodness of your heart” Trauma Center lets years go by without dropping a single bill and looses hundreds of thousands of dollars OPO is secretly pleased they have saved a fortune.

26. Finances New Leadership at the OPO CEO makes it a high priority to see that the TC is paid Directs her staff to track cases on behalf of this donor hospital Creates a “Mock invoice” and meets with donor hospital finance staff quarterly and “oversees and forces the dropping of a Donor Maintenance bill” OPO cuts a make –up check for $200k!.

27. Enforcement-Variance What not to do Don’t send a letter threatening action against a donor hospital if your are trying to build/or rebuild a relationship Threatening to rain down CMS on a well meaning Donor Hospital is a bad, bad, bad idea. It took the new OPO CEO months to undo that harm Enforcement is a last resort , if all else fails that decision should be made by the BOSS

28. The NYC Environment-Consent AKA Authorization The old thought that the donor hospital (doctors and staff) should walk on egg shells around discussions of transplant / donation may have been misguided A better model may be an integrated approach, both with the hospital social services people, the involved critical care attending/staff and the OPO family support people Its seems kinder and more humanitarian

29. The NYC Environment-Consent AKA Authorization • The hospital case worker (particularly in a circumstance of urban violence), Is in a better position to judge the initial family circumstance –they are already involved. • Clarification-the OPO staff still handles all matters related to consent-there is simply a better handoff and integration of the process. • A better coordination with the Social Services professionals already involved in the case

30. The NYC Environment-Consent AKA Authorization

31. Rebuilding Trust and ProcessChallenges No clear cut leadership and follow through at the OPO No trust in the integrity of the process at the host hospital No clear cut “Medical Control” of each individual case by the OPO. The Organization a macrocosm. for each Pt.

32. Rebuilding from the Ground up-New leadership Individual meeting (one on one) between the leadership at the OPO and host hospital leadership and faculty Real work – not just “window dressing” Donor Council set aside until this work was done.

33. Rebuilding from the Ground Up-New LeadershipTenants-Jacobi Protocol • Protocols are important but each case is different • All invasive procedures and tests are first discussed with the OPO’s Medical Director or designate – Also applies to unusual requests or repeat of previous test. • Are they truly necessary? Will they help the donation process or add unnecessary delay. Will “we” loose the “entire donor”?... • IS SOMEONE STEERING THE SHIP ?

34. Rebuilding from the Ground Up-New LeadershipTenants • After certifying a procedure-OPO facilitates a conversation between OPO medical control and the donor’s Critical Care attending • Overall trajectory of the donor is discussed. • Upon reaching agreement the Critical Care attending moves mountains to facilitate the procedure

35. Rebuilding from the Ground Up-New leadershipTenants-Controlling Transplant Center Demands Example: Donor case has been running for 3 days post consent. Lung Center wants a repeat Bronch, Heart Center wants a Swan and dobutamine, Liver Center wants a repeat CT OPO Medical Director-who is/was a Transplant Surgeon ( and know BS when he/she sees it). JUST SAYS NO!!!!!

36. The Tipping Point

37. The Tipping Point-Case Study • 22 Y.O. Female a victim of violent trauma- Pronounced brain dead • A pre-existing first person consent from an out of state drivers license is discovered after routine registry search • The family is adamant. There will be no Donation! • They are angry and hostile almost to the point of physical violence • They deny that facts about the donor registry

38. The Tipping Point-Case Study • Time is going by and neither FSC nor MSW make progress • Because of the trust built the hospital assumes guardianship of the patient-a first for NYC • The family is told forcefully, but as gently as possible, that their daughter’s last wish must be honored • A deadline is set/ the campus is locked down • There is the threat of civil disobedience

39. The Tipping Point-Case Study Six organs were recovered. A letter was read at the Young Woman's funeral-It was authored by the OPO’s FSC-it detailed the young woman’s heroism and the lives that were saved. The family clutches at the letter to this day and praises the OPO and the Hospital for the courage it showed that day. They are so very proud of their lost child!

40. Rebuilding from the Ground Up-New LeadershipTenants-Jacobi Protocol • Donor Hospital- “Greases the skids” • Trauma Surgeons facilitates OPO access to OR • We facilitate procedures/ expedite declaration • Initiate bed side goal rounds with the Transplant Coordinator • Optimize donor • Everyone on the same page

41. American Association for the Surgery of Trauma- Sept 20th 2013

42. Summary Real time communication between OPO Medical control and the bed side physician is critical to avoiding conflict in difficult cases. Unnecessary tests and endless days of donor management are an anathema to procurement. A true partnership ( one on one) between the OPO medical staff and the Donor Hospital staff (and executives) is essential. ( not just a donor council)

43. Summary Don’t allow staff members to “blow” up the relationship by self righteousness, ill conceived enforcement proceedings and bad behavior in some else's home. It Pays to Pay- Make sure the Donor Hospital is getting at least something back for their good work. Hospital Development Specialist checks “the pulse” of the relationship and keeps it on track

44. Summary • Make sure you have a CEO and a Medical director who are committed to the relationship and use their personal credibility and integrity to maintain it! • Ensure that there is an overall strategic plan that builds on and reinforces each successive victory and milestone • And make sure that message goes all the way down the line to everyone that enters a donor hospital • Each and every day • Each and every case