Regulatory Agencies and Partnerships

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Regulatory Agencies and Partnerships

• Regional Collaborative
• June 2009

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Agencies

• JCAHO
• Accrediting
• Active in promoting organ donation
• Standards guided by CMS and best practices
• CMS
• Regulatory
• Active in promoting improving performance in
  organ donation
• Conditions guided by some best practices, other
  regulations, and desire to reduce payments

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JCAHO

• Our shared vision must be to narrow
  (significantly) the organ donation gap and save
  lives!

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JCAHO

• Organ donation desired future state
• No one dies while waiting for a life-saving organ
• The number of transplants performed each year
  exceeds new demand, resulting in a sustained
  decrease in the Waiting List for Life
• Organ yield will increase from 3.06 organs per
  donor to over 3.75 organs per donor

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JCAHO

• Organ donation desired future state
• Cardiopulmonary criteria for determining donation
  potential are well-established in hospitals
• Hospitals will consistently maintain organ
  donation conversion rates that exceed 75
• The disparity in available organs for racial and
  ethnic minorities will be eliminated

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The low lying fruit

• Overall consent rate through 6.6.09 70
• 64 conversion rate with 17 shutdowns
• Untrained hospital staff consent 15 (3/20)
• If you take out UHS approaches the overall
  consent rate would be 81
• If those approaches would have been done by LOPA
  there would have been 16 more consents 10 more
  donors and 36 more lives saved

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JCAHO

• Organ donation desired future state
• The donation wishes and advance directives of
  deceased potential donors will be respected and
  carried out
• The opportunity for individuals to make a living
  donation will be facilitated through changes in
  employment and insurance policies and practice
• The increase in demand for organ transplantation
  will slow as a result of more effective health
  promotion and disease prevention programs

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JCAHO

• Achieving the desired future state
• How can we get there?
• All stakeholders need to do their part!

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JCAHOLatest updates

• In March 2009 the standards addressing organ and
  tissue donation moved from the Leadership chapter
  to Transplant Safety to make it easier to
  reference
• Your handouts include the JCAHO Crosswalk for
  standards pertaining to donation

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Overview of JCAHOchanges

• TS.01.01.01 EP 3
• The hospital has a written agreement with at
  least one tissue bank and at least one eye bank
  to cooperate in retrieving, processing,
  preserving, storing, and distributing tissue and
  eyes.

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Overview of JCAHOchanges

• Note 1 This process should not interfere with
  organ procurement.
• Note 2 It is not necessary for a hospital to
  have a separate agreement with a tissue bank if
  it has an agreement with its OPO to provide
  tissue procurement services nor is it necessary
  for a hospital to have a separate agreement with
  an eye bank if its OPO provides eye procurement
  services. The hospital is not required to use
  the OPO for tissue or eye procurement, and is
  free to have an agreement with the tissue bank or
  eye bank of its choice

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Overview of JCAHOchanges

• TS.01.01.01 EP 9
• The hospital notifies the OPO of patients who
  have died or whose death is imminent according to
  the following
• Clinical triggers defined jointly with its
  medical staff and the designated OPO present.
• Within the time frames jointly agreed on by the
  hospital and the designated OPO (ideally, within
  one hour).
• Prior to the withdrawal of life-sustaining
  therapies including medical or pharmacological
  support.

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Overview of JCAHOchanges

• TS.01.01.01 EP7
• The individual designated by the hospital to
  notify the family regarding the option to donate
  or decline to donate organs, tissues, or eyes is
  an OPO representative, an organizational
  representative of a tissue or eye bank, or a
  designated requestor.

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Overview of JCAHOchanges

• EP 7 cont.
• Note a designated requestor is an individual who
  has completed a course offered or approved by the
  OPO. This course is designed in conjunction with
  the tissue and eye bank community to provide a
  methodology for approaching potential donor
  families and requesting organ and tissue donation.

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JCAHO10 Cs for Success

• Champion for the cause!
• Commitment of leadership
• Culture of priority for organ donation
• Collaborative effort
• Communicate rapidly (call within 1 hour)
• Clinical trigger for call to OPO
• Conversion rate improvement
• Counsel potential donor families to increase
  consent
• Clarify procedures
• Consider establishing DCD protocols

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CMS

• 482.45(a)(3) Ensure, in collaboration with the
  designated OPO, that the family of each potential
  donor is informed of its options to donate
  organs, tissues, or eyes, or to decline to
  donate.
• Interpretive Guideline
• OPO screens for medical suitability
• Family must be informed of the familys donation
  options
• Ideally, the OPO and the hospital will decide
  together how and by whom the family will be
  approached

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CMS

• 482.45(a)(3) The individual designated by the
  hospital to initiate the request to the family
  must be an organ procurement representative or a
  designated requestor.
• Interpretive Guideline
• A designated requestor is a hospital-designated
  individual who has completed a course offered or
  approved by the OPO and designed in conjunction
  with the tissue and eye bank community

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CMS

• 482.45(a)(5) Maintaining potential donors while
  necessary testing and placement of potential
  donated organs, tissues, and eyes take place.
• Interpretive Guideline
• The hospital must have policies and procedures,
  developed in cooperation with the OPO, that
  ensure that potential donors are maintained in a
  manner that maintains the viability of their
  organs
• The hospital must have policies in place to
  ensure that potential donors are identified and
  declared dead within an acceptable time frame by
  an appropriate practitioner

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CMSImportant changes to OPO CoP

• Definition of an eligible donor
• For brain dead patients aged 70 and younger,
  everyone is eligible unless and until we can
  document otherwise
• Declaration in accordance with hospital policy or
  state law
• Documentation must be of a specific diagnosis
• Medical record reviews
• Level I or Level II trauma center or
• 150 beds, a ventilator, and an ICU

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Donate Life LouisianaHospital Campaign

• LHA and LOPA Partnership

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The Vision
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Donate Life Louisiana Hospital Campaign

• Our vision was to create a campaign that every
  hospital, regardless of size or type, could
  implement and have an impact on the waiting list.
• Campaign was launched at the 2008 LHA Summer
  Conference.
• We wanted to increase the registry list while
  educating our communities.

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Donate Life Louisiana

• A collaboration of organizations with the goal of
  educating the public about organ and tissue
  donation and to encourage our citizens to join
  the Louisiana donor registry.
• Including LOPA, Legacy Donor Foundation, Office
  of Motor Vehicles and the Louisiana Hospital
  Association

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Louisianas Need

• As of June 12, 2009, 101,894 people are waiting
  for a life saving organ transplant.
• 1,828 of them are in Louisiana
• An average of 18 people die a day waiting
  (nationally).

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Campaign Goals

• To increase the Donate Life Louisiana Registry by
  10 or 160,676 new registrations by the end of
  2009.
• Step 1 CEO Support
• Step 2 Assign a Champion
• Step 3 Hospital Commitments
• Step 4 Implement Campaign

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CEO Support

• Get LHA Board to Accept Challenge
• Send Out Letter to CEOs
• Distributed Packet with Hospital-Specific
  Materials
• Introduced Challenge at Summer Conference
• Reiterate Challenge at District Meetings and
  Annual Leadership Symposium
• Disseminate Reminders in Member Publications

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Assign a Champion

• Who Makes A Good Champion?
• PR/Marketing Staff Members
• Medical Staff, Including Doctors and Nurses
• Person with Personal Connection to Donation
• The Champion recruits others at the hospital to
  form a Donate Life Louisiana Campaign Team.

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Champion Buy-In

• Orientation
• Electronic Toolkit
• LOPA Partner
• Webinars
• E-mail Updates
• Tips and Ideas
• Other Hospital Success Stories

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Hospital Commitments

• Over 55 Hospitals Actively Participating
• Each Hospital Set a Goal
• Types of Hospitals
• Acute Care
• Rural
• LTAC
• Rehabilitation

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Implementing the Campaign
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Support and Resources

• LHA Website Campaign Section
• Electronic Toolkits Modeled after WPL
• Letter from CEO
• Press Release Templates
• Newsletter Templates
• Donate Life Louisiana Logo
• Tent Cards and Posters Templates
• Registry Form
• Action Ideas
• Rose Bowl Toolkit

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Support and Resources

• LOPA Hospital Resource Coordinators
• LHA Staff
• Donate Life Louisiana Brochures
• Donate the Gift of Life DVD
• HHS Resources
• Champion Network
• Tip Updates
• Webinars
• Templates

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Measuring Progress

• Code registry forms with hospital name.
• Record number of electronic registrations.
• Hospitals submit a three month progress report on
  actions completed and proposed actions for next
  quarter.

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Top 10 Ideas for Implementation

• Registry Drives
• CEO E-mail to Hospital Staff
• National Donate Life Month Activities
• Donor/Recipient Walk Through
• Payroll Stuffers

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Top 10 Ideas for Implementation
6. Local TV/Radio Shows 7. Newsletter Articles
(Internal/External Publications) 8. Bulletin
Boards 9. Partnering with Blood Bank 10. Lunch
and Learn
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Campaign Status
Our Goal 160,676 New Registrations Current
Number 143,630 Left to Go 17,046 As of June
9,2009 we are at 89 of our goal.
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Success comes in all sizes

• Bunkie General registered 75 people during a
  health fair
• Acadian Medical Center Flag Raising Ceremony
• Baton Rouge General Take 5 Leadership Challenge
• Ochsner multi-campus challenge hundreds
  registered in one week

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