AOPO DFSC Webinar PDSA Engage and Change AJ Johnson UPDATED
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AOPO DFSC Webinar PDSA Engage and Change AJ Johnson UPDATED
- 1. The PDSA Engage and Change: A Multi-Disciplinary Process Model to Serve African American Families AOPO DFSC Webinar – Focus on Authorization AJ Johnson, CPTC Senior Organ Recovery Coordinator Sierra Donor Services
- 2. The Why? Multi-disciplined Program Approach NEED ACKNOWLEDGED
- 3. The Why? 2013 Deceased Donor Rates By Race in California U.S. Department of Health and Human Services, HRSA, Organ Procurement and Transplantation Network 46.1 8.7 37.1 6.8 0 5 10 15 20 25 30 35 40 45 50 Caucasian African American Hispanic Asian
- 4. The Why? Sierra Donor Services (SDS) DSA Population by Race White 34% Hispanic 28% Asian 18% African- American 14% Pacific Islander 1% Races in SDS DSA 2012 White Hispanic Asian African-American Pacific Islander American Indian Other Race Multiple Race
- 5. The Why? African American Consent Rates in Sierra Donor Services (SDS) DSA In 2010, Sierra Donor Services (SDS) African- American consent rates were 23%. In 2011 the following year showed increased gains, but still were only 40%.
- 6. The Beginning Call to Action The Case That Started It ALL On June, 2nd 2013, a prominent African- American Minister in our DSA chided us… “Ideally, a person should not hear about nor discuss donation for the first time at the deathbed of their loved one. This discussion should take place NOT where a person DIES, but where they LIVE…!”
- 7. The Beginning Call to Action “…people LIVE in communities…” “…that is where your message should be heard first!”
- 8. The Beginning Listen to the Needs of the Community It was clear, we needed a revised plan…but what exactly?! Before we took action to respond to the assumed needs, we first went to the community and listened! We heard what the needs were and HOW the community wanted these needs addressed. And then…WE took ACTION!
- 9. PDSA Framework and Team A team of ONE Clinician and ONE Community Outreach Coordinator was created. The PDSA officially began on October 19, 2013 with the COMMUNITY OUTREACH PHASE. The CLINICAL RESPONSE/MNGMT. PHASE began December 17, 2013 and came to a close on August 26, 2014. The PDSA Team met with the SDS Executive Director and Senior Leadership once a week to give a progress report.
- 10. PDSA Fearless Messaging Engagement of individuals with transparency, an informative open dialogue validating their experiences, while addressing each misperception head on. The goal is not to allow anyone to leave a conversation, or engagement with negative rhetoric endorsed by the silence of the OPO, or it’s perceived representative. Fearless messaging was proven to be effective in community, hospital and family engagement opportunities.
- 12. LIKE REQUESTOR RIGHT REQUESTOR LIKE Requestor is incomplete. RIGHT Requestor is a Public Education, Hospital Services, Clinical Services, and Family Care subject matter expert on donation. RIGHT Requestor is a professional ADVOCATE for donation and transplantation throughout the entire process. RIGHT Requestor cultivates a DONATION subculture within the many layers of the hospital. RIGHT Requestor recognizes this work in its nature is about Collaboration, Respect and Trust.
- 13. LIKE REQUESTOR RIGHT REQUESTOR Donation is a focused, but fluid linear process from A to Z. The PDSA allowed for consistent, focused execution of action steps throughout the referral process, Donor Family engagement, organ donation process, and follow-up. Created collaborative hospital relationships. Donor Family advocacy created Donate Life Ambassadors/Advocates.
- 15. LIKE REQUESTOR RIGHT REQUESTOR STAGES of A’s ARRIVE ASSESS ADDRESS APPROACH/ADV OCATE TOOLS - FOUR D’s DRESS DEMEANOR DIALOGUE DATA
- 16. ARRIVE THE FOUR D’S OF EFFECTIVE REQUESTINGBE • Present/behave in a professional manner in all that you do and to all you engage. • Aware of your surroundings. KNOW • The Culture of hospital/Intensive Care Unit which is unique unto itself. • The Gatekeepers DO • Observe the Four D’s of the PATIENT, FAMILY, HOSPITAL TEAMS. • Listen, observe, and be silent. ARRIVE DIALOGUE DEMEANOR DATA DRESS
- 17. ASSESS THE FOUR D’S OF EFFECTIVE REQUESTING BE • Diligent and Discerning in your FACT gathering. KNOW • The patient and their hospital course, medical/social history if available. DO • Collect ALL pertinent data regarding patient. • Testimonials from MD, RN, RT, etc. can provide valuable information about the family’s experience with the hospital during the patient’s course. ASSESS DIALOGUE DEMEANOR DATA DRESS
- 18. ADDRESS THE FOUR D’S OF EFFECTIVE REQUESTING BE • Aware of specific needs, beliefs, and practices of the patient and the culture he/she is from. KNOW • Your EVOLVING audience! DO • Provide Family Centered direction and motivation when needed, setting expectations moving forward through the evolving process. • Guide Staff to a place where they are comfortable with our presence and the situation while maintaining an effective collaborative environment. ADDRESS DIALOGUE DEMEANOR DATA DRESS
- 19. APPROACH ADVOCACY THE FOUR D’S OF EFFECTIVE REQUESTING BE • Culturally Humble KNOW • The wealth and depths of your own personal biases. • Differences may exist between your values and beliefs and respect those differences. DO • Constantly “scan your sector” for changing attitudes, verbal and non verbal communication of the approached family. APPROACH DIALOGUE DEMEANOR DATA DRESS
- 20. APPROACH ADVOCACY THE FOUR D’S OF EFFECTIVE REQUESTING BE • Supportive and have an genuine expressive and expansive philosophy of Dual Advocacy. KNOW • Where it may be unrealistic to know ALL the common beliefs of the communities we serve, it is reasonable to be informed about the practices and needs of the communities we see with regularity. DO • Ask open ended questions, make empathic comments, and probe to elicit families own perspectives. APPROACH DIALOGUE DEMEANOR DATA DRESS
- 22. Cultural Competency vs. Cultural Humility Cultural Competency •Organizational systems •Cultural resources to facilitate care •Understanding local demographics Cultural Humility •Awareness of personal biases •Listen rather than assume •Identify what is “beneath the iceberg” Cultural Dignity •The goal of culturally appropriate, competent, sensitive care •What the patient/family/ community bring to the encounter •What the patient/family/community take away from interactions
- 23. Cultural Competency vs. Cultural Humility Cultural Competency Systems Level Cultural Humility Provider’s Stance Cultural Dignity Patient and Family Experience
- 25. Measurement of Results Clinical Response/ Approach and Authorization PDSA ONLINE INTAKE FORM Referral data collected and maintained by one clinician for consistency. In addition to data the intake form collected testimonials in real time from potential donor families and hospital teams. Demographic data, not typically collected, assisted in gleaning information for future engagements.
- 26. Measurement of Results Clinical Response/Approach and Authorization 0 10 20 30 40 50 60 70 80 90 2010 2011 2012 2013 2014 Consent Rates
- 27. Measurement of Results Clinical Response/ Approach and Authorization The PDSA outcomes have demonstrated that customization of the message for the targeted community in concert with the appropriate messengers will increase dissemination of accurate information and most importantly get the “yes” from the donor family. This Approach/Authorization Protocol demonstrated the “Like Requestor, Right Requestor” aligned with fearless messaging techniques is effective. These methods could be considered for those DSA’s with low consent rates in communities of color.
- 28. A Few Things to Consider Developed clear and concise goals and constantly evaluate their efficacy. Use the PDSA model for improvement as a framework for developing, testing, learning and refining processes as it relates to present and future engagement of communities of color. Replication is possible through Effort, Energy, and Excitement! Focus on the entirety of the Linear Process of Donation, from A to Z. The greatest yield will not be met by focusing on one area of it.
- 29. LASTLY: A Renewed Challenge Let’s Talk About It! "Change will not come if we wait for some other person or some other time. We are the ones we've been waiting for. We are the change that we seek." - President Barrack Obama
- 30. Contact Information AJ Johnson, Senior Organ Recovery Coordinator Phone: 206-419-0151 Email: ajohnson@dcids.org Nicki Carrillo, Senior Public Education Coordinator Phone: 206-931-7925 Email: ncarrillo@dcids.org
- 31. References Racial Microaggressions in Everyday Life, Implications for Clinical Practice May–June 2007. American Psychologist 271 Copyright 2007 by the American Psychological Association 0003-066X/07/Vol. 62, No. 4, 271–286 DOI: 10.1037/0003-066X.62.4.271 Clinicians’ Implicit Ethnic/Racial Bias and Perceptions of Care Among Black and Latino Patients ANNALS OF FAMILY MEDICINE. WWW.ANNFAMMED.ORG VOL. 11, NO. 1 JANUARY/FEBRUARY 2013 The State of Research on Racial/Ethnic Discrimination in The Receipt of Health Care May 2012, Vol 102, No. 5 | American Journal of Public Health Shavers et al. | Peer Reviewed | Framing Health Matters Coalition of Compassionate Care of California-Building Bridges Cultural Diversity and End of Life Care Seminar, End of Life Care Through a Cultural Lens Strategies for Culturally Effective End-of-Life Care, ACADEMIA AND CLINIC, 2002 American College of Physicians-American Society of Internal Medicine I www.annals.org
Editor's Notes
- My name is AJ Johnson, Senior Organ Recovery Coordinator from Sierra Donor Services located in Sacramento California. I am both honored and humbled to address you all today. This presentation is MY first person account from personal and professional experiences, and education within the realms of Organ Donation/Transplantation. With more than a decade of experience and service in this field, this presentation is a culmination of those experiences coalesced with evidence/outcomes from this PDSA change model.
- I spent 13 years in the United States Army, and I’d like to share with you all something that was taught to me while I was there. The B.L.U.F.F.!!!! (BOTTOM LINE UP FRONT FIRST!) This is a way of speaking that we use in the Army! It’s a type of speak, that gets to the ROOT of the matter quickly without any added fillers or fluff. It’s efficient. It’s HONEST. And most of all, it’s effective. The BLUFF here AS it pertains to this PRESENTATION and more importantly the NEED, is simple! YES! As you all can see on the screen, “The need of ALL has been ACKNOWLEDGE!” But this STATEMENT is incomplete! YES! THERE IS A PROBLEM THAT WE HAVE ALL ACKNOWLEDGED! THIS is EVIDENT by your attendance on today’s call. The BOTTOM LINE UP FRONT FIRST as it pertains to what faces us, is a SIMPLE SOLUTION that has been made far too COMPLEX! By institutional and organization apathy, and unwillingness to fully engage this problem head on, we ALL are culpable. Sure! We have studied, probed, poked, and postulated for years! But what have we DONE? Time is wasted and with this stagnancy comes with it the unnecessary loss of lives. Lives WE are committed to saving.
- I know you all have seen and are quite familiar with the national numbers. Allow me to show you what we are up against in California. In 2013 DECEASED DONOR RATES in California were slightly higher than the population of AA in the state. AA make up 6.9% of residents of California and 8.7% of deceased Donors. 2709 are awaiting transplant, of 12.2% of the California Waiting List. 2551 are waiting for kidneys. WAIT TIMES ARE ON AVERAGE 10 YEARS!!! California Active OPOs 4 Active TXCs22 OPO : Organ Procurement Org. TXC : Transplant Center
- African Americans only account for appx 6.9% of the California Population. However, African Americans more than double that in SDS DSA and is more in line with the National Population rates.
- And from the CHALLENGE grew a relationship! And an commitment to MEET people where they LIVE. Dr. Brown would invite SDS to join his church in their first annual Community engagement event called the “Capitol City Block Party!”
- It was clear we NEEDED a plan! For the “in box thinking” one size fits all approach we had was a complete and utter failure as it pertained to communities of color.
- We developed an effective way of engaging It’s my opinion that consent or authorization was not given the importance that it deserves, for without the “Yes”, there is no case. No organs recovered, no lives saved. Without the “YES” lives are not saved. BOTTOM LINE UP FRONT FIRST! What’s the BLUFF?!
- LIKE REQUESTOR, RIGHT REQUESTOR-Traditionally Like requestor was and is in present day as I understand it, is a requestor who shares the same ethnic or racial profile of the patient’s and their family.
- 1) Like Requestor is only a part of what is needed to truly address the totality of the ‘IN ROOM” challenges. 2)Cultural Norms Linguistics Cultural History first person accounting 4) TREAT HOSPITAL STAFF AS A PARTNER! Invest in them with each opportunity you interact with them. Hospital Staff “buy-in” is essential to its success. Creation of sub culture of DONATION identifiable by its language, its behavior, and its structure is key to creating an environment and situation that creates successful outcomes, i.e. the “YES!” This identifiable sub culture or donation culture is triggered by the very presence of the RIGHT requestor as the DONATION need emerges from the HOSPITAL CULTURE. The RIGHT requestor facilitates a transition of these CULTURES. How does the RIGHT requestor go about doing this, you ask? By approaching every situation as it’s own unique cosmos of moving parts and energy. Respectfully addressing the needs, concerns, and the work of our external partners in our hospitals while focusing on the needs of our potential donor family. Further, it is important to acknowledge no matter how much we train hospital staff about our policies and structures they remain esoteric to many and misunderstood and misinterpreted by a few.
- Donation is a linear process from A to Z. The PDSA has allowed us to be involved in each linear step. From education of the community to real time hospital engagement and education to the approach it self. But not ending there! The PDSA allows us to be involved from the beginning to the end. but to also creation of advocacy from donor families.
- Now that we have a 30,000 foot level perspective of LIKE REQUESTOR, RIGHT REQUESTOR. Allow me to go a more ground level perspective from the day in the life of a LIKE and RIGHT REQUESTOR! Beginning with PREPARATION. In my practice I have found the little details are the ones that kill!
- The A’s! are STAGES of the Process! And they are for the most part, self-explanatory. However, they ARE fluid and often are changing from moment to moment---to phone call to phone call---to each face to face engagement. STAGE 1: ARRIVE-On site for the first time. This is at the beginning of the referral process/referral response. STAGE 2: ASSESS This is done in each engagement of the referral/donor process. From telephonic conversation to on site/rounding/approach. It is not a static construct, but fluid. STAGE 3: ADDRESS This is the time proceeding when the family may be approached for donation. It normally occurs when STAGE 4: APPROACH/ADVOCACY-This is the “in room” approach. The Four D’s are TOOLS used in engagements. The D’s are a sensory exchange of all who are involved in any and every part of the stages. They include, RN’s, MD’s, HOC’s, the person in elevator who notices something different about you to the family member to whomever! YOU are not only USING these TOOLS for your own assessment of your surroundings, to a certain degree those around are using their own mnemonic to evaluate YOU! The D’s are all about that ICEBERG analogy we’ve so often used and heard. Your physical appearance to your demeanor and tone. DRESS and DEMEANOR: Exude Professionalism! It is a weapon! Your appearance is the one personal characteristic that is immediately obvious and accessible to others. You can’t hide it. Your appearance makes a strong statement about your personality, values, attitudes, interests, knowledge, abilities, roles, and goals. You can’t afford to be seen as disrespectful, antagonistic, pretentious, scatterbrained, irresponsible, ineffective, or unproductive. You can’t afford to create a negative impression or to build barriers between you and others because of your appearance. This sets the stage for those who will interact with you and to create a positive first impression. DIALOGUE: Professional and concise. Be Brief, But Brilliant. DATA: Clinical Data collection as well as the testimonials of staff and other noted interdisciplinary evaluation. Your D’s tell YOUR story! And other’s D’s tell theirs! So listen, and investigate. The D’s and the A’s are fluid, so my evaluation of them is equally without form.
- BE KNOW DO is another ARMY model. It is one that is used to teach Military Leadership and Troop Engagement. STAGES OF PROCESS! The A’s! are STAGES of the Process! ARRIVE-On site for the first time. This is at the beginning of the referral process/referral response. DRESS and DEMEANOR: Exude Professionalism! It is one of my best weapons Your appearance is the one personal characteristic that is immediately obvious and accessible to others. You can’t hide it. Your appearance makes a strong statement about your personality, values, attitudes, interests, knowledge, abilities, roles, and goals. You can’t afford to be seen as disrespectful, antagonistic, pretentious, scatterbrained, irresponsible, ineffective, or unproductive. You can’t afford to create a negative impression or to build barriers between you and others because of your appearance. This sets the stage for those who will interact with you and to create a positive first impression. DIALOGUE: Hospital Concerns
- STAGE 2: ASSESS This is done in each engagement of the referral/donor process. From telephonic conversation to on site/rounding/approach. It is not a static construct, but fluid. Ongoing evaluation of Four D’s as they EVOLVE in Patient, Family, and Hospital Staff. They can often change as the referral process evolves into an Approach/Advocacy Opportunity.
- STAGE 3: ADDRESS This is the time proceeding when the family may be approached for donation. It normally occurs when
- STAGE 4: APPROACH/ADVOCACY-This is the “in room” approach. Concepts of culture and ethnicity may be useful for making generalizations about populations; however, if used to predict individual behavior, they may be dangerous and lead to stereotyping.
- I believe Donation is the BEST option for all families given the choice of donation. The requestor can avoid stereotyping by asking EXPLICITLY whether the patient/family holds a belief that is prevalent within the culture to which they belong. Further, draw down on the individual in the room…Make the discussion about the patient and his/her good will in life, contrasting that his/her death should be commensurate with the way they lived their life. This can be an effective tool one can place in their approach tool box! Offer emotional support, through touch, hugs, or whatever is REQUESTED by the family.
- Cultural competency is the organization structures broad strokes definition of the entirety of a community. Normally filled with generalizations and assumptions of the population, Cultural Humility is more a CURIOSITY and INVESTIGATION into the PERSON. It is the engagement of the person beneath the “iceberg” rather than that of what’s perceived on the surface. This EXPLORATION comes with questions from the requestor to the patient’s family, not assumptions based merely on appearance. CULTURAL DIGNITY creates an openness, safe to be “who they are.” Patient’s family is left feeling acknowledged, supported, and with their dignity intact and they were dealt with integrity.
- Our patients do not lives in our CULTURE! We must MEET them in theirs. MEET them where they ARE! In some cases, the understanding of disease, illness, and death itself can be difficult to grasp for the family given the wealth of emotions they may be dealing with in the moment. Remember, while you may be present in this experience in clinical and intellectual sense, their experience may be solely emotional. Experiences are different than diagnosis. Distinguish between magical thinking vs Reality? What is their understanding that allows for magical thinking.
- Our data collection was not limited to just that of demographic and clinical details, we also collected testimonials from family members, deviations of standards of care practices, observations of staff cultural competency as it relates to this population.
- We created an online data base. What you see is a copy of our electronic intake form. It tracked all of the common information seen in most OPO’s, but there’s a wealth of additional data not traditionally tracked by OPO to include testimonials, deviation of standard of care, social economic status, ethnic background, specific religious adherents and practices.
- Including a consent done at the Sacramento County Jail of a mother suspected of NAT of her own child. 2014 2013 2012 2011 2010 7/3(2 PDSA declines) 11/5(1 PDSA consent) 6/8 4/6 78.7% 68% 57% 40% 23%
- Always keeping the NEEDS of THOSE WE SERVE and their families at the forefront of what we do. Engaging organizational and senior leadership support to help reduce barriers and obstacles that may occur. Focusing on strategies to facilitate the spread and sustainability of this EFFORT.
- In order that we SAVE lives tomorrow and in the days and years to come, we must leave today committed to the level of courage and selflessness that our DONOR family exemplifies. When given the hard choice, THESE FAMILIES chose to GIVE, they chose to SERVE! They chose a path that certainly at the very least IS uncomfortable. But look at what that BRINGS--- LIFE! We MUST put aside ourselves, for the better of all, for ALL are whom we serve. IMAGINE If every person on this call, including myself---OPO staff, ICU nurses and physicians, Hospital Administrators and ancillary staff commit to this example of selflessness and service now, over the next year many lives will be impacted? Bodies will be healed; families will be comforted, because lives will be saved. SO I ask you, what choice will you make when today? Will you let the ordinary and the familiar routines as you return to your respective places of employment lead you away from what WE shared here today? As the echoes of the words spoken become mere whispers, and the emotions WE have shared become faded recollections of a whimsical day, will the routines of your comforts paralyze you to inaction and apathy? Or will you take what WE have been given here today and let this newfound SPIRIT of COOPERATION and TEAMWORK guide US to selflessly serve ALL who we are in NEED? The CHOICE is yours---Unite as ONE team across this GREAT NATION with ONE mission and the COMPLEX will become SIMPLE and the impossible becomes POSSIBLE. This is my BLUFF!!!