This document describes a PDSA cycle conducted by the Theda Clark Medical Center Intensive Care Unit to improve the timeliness of referrals to the organ procurement organization (UWOPO). The current state showed that ICU staff were calling UWOPO within one hour of patients meeting clinical triggers only 62% of the time. Experiments conducted included staff education on triggers and daily tracking of patients. These interventions improved the timely referral rate to 100% in December and January. The document emphasizes that organ donation is important to the organization and that using the PDSA format helps maintain focus on solving identified problems.

1. TIMELY REFERRALS TO
UWOPO-PDSA THINKING
Theda Clark Medical Center Intensive Care
Unit

2. Why did we start a PDSA?
 During our monthly ICU leadership meetings we evaluate our
UWOPO dashboard
 Starting in June 2011, we began to separate ICU and ER
data for Theda Clark Medical Center, to understand our
opportunities
 When the numbers were separated we saw an opportunity for
the ICU
 Over the next few months we began to collect our
background/current state data and documented this in our
standard PDSA format
 By using the PDSA format we are able to maintain focus on
the real problems, focus on working one solution at a time,
study our experiments and act if we are not seeing the
anticipated outcomes

3. What did our current state
show?
 Problem Statement: Within the TC ICU, when ICU patients
meet UWOPO clinical triggers staff are calling statline within
one hour 62% of the time from January-Sept 2011, potentially
missing donation opportunities, delaying UWOPO analysis for
appropriate candidates and increased family dissatisfaction
with donation process.
 Average call time 20.6 hours. Only 4 out of 16 late calls met
triggers at time of admission to the ICU.
 Ideal State: The TC ICU staff will be timely on 100% of all
calls to UWOPO within one hour of ICU patients meeting
UWOPO clinical triggers.
 Organizational Tie: By increasing timeliness of calls made to
UPOPO we will impact customer satisfaction with our
patient’s families and UWOPO by increasing the quality of
time and increasing the turnaround time to a decision.

4. Next Steps
 Through process observation, process flow mapping, staff interviews, 5
whys we were able to understand our problems, root cause and potential
solution

5. Experiments tried and
outcomes
 -11/16 Sam Taylor from UWOPO
presented at ICU staff meeting
refresher on UWOPO clinical triggers
(small staff attendance, but
communicated in weekly email
update)
 -11/24 all staff given updated
UWOPO badge backers with clinical
trigger information
 -11/24 UWOPO clinical trigger
reminders posted in all nursing pods
and workstations
 -1/6/2012 twice daily tracking of all
ICU patients to determine those
meeting clinical triggers implemented
to be completed by resource RN
 -October timely referrals at
75% for all ICU patients
 -November timely referrals
at 50% for all ICU patients
 -December timely referrals
at 100% for all ICU
patients
 -January timely referrals at
100% for all ICU patients
Experiments Outcomes to date

6. Why do we keep doing this
work?
 Organ donation is a key driver for our
business line
 This work has engaged staff in process
improvement
 Our unrelenting drive for perfection uncovered
more opportunities than we first considered
 By using a consistent format and process, you
are able to prove you have a problem and
maintain focus on solving that problem
 PDSA work is a significant component of the
ThedaCare Improvement System, and
integrated into our culture of continuous

7. Why do we keep doing this
work?
 Organ donation is a key driver for our
business line
 This work has engaged staff in process
improvement
 Our unrelenting drive for perfection uncovered
more opportunities than we first considered
 By using a consistent format and process, you
are able to prove you have a problem and
maintain focus on solving that problem
 PDSA work is a significant component of the
ThedaCare Improvement System, and
integrated into our culture of continuous