DONATION BEST PRACTICES: The Secret to Successful DNV Accreditation Is Continuous Improvement 365 Days a Year
An interview with Catherine Stephens, RN, MSN, CNRN, the Patient Service Supervisor in the neuroscience ICU at SUNY Upstate Medical University in Syracuse, NY.
In October 2013, DNV Healthcare Inc. conducted an accreditation survey at Upstate Medical University, which included an assessment of the hospital’s organ donation performance over the past year.
Catherine, with 30 years’ experience as a nurse and manager, talks about DNV’s collaborative approach that’s based on the premise: What can we do even better next time?
Q: How would you summarize what the DNV surveyors were looking for during their visit to SUNY Upstate Medical University?
Catherine: As they did throughout the hospital’s other departments, the focus for organ donation was to demonstrate how we’re aligning ourselves with quality indicators and that we’re seeking continuous quality improvement.
Q: How did the DNV visit go?
Catherine: It went well over all on our two campuses and specifically with respect to organ donation. This was my second experience with DNV certification. They come every year. It keeps you on your toes and you’re learning things.
Q: Who did DNV surveyors meet with as it relates to organ donation?
Catherine: At our downtown campus, they interviewed me, our transplant director, our supervisor for tissue typing, one of our nursing directors, and our clinical nurse educator from our Community Campus.
Catherine: It’s not one person’s responsibility with organ donation and that’s what DNV is looking for. It was great because team members could answer questions based on their specialty.
Q: When a hospital awaits accreditation or re-accreditation, it’s not uncommon for an air of anxiety to set in. Was that the case at Upstate?
Catherine: I wouldn’t say my pulse rate wasn’t high in October when I was meeting with DNV! Everyone wants to do a good job. But I think if you can speak to what you do, and that you’re doing things according to best practice, that you have qualities and procedures in place and have a way to measure quality improvement, there’s nothing to have anxiety attacks over.
Q: DNV advises hospitals not to prepare for their surveys. It sounds counter-intuitive.
Catherine: Basically, you’re preparing 365 days a year. DNV’s approach focuses on quality indicators every single day. Don’t just benchmark yourself against other institutions; benchmark yourself against yourself.
Q: Though you didn’t formally prepare before the surveyors arrived, give us an example of what was on your checklist ahead of the visit.
Catherine: DNV are sticklers that your policies and forms are current, and that they’re in line with best practice. They check the charts to be sure you’re holding up your own standard. If you designate that you’re going to update policies every two years, then you shouldn’t have any forms that are older. So I made certain our written agreements, contracts and forms were up to date. When DNV asked about our agreements, including the one with Finger Lakes Donor Recovery Network (FLDRN), I could easily pull it from my notebook.
“For one thing, DNV asked how our hospital identifies potential donors and about our policies and procedures that address brain death criteria.” — Catherine Stephens
Q: Policies and procedures are necessary not only for regulatory compliance but also for standards of care. Can you share examples of DNV questions that probed whether Upstate is on top of its organ donation policies and procedures?
Catherine: For one thing, DNV asked how our hospital identifies potential donors and about our policies and procedures that address brain death criteria. Typical questions: “What’s your procedure of notifying the OPO about every death and every imminent death? If you’re doing this, how well are you doing it?” Another question: “How is your hospital following new standards for determining brain death that have changed over the last year or so?” We were able to show that we’d incorporated the new standards into our policies and procedures. All hospitals should be working with FLDRN to incorporate these changes.
Q: You mentioned notifying the OPO about potential donors. What were DNV attempting to find out from you?
Catherine: They wanted to be sure our nurses know about clinical triggers and that our hospital is calling FLDRN every time there’s a death or imminent death. We answered in great detail and also showed them a list of potential organ donor clinical triggers for our nurses that we got from FLDRN.
Q: How did DNV assess your team’s ability to adhere to those clinical triggers?
Catherine: They got us involved in lots of scenarios from which I learned a great deal. They’d say things like: “Teach us how you do something. Let’s say I’m 21-years-old and I come into the hospital’s emergency room. I have my family with me. I’m ventilated. I have no pupillary reflex and I’m not responsive to pain. Tell me how your hospital handles this patient? What would the nurses do first? What would they do next?” DNV wants you to walk them through how you would handle that patient. That’s when we referred to the clinical triggers that would lead to the phone call to notify the OPO.
Q: And give us a little more detail as to what they asked about a patient progressing to brain death.
Catherine: The DNV surveyors wanted us to walk them through our process. For instance: Who talks to the family? They were making sure we have an outside agency—FLDRN—as the designated requestor and that we don’t approach families for donation ourselves. DNV were very happy with the support we get from FLDRN and the way we work together. The key is a separation between the hospital staff and FLRDN when talking to the family about organ donation, even if their loved one signed the donor registry.
Q: What did DNV ask you about how you measure whether you’re meeting your goals?
Catherine: They linked how we measure success with how we can go about making improvements. We explained how we review cases at our monthly quality meetings and when the Donor Council meets. We told them we look at quality data, and evaluate what went well and what we should have done better. We review our referral rate. Did we have a 100% referral rate? Were there late referrals or missed referrals? Were there pre-approaches (nurses or doctors approaching families before the OPO arrives)?
Q: Now that you’ve successfully completed another DNV survey what, in your opinion, is the most important advice you can share with other hospitals? What’s the take-away?
Catherine: DNV validates how your hospital provides care. Their approach to continuous quality improvement is what we should all be doing in healthcare for everything. When you’re doing something, DNV takes it one or two steps further. For example, how does interaction with the patient’s family impact the community? Is your hospital promoting donation in the community? What refresher training do we offer about donation? How do we ensure all nurses, doctors, anyone who touches the patient, knows about organ donation, and knows about the rules and policies?
Q: You seemed to enjoy the experience with DNV. Why?
Catherine: All through the process, I felt like I learned a lot from the conversations with DNV surveyors. What makes you get better is the accountability toward continuous quality improvement and having procedures so people know what a good job looks like.
Editor’s note: As was stated in this interview, Catherine Stephens co-chairs the Organ Donor Council in the area served by SUNY Upstate Medical University. The other co-chair is Julius Gene Latorre, MD, MPH. Council members include staff from the hospital as well as representatives from Finger Lakes Donor Recovery Network, Central New York Eye and Tissue Bank and Musculoskeletal Transplant Foundation.
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