/policies/,/policies/administrative/,/policies/administrative/uwhc/,/policies/administrative/uwhc/department-specific/,/policies/administrative/uwhc/department-specific/uw-organ-and-tissue-donation/,

/policies/administrative/uwhc/department-specific/uw-organ-and-tissue-donation/401.policy

20180232

page

100

UWHC,

Policies,Administrative,UWHC,Department Specific,UW Organ and Tissue Donation

Medical Record Review, Hospital Classifications, and True Conversion Rate (4.01)

Medical Record Review, Hospital Classifications, and True Conversion Rate (4.01) - Policies, Administrative, UWHC, Department Specific, UW Organ and Tissue Donation

4.01



POLICY
Established Date: December 2005
Effective Date: January 2018
Title: Medical Record Review, Hospital
Classifications, and True Conversion Rate
Policy Number: 4.01

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 1 of 6
PURPOSE

The purpose of this policy is to describe how the University of Wisconsin Organ and Tissue Donation (UW
OTD) will complete medical record reviews to identify the number of potential organ donors and will
compare the number of potential donors to the number of referred and actual organ donors in the UW
OTD donation service area (DSA). This policy also describes the medical record review quality assurance
(QA) review process. Information compiled through this process is evaluated to help create hospital
development plans and is reported to regulatory agencies. The medical record and QA reviews will be
completed according to all applicable regulatory requirements. This policy also identifies how hospitals are
classified, according to donor potential and use of the true conversion rate (TCR) as a performance metric.

FORMS

Chart Review Form
QA Chart Review Form
Death Notification Registration Form
Hospital Dashboard

POLICY
Potential Donor and True Conversation Rate (TCR) Definitions
A. UW OTD defines a potential organ donor as follows:
1. A “potential donor” is a term used industry-wide to describe a patient that is being
evaluated for organ donation. It is used to reference the patient throughout the referral
process until the patient becomes an actual organ donor.
2. A “Potential Donor” is a UW OTD-specific term used to describe a patient that was
determined to be medically suitable for organ donation (either donation after brain
death or donation after circulatory death) based on known clinical information at the
time of referral closure, but did not progress to be an actual donor. This is used by UW
OTD to identify the total donation potential in the DSA beyond the regulatory definition
of eligible and to include additional DCD potential.
B. For the purposes of this policy, the term “potential donor” will be the industry-wide term unless
otherwise noted.



POLICY
Established Date: December 2005
Effective Date: January 2018
Title: Medical Record Review, Hospital
Classifications, and True Conversion Rate
Policy Number: 4.01

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 2 of 6
C. The TCR is a measure used by UW OTD to quantify the percentage of UW OTD Potential Donors
that become actual donors. The TCR is included on hospital and UW OTD dashboards. The TCR
is calculated as follows:
1. The number of actual donors (numerator) divided by the number of actual donors plus
the number of Potential Donors (denominator).
2. The number of attempted DCD cases and medical rule-outs in the operating room is
added to both the numerator and the denominator.

Hospital Classifications
A. The hospital classification determines how frequently medical records are reviewed and data is
distributed, among other services provided to hospitals (i.e. customized hospital development
plans).
B. Each hospital in the UW OTD DSA will be classified into either category; “A”, “B”, “C”, or “D”.
1. “A”: The hospital is amongst the group of hospitals collectively producing approximately
80% of total organ donation potential in any year measured over the last five years.
Potential, referred, and actual donation data reviews will be conducted at minimum
monthly.
2. “B”: The hospital has had at least one organ donor or eligible death during any year
measured over the last five years. Potential, referred, and actual donation data reviews
will be conducted at minimum semi-annually.
3. “C”: The hospital has had zero organ donors or eligible deaths measured over the last
five years. Potential, referred, and actual donation data reviews will be conducted at
minimum annually.
4. “D”: The hospital is a psychiatric or mental health institution. Potential, referred, and
actual donation data reviews will be conducted at minimum annually.
C. Additionally, per regulations from the Centers for Medicare and Medicaid Services (CMS), any
hospitals other than “A” hospitals that are certified for 150 beds or more will be classified with
the number 1 after the letter classification. Medical record reviews and data distribution will be
conducted monthly for “B1” and “C1” hospitals.
D. The criteria for hospital classification will be reviewed annually and hospitals will be reclassified
when criteria changes or when hospital characteristics change.
E. Each hospital within the UW OTD DSA will be assigned to a UW OTD hospital development
specialist (HDS) who will be responsible for medical record reviews of potential, referred, and
actual donation data.



POLICY
Established Date: December 2005
Effective Date: January 2018
Title: Medical Record Review, Hospital
Classifications, and True Conversion Rate
Policy Number: 4.01

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 3 of 6

Medical Record Reviews for Patients Not Referred to UW OTD (identifying the number of potential donors)
F. A HDS or other designated UW OTD staff member will review reports provided by Statline, the
UW OTD answering service, to identify deceased patients that were previously ventilated but
not reported to UW OTD for organ donation evaluation for all DSA hospitals at a frequency as
determined by each hospital’s classification.
G. UW OTD will review the referring hospital records of previously ventilated patients to determine
whether the patient met clinical triggers and was considered imminent and/or eligible at the
time of the patient’s death (also referred to as a chart review). Clinical triggers are defined in
UW OTD policy 2.01.
H. Medical record reviews will be conducted either through remote access to electronic hospital
medical records, onsite at a hospital, or the hospital will fax records to UW OTD as requested.
I. Data collected from medical record reviews will be documented on a Chart Review form.
Completed chart review forms will be maintained as outlined in UW OTD policy 1.09.
J. Outcomes of a medical record review include:
1. The patient did not meet clinical triggers and it was appropriate to not be referred to UW
OTD. No further action is required.
2. Missed Referral: Patient met clinical triggers and should have been referred to UW OTD.
i. Detailed data reports will be generated from the UW OTD database and shared
with the referring hospital via email or in-person
ii. A first offense will be used as a learning opportunity to educate the hospital staff
and/or unit involved on clinical triggers and the referral process
iii. Education provided to hospital will be documented in Donor Tracking HD
Activities per UW OTD Policy 4.03.
iv. HDs will monitor any trend of multiple missed referrals occurring at a hospital
and share with key hospital contacts
v. If a trend in missed referrals is identified, HDs will communicate with UW OTD
leadership and hospital senior administration to discuss the impact of having
missed referrals and create a plan for further education and/or process
improvement to resolve the issue
3. Missed Imminent Death/Missed Eligible Death: Patient met clinical triggers and also met
the criteria for imminent or eligible death as defined by the United Network for Organ
Sharing (UNOS) will require further action in addition to the steps outlined for a missed
referral.



POLICY
Established Date: December 2005
Effective Date: January 2018
Title: Medical Record Review, Hospital
Classifications, and True Conversion Rate
Policy Number: 4.01

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 4 of 6
i. The Death Notification Registration form will be completed.
ii. The UW OTD data coordinator and senior organ procurement coordinator (OPC)
will be notified.
iii. An occurrence will be reported per UW OTD policy 1.08.

Medical Record Reviews for Patients Referred to UW OTD
K. UW OTD staff may review the hospital medical records for patients that were referred to UW
OTD if the referral is recommended for chart review by a UW OTD AOC.
L. The UW OTD data coordinator will be notified of data changes to the patient chart if the changes
include imminent or eligible death information.
M. UW OTD AOC, with the assistance of OPC and/or HDS staff as needed, will review closed
referrals to determine if a patient is considered a UW OTD Potential Donor. If a patient is
confirmed as a UW OTD Potential Donor, the AOC will denote the referral as such in the UW
OTD patient chart.

Identifying the Number of Referred Organ Donors
N. Organ donation referrals will be called into Statline by DSA hospital staff per UW OTD policy 2.01
and documented in the patient chart as outlined in UW OTD policies 2.01and 1.09.
O. The data in the patient charts will be reviewed to determine the number of referred organ
donors per each DSA hospital and included in the hospital dashboards.

Identifying the Number of Actual Organ Donors
P. Actual organ donor information will be recorded in the patient chart per UW OTD policy 1.09.
Q. The data in the patient chart will be reviewed to determine the number of actual organ donors
for each DSA hospital and included in the hospital dashboards.

Reporting Potential, Referred, and Actual Organ Donation Data
R. The data will be reported monthly to regulatory agencies through UNET per UW OTD policy
1.07.
S. Data reports (dashboards including, but not limited to, the number of referred patients, number
of UW OTD Potential Donors, and number of actual donors) will be provided to DSA hospitals
based on the hospital classification.
1. “A” hospitals will receive reports at least once monthly.
2. “B” hospitals will receive reports at least once semi-annually.



POLICY
Established Date: December 2005
Effective Date: January 2018
Title: Medical Record Review, Hospital
Classifications, and True Conversion Rate
Policy Number: 4.01

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 5 of 6
3. “C” and “D” hospitals will receive reports at least once annually.
HDS staff will use the data to help create hospital development plans per UW OTD Policy 4.03.

Quality Assurance Reviews
T. The purpose of the QA reviews is to review a random sample of completed medical record
reviews to confirm the outcome of the original review.
U. The QA reviews will be completed at least once a quarter by a designated HDS (also referred to
as the QA reviewer).
V. The hospital and community development manager or designee will randomly select at least 12
previously ventilated patients from Statline reports per quarter. This will equal 48 total QA
reviews a year.
1. Quarter one data set will include patients from A hospitals during the previous quarter,
patients from B hospitals during the previous two quarters, and patients from C hospitals
during the previous year.
2. Quarter two data set will include patients from A hospitals during the previous quarter.
3. Quarter three data set will include patients from A hospitals during the previous quarter
and patients from B hospitals during the previous two quarters.
4. Quarter four data set will include patients from A hospitals during the previous quarter.
W. If any of the selected patients were originally reviewed by the designated HDS performing the
QA reviews, the hospital and community development manager or designee will complete the
QA reviews for those charts.
X. The QA reviewer will not review the previously completed chart review form before beginning
the QA review.
Y. The QA reviewer will review the data in the Statline report and in the patient’s referring hospital
medical record and complete a QA Chart Review form.
Z. The QA reviewer will compare the original Chart Review form to the QA Chart Review form to
confirm the outcome of the original review is accurate.
1. If the outcomes are the same on both forms, the QA Chart Review form will be filed with
the original form. No further action required.
2. If the outcomes do not match, the QA reviewer will consult with the hospital and
hospital and community development manager to determine next steps, including but
not limited to updating internal databases and communicating updates with impacted
referring hospitals. This will be recorded on the QA Chart Review form.




POLICY
Established Date: December 2005
Effective Date: January 2018
Title: Medical Record Review, Hospital
Classifications, and True Conversion Rate
Policy Number: 4.01

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 6 of 6
REFERENCES
UW OTD Policies 1.07, 1.08, 1.09, 2.01, and 4.03