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Hospital Development Activities and Hospital Plans (4.03)

Hospital Development Activities and Hospital Plans (4.03) - Policies, Administrative, UWHC, Department Specific, UW Organ and Tissue Donation

4.03



POLICY
Established Date: 11 February 2015
Effective Date: 23 June 2016
Title: Hospital Development Activities and
Hospital Plans
Policy Number: 4.03

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


Page 1 of 3

PURPOSE

The purpose of this policy is to define the University of Wisconsin Organ and Tissue Donation (UW OTD)
procedures for documenting hospital development (HD) activities and creating HD plans for hospitals
within the UW OTD donation service area (DSA).

POLICY

Hospital Activities
A. UW OTD HD staff, or other designated UW OTD staff, will document hospital related activities
using Donor Tracking, a Microsoft Access database developed and maintained by UW OTD.
B. Hospital related activities that will be documented include, but are not limited to:
1. After action reviews (AAR)
2. Chart reviews
3. Needs assessments
4. HD plan creation
5. Committee/resource team meetings
6. Trainings and presentations
7. Outreach activities
8. Celebratory/remembrance ceremonies
9. Pertinent communication with hospital staff
10. Activities related to achieving HD plan goals and objectives, etc.
C. Minimum documentation will include:
1. Hospital name
2. Date
3. Type of event
4. UW OTD staff involved
5. Explanatory text (“Results”).
D. Evidence of hospital related activities documentation may be queried for reporting purposes
either by hospital name or UW OTD HD staff name.



POLICY
Established Date: 11 February 2015
Effective Date: 23 June 2016
Title: Hospital Development Activities and
Hospital Plans
Policy Number: 4.03

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


Page 2 of 3
Hospital Development Plans
A. HD plans will be completed annually by HD staff, or other UW OTD designated staff, for all
hospitals within the UW OTD DSA in order to optimize donation. Needs assessment and
customization for each HD plan is determined by the hospital classification per UW OTD policy
4.01.
B. “A” and “B” Hospitals:
1. The process will include an annual review of trending donation data (i.e. true conversion
rate, referral rate, organs transplanted per donor, etc.) and completion of the donation
needs assessment (DNA) in collaboration with key hospital stakeholders.
2. All plans will be completed using a standard format template. The content will be
customized defining key information, strengths, areas for improvement, and measurable
objectives.
3. For A hospitals only, the HD plan will be signed by key hospital stakeholders (i.e.
donation liaison) and UW OTD staff.
4. A copy of the DNA and HD plan will be shared with collaborating hospital staff, an
electronic copy will be maintained by UW OTD, and a hard copy will be filed in the UW
OTD hospital binder.
5. The hospital profile, hospital preferences, and letter of agreement (LOA) will be reviewed
and updated at minimum annually, but also as needed.
6. All applicable HD plan activities will be completed and documented annually
7. Documentation of hospital related activity will be recorded in Donor Tracking, the HD
activities database.
C. “C” Hospitals:
1. Annually HD staff will create an HD plan template with standardized goals and objectives.
i. If desired by the assigned HDS, a DNA and customized HD plan may also be
executed.
2. A copy of the HD plan will be shared with hospital staff, an electronic copy will be
maintained by UW OTD, and a hard copy will be filed in the hospital binder.
3. The hospital profile, hospital preferences, and letter of agreement (LOA) will be reviewed
and updated at minimum annually, but also as needed.



POLICY
Established Date: 11 February 2015
Effective Date: 23 June 2016
Title: Hospital Development Activities and
Hospital Plans
Policy Number: 4.03

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


Page 3 of 3
4. All applicable HD plan activities will be completed and documented annually.
5. Documentation of hospital related activity will be recorded in Donor Tracking, the HD
activities database.
D. “D” Hospitals:
1. An HD plan will be not be completed due to lack of organ donation potential.
2. The hospital profile, hospital preferences, and letter of agreement (LOA) will be reviewed
and updated at minimum annually, but also as needed.

REFERENCES

UW OTD Policy 4.01