The Joint Commission is coming. Well, no, not this week. But it's our year - our third year in a 3-year cycle. So, sometime this year surveyors from the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) will arrive on our doorstep, with a mandate to assess how we do what we do, from the bedside to the boiler room. (And we pay them for this!)
Ours is a small hospital, and many of us in leadership have multiple roles. One of mine is to oversee our compliance on organ and tissue donation. That involves a number of things: reviewing policies, teaching nurses, monitoring charts, and keeping statistics. It definitely involves preparation for one question: "What is your conversion rate?"
"Conversion rate" is the percentage of severely brain-injured, ventilator-dependent patients eligible to donate organs, whose families do consent to donate. It is a statistic monitored by the Center for Medicare/Medicaid Services (CMS), and so on their behalf by the Joint Commission. It's considered a measure of the institution's commitment to organ donation efforts; and institutions not sufficiently committed can lose Medicare funding. It is the one question related to donation that I know the surveyors will ask.
And, based on past experience, it's the only question the surveyors will ask; and that troubles me. You see, I think that can be a misleading statistic in a hospital like mine.
First and foremost, my hospital is a small, suburban community hospital. We're not a trauma center or a major stroke center, so most patients who might be eligible - severely brain-injured and needing a ventilator - pass us by. In the last two years we had only a handful of brain-injured, ventilator dependent patients, and all but one were ineligible to donate for medical reasons. So, we had one patient who might have been eligible. His family chose not to donate; so, our “conversion rate” for that period of time was 0%. Of course, that wasn’t the fault of our hospital. The death was appropriately reported, and the family was appropriately approached. They simply declined to donate; but their decision is somehow a reflection on us. And, of course, with so few patients in the “eligible” group (N=1), the statistical consequences of even one family’s decision to decline are significant.
Second, the family’s decision isn’t really reflection of the process of the hospital or the organ procurement organization, much less the hospital’s commitment to that process. The process functioned, but wasn’t really measured. Only the outcome was measured, and that, again, was largely the result of factors beyond our control. We can offer families the opportunity to donate. We can discuss the need, and the generosity the gift would demonstrate. We can describe it as a service to the family, and as a gift that brings some blessing in their grief. What we can’t do is control their decision. Indeed, to suggest we could control the decision would be to imply coercion, or, worse, to encourage it.
There are other questions that might be asked, and these would provide a much better, and certainly more complete, perspective on the institution’s commitment to donation. The first would be to ask about the hospital’s “referral rate.” We, like other hospitals, are required to inform the organ procurement organization (OPO) of every death. So, a good measure would be how consistently we make that required phone call, and make it in the appropriate time frame (a measure that in my hospital is, by the way, 100%). Hospitals with lower referral rates would certainly demonstrate less commitment to donation.
The second question that might be asked would be about the conversion rate for donation of tissues. Skin, long bones, heart valves, corneas, and other tissues that aren’t directly sustained by blood flow, can be donated by patients who have died cardiac death, and so have not been severely brain injured, or sustained on the vent. The corollary to the low incidence of deaths of severely brain-injured patients in my hospital is that all the other deaths were cardiac deaths. Those patients were appropriately assessed for their potential for tissue or cornea donation; and when the patients were eligible, their families were appropriately approached. For hospitals like ours, with so few patients who might even be assessed for organ donation, eligibility for tissue donation and tissue conversion rates would seem more appropriate measures.
Now, the number of families who choose to donate is certainly a relevant number. Even with recent questions about the accuracy and adequacy of the lists of patients who would benefit from transplants, there is agreement that there are many more patients who might benefit from transplant than there are organs currently being donated. And for large hospitals, and especially those with transplant services, trauma centers, large stroke programs, or other factors that would suggest larger populations of patients who might be eligible, perhaps there’s some reason to measure the conversion rate. However, that number is really controlled by families making decisions in emotionally difficult times. That means the number is really more a factor of discussions that happen over the dinner table than of discussions, however persuasive, at the bedside in ICU. Rates of donation will be affected much more by education and information in the community than by even the best recovery processes of hospitals or organ procurement organizations. That doesn’t mean hospitals and OPO’s shouldn’t be involved; but perhaps the questions need to be about their educational and public service efforts, as well as rates of appropriate referral. Those activities will have a better effect on how many families are willing to donate. So, those questions would say a lot more than conversion rates about an institution’s support for donation efforts.