Fourteen Late or Missed Calls in a Year: Choosing the Organ and Tissue Donation Referral Process for a Workflow and Data Analysis in a Regional Hospital
[Student Name]
University of Phoenix
NSG/542: Information Workflow
Week 1 Assignment
[Instructor Name]
[Date]
The hospital, its units and all data are a composite written for a model paper.
Workflow is the sequence of work that people and systems carry out to accomplish something, and in a hospital almost every workflow creates data or depends on it. As the informatics nurse for critical care services at a 280-bed regional hospital, I was asked by the quality department to review a process that repeatedly appeared in our regulatory reports: referrals of dying and deceased patients to our organ procurement organization. This paper introduces workflow analysis, explains why this process was chosen and describes what the rest of the course will examine.
What Workflow Analysis Examines
Unertl et al. (2010) reviewed the workflow literature in health care and proposed a framework that describes workflow through its actors, the people and systems who do the work; its artifacts, the tools and records they use; its actions, what is done and in what order; its characteristics, such as timing, frequency and variability; and its outcomes. The framework is useful because it treats workflow as more than a sequence of steps: it asks who does each step, with what, how reliably and with what result. For an informatics nurse, the most important point is that data are both produced by workflow and needed by it, so a gap in one shows up as a failure in the other.
Selection Criteria
I considered three candidate processes against four criteria: the process crosses several roles or departments; it creates or depends on data used by others; it has a documented problem; and it is frequent enough to observe and important enough to justify redesign.
Candidate 1: Discharge Medication Reconciliation
This process crosses nursing, pharmacy and providers and has known errors, but it has been studied and redesigned twice at our hospital in the past three years, and a pharmacy-led project is underway. Another analysis would duplicate work.
Candidate 2: Rapid Response Team Activation
Activations cross units and roles and generate data, but a recent review found good performance, with most calls answered within the target, and no pressing problem.
Candidate 3: Organ and Tissue Donation Referral
This process met all four criteria. It crosses bedside nurses, charge nurses, physicians, the unit clerk, chaplains, the organ procurement organization's call center and coordinators, decedent affairs and the quality department. It depends on data: clinical triggers in the record, the time of death, the referral number issued by the organization and documentation of the family conversation. And it has a documented problem. In the past year, 58 patients in the intensive care units and emergency department met the clinical triggers in our agreement with the organization. Of those, 44 were referred within the required hour, 9 were referred late and 5 were never referred, 14 failures in all. In addition, 11 deaths on general units were not referred for tissue and eye donation.
Why the Process Matters
The referral process is required by regulation. Medicare's conditions of participation require hospitals to have an agreement with an organ procurement organization and to notify it in a timely manner about individuals whose death is imminent or who have died in the hospital, and to ensure that the family is approached about donation by the organization or a trained designated requestor (Condition of Participation: Organ, Tissue, and Eye Procurement, 2023). Late or missed referrals are compliance findings for the hospital.
The process also matters to families and to patients waiting for transplants. A late referral can mean that an evaluation cannot be completed before life support is withdrawn, removing a family's chance to make a choice about donation. Research on donation decisions has found that the way families are approached, including contact with organization staff and the time spent discussing donation, is associated with whether they consent (Siminoff et al., 2001). A process that delays the organization's involvement also shortens that conversation.
The Process in Brief
In outline, the process begins when a patient meets one of the triggers in the hospital's agreement, such as a ventilated patient with a very low Glasgow Coma Scale score, a plan to discuss withdrawal of life-sustaining treatment or an evaluation for brain death. The bedside nurse or charge nurse is to call the organization's referral line within one hour, give clinical information and record the referral number in the record. The organization then decides whether to send a coordinator. Separately, every death in the hospital is to be referred for tissue and eye evaluation, usually by the nurse who cares for the patient at the time of death.
The People Involved
The actors in this process include people who rarely work together. Bedside and charge nurses care for the patient; intensivists and emergency physicians lead goals-of-care discussions; unit clerks manage phones; chaplains and social workers support families; the organization's call center and coordinators evaluate potential donors; decedent affairs releases the body; and the quality department reports compliance. Several of these actors never see each other's documentation, which is one reason the process depends so heavily on data being in the right place.
Why Informatics Is the Right Lens
This is not the first attempt to fix referrals at the hospital. Two past efforts relied on education alone: annual reminders and posters in staff lounges. Both produced short-lived improvement. An informatics lens asks a different question: what information does each person need at the moment they must act, and does the system give it to them? If the answer is no, education will keep fading.
Where Data Enter the Picture
Each step uses or creates data: the triggers are recorded in flowsheets and orders; the time of the call must be documented; the referral number links hospital and organization records; and the quality department needs all of it to report compliance. Early review suggests that many failures happen not because nurses do not care but because the trigger is hard to notice in the record, the referral line is not part of the usual workflow and the documentation is scattered.
Scope
The analysis covers the intensive care units and emergency department for organ referrals and all inpatient units for tissue and eye referrals. It does not cover the organization's internal processes or the family approach itself, which belong to the organization.
Plan for the Course
Week 2 will map the current workflow in detail, Week 3 will identify the data each department needs and where the workflow fails them, Week 4 will propose a redesigned workflow, Week 5 will address interoperability, standards and privacy and Week 6 will present a data distribution plan.
Conclusion
Of three candidate processes, organ and tissue donation referral best fits the purpose of workflow analysis: it crosses many actors and systems, depends on data at every step, carries regulatory weight and has a measurable failure rate of 14 late or missed organ referrals and 11 missed tissue referrals in a year. The rest of this course will trace the workflow and the data that move through it.
References
Condition of Participation: Organ, Tissue, and Eye Procurement, 42 C.F.R. ยง 482.45 (2023).
Siminoff, L. A., Gordon, N., Hewlett, J., & Arnold, R. M. (2001). Factors influencing families' consent for donation of solid organs for transplantation. JAMA, 286(1), 71-77. https://doi.org/10.1001/jama.286.1.71
Unertl, K. M., Novak, L. L., Johnson, K. B., & Lorenzi, N. M. (2010). Traversing the many paths of workflow research: Developing a conceptual framework of workflow terminology through a systematic literature review. Journal of the American Medical Informatics Association, 17(3), 265-273. https://doi.org/10.1136/jamia.2010.004333
How this NSG 542 Week 1 example is structured
The NSG/542 description requires defining patterns of workflow in order to manage data and knowing what data different departments need. This paper opens the course by defining workflow analysis with a published framework, applying selection criteria to three candidate processes and describing the chosen process, its actors, systems and data, and why its failures are a data problem as much as a clinical one. Students search this week as NSG 542 Week 1, NSG542 Wk 1 or NSG/542 Wk 1; all three are the same assignment.
NSG/542 Week 1 questions, answered
What does NSG/542 Week 1 usually ask for?
The course description centers on defining workflow patterns to manage data. Many sections begin by introducing workflow analysis and selecting a process that creates and uses data across departments.
What must hospitals do about organ donation referrals?
Medicare conditions of participation require hospitals to notify their organ procurement organization in a timely way about patients whose death is imminent or who have died, under the terms of their agreement with that organization.
What makes a good process for workflow analysis?
One that crosses several roles or departments, creates or depends on data, has a known problem and is frequent enough to observe and important enough to fix.
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