Opo Functions

In the late 1960s and early 1970s, OPOs were often located in academic hospitals as programs within the hospital's Department of Surgery or Transplantation. The organ procurement functions of those OPOs were typically limited to assisting in the operating room with kidney recoveries, kidney preservation, and transporting kidneys to neighboring transplant centers if they could not be used locally. At that time, kidneys were preserved almost exclusively by continuous pulsatile preservation. The job of the early procurement coordinators was usually more technical than clinical. The OPO's employees were often technicians, seldom nurses, and almost never business people. It was very common for OPO staff members to have other responsibilities in the hospital or department in which they were employed. Often they were research technicians, dialysis nurses or technicians, heart pump technicians, or operating room nurses or technicians.

Since the mid-1980s, the overwhelming majority of OPOs have become independent of hospitals. The number of hospital-based OPOs still in existence today is very small and often function in a manner similar to independent OPOs. There are, however, a few ways in which hospital-based OPOs differ from independent OPOs. Independent OPOs are self-supporting, nonprofit corporations. Hospital-based OPOs may have segregated finances, but they are still financially tied to a hospital. The hospital-based OPO's finances are reported as part of the hospital's financial reports. The insurance umbrella of the hospital or university typically covers the hospital-based OPO, whereas independent OPOs must obtain their own insurance policies. Employees of hospital-based OPOs are really hospital employees and are subject to the hospital's employment policies. Independent OPOs are companies that have anywhere from a handful to more than 150 employees; many have fewer than 30. Independent OPOs must adhere to state and federal employment laws, and most hire human resource consultants to ensure compliance. A number of OPOs have even hired full-time human resources personnel.

Most independent OPOs rent office space at one or more locations within their service area. A number have purchased their own buildings. Staffing has evolved to the point where many OPOs have departments including procurement, marketing, education, hospital development, human resources, information systems, accounting and others. Registered nurses and degreed nurses dominate the procurement staffs. Directors of OPOs, who had previously been clinical staff promoted from within, are increasingly becoming business or hospital executives hired from outside. Most OPOs have full-time accountants, and many now have fulltime information systems specialists. As the focus on public and professional education has increased, most OPOs have hired marketing or education specialists. The annual operating budget of some of the larger OPOs is in the tens of millions of dollars.

Not only do OPOs look like serious corporations, they also act like serious corporations. Concepts such as strategic planning and strict adherence to employment laws that have long been commonplace in corporate America are now common in OPOs. Well-established OPOs have formal in-house training programs, employee handbooks, policies for compliance with environmental and health safety standards, internal performance standards and overall sound business practices.

The primary purpose of OPOs is to coordinate all aspects of organ donation and to maximize the recovery of usable organs for transplantation. This involves HI many functions beginning with public and professional education, media relations, hospital relations, tissue and eye bank relations, donor evaluation, family counseling and consent, medical management of the donor, and the surgical removal of organs. Additionally, OPO employees are responsible for organ preservation, organ distribution, transportation of organs, follow-up to donor families and medical staff, accounting and reporting, and contributing to industry knowledge. Add to that interpreting organ allocation policies, acting as a liaison between multiple surgical recovery teams and hospital staff, and ensuring compliance with all federal, state, OPTN, OPO, and hospital policies. The staff members of OPOs must juggle numerous medical, ethical, political and regulatory issues simultaneously, and they must do so under intense public, professional and regulatory scrutiny. It is not surprising that the burnout rate for OPO staff, especially clinical coordinators, is extremely high. An important OPO task is to develop employment screening techniques, training programs and retention programs aimed at maintaining adequate staffing experience and staffing levels.

Promoting donation is a key function of OPOs that have recognized that their operations are not driven by organ recovery, but that organ recovery is a result of effective marketing and education. OPOs are motivated by numerous factors to play a leading role in improving the rate of organ donation. Public interest is one of the motivating factors. Although there has been steady, but modest, growth in the number of organs recovered from deceased donors each year, the percent of increase has flattened since 1995. From 1988 to 1994, the number of organs recovered increased an average of 9.1% per year; from 1995 through 2002, the average annual growth was only 1.8%. Even more disturbing is the fact that the transplant waiting list is expanding at a much more rapid rate and shows no signs of slowing. In fact, the average annual increase in the size of the waiting list at year end from 1988 through 2002 was 28.6%.6 Additionally, OPOs are subject to intense pressure from affiliated transplant programs to provide organs for their patients. The third factor that motivates OPOs to increase the rate of donation is survival. Simply stated, OPOs that fail to meet government-imposed performance standards will be shut down.

In order to impact organ donation rates, OPOs must attempt to modify the attitudes and behaviors of the general public and medical professionals regarding organ donation. According to a survey conducted by the Gallup Organization, while 85% of the public claims to support organ donation, only 28% have signed a license or donor card indicating their intent to donate.7 Actual consent rates further demonstrate the discrepancy between the stated attitudes of Americans toward donation and their actual behavior. According to the Partnership for Organ Donation, the rate of refusal to consent to donation was 50% in its study group.8 Assuming that study reflects national behaviors, one out of every two Americans asked to donate refuses. Many OPOs and others are focusing efforts to improve the consent rate through education about organ donation and by encouraging individuals to discuss their wishes to donate with their families. Groups within the general public that have particularly high refusal rates are being stud-4 ied to determine what factors cause them to refuse to donate. As more is learned about the reasons for refusal, these groups are being targeted for focused education campaigns. Many OPOs have employed full-time staff specifically to coordinate public education campaigns. Interaction with the mass media, which had once been only reactive, is now a primary tool of public education for OPOs. In many OPOs, full-time public relations staff plan media events and work steadfastly to develop relationships with key media representatives in their service areas. This not only facilitates a more proactive approach to media involvement, but also creates a less adversarial environment when difficult news stories arise.

Although public attitude is the most significant determinant of organ donation activity, the attitudes of medical professionals also have a profound impact. A study by the Partnership for Organ Donation revealed that only one third of potential donors in hospitals actually became donors. Twenty-seven percent of the potential donors were either not identified or the family was not asked to donate, while the remaining third refused donation when asked. Although OPOs expend significant resources to develop strong relationships with hospital personnel, there is still a lack of participation among many medical professionals. Some of this can be attributed to personal feelings about donation, some to a lack of clear procedures, and some to a workload that causes them to view donation as a low priority. Virtually all OPOs have marketing or hospital development staff to work closely with hospitals toward an objective of improved participation. In some OPOs, the marketing staff is as large or larger than the clinical staff. These individuals facilitate the donation process by endeavoring to make a seemingly complicated process as simple as possible. They help the hospitals develop written policies and procedures, they provide around-the-clock in-service education programs, they provide role-playing opportunities, and they conduct postrecovery debriefing conferences. Some OPOs even provide debriefing sessions in situations when a referral does not result in a donation. Marketing personnel provide one-on-one support and recognition for hospital employees who participate in an the organ donation process. Many OPOs also host annual conferences for nurses and physicians in their service area.

One of the most important activities of the marketing staff is to determine the annual donor potential in every donor hospital in the OPO's service area. This is actually one of the best methods for an OPO to evaluate its own performance, and it is critical to resource planning. If an OPO can identify which hospitals have the highest donor potential, it can focus more of its resources toward those hospitals. Further, if the OPO can determine which hospitals are falling short of their potential, it can reallocate its resources to improve performance in those hospitals. Knowing this information creates an opening for OPOs to give direct feedback to hospital administrators about the level of donor potential versus actual recoveries for any given period. The mechanisms for determining donor potential vary, but most involve some sort of retrospective review of medical records. Each OPO utilizes the methodology and criteria for donor suitability that best meet local needs. While this may be useful on a local level, the lack of consistency makes it impossible to determine donor potential at the national level. Beginning m in 1997, the AOPO conducted a pilot project designed to develop a methodology HI for estimating organ donor potential. A secondary motive of this project was to I provide the data necessary to develop better national performance standards based on true donor potential rather than the current standards that are based on population. There have been many estimates of the national donor potential calculated by numerous methods involving extrapolation. The AOPO Death Record Review study recently projected the national donor potential at 11,000 to 14,000 potential donors per year.

Relationships with eye and tissue banks can have a direct impact on the performance of an OPO. By association, medical professionals and members of the general public often assume that the OPO, the eye bank and the tissue bank are a single entity. While in some cases this may be true, it most frequently is not. It is important for these three entities to coordinate education programs, donor referrals and recoveries to provide the smoothest possible procurement service to donor hospitals. Any complications in the process that can be attributed to poor communications between OPOs, eye banks and tissue banks can create a risk that hospital participants or public attitudes will be compromised. It is the responsibility of OPOs to take the lead in coordinating the activities of the three entities since it is mandated that all hospital deaths must be reported to the OPO.

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