820 to 1 Celeste Ford LifeBridge NIST Organ and Tissue ... · The LifeBridge Organ and Tissue Sharing Case Study is a fictitious Baldrige Award application prepared for use in the

2019

LifeBridge Organ and Tissue Sharing Case Study

www.nist.gov/baldrige

2019–2020 Bald

rige Excellence Framew

ork

T1550

The ratio of the Baldrige Program’s benefits

for the U.S. economy to its costs is estimated

at 820 to 1.

110 Baldrige Award winners serve as national

role models.

2010 –2018 award applicants represent

641,693 jobs,

3,072 work sites, over $166 billion in

revenue/budgets, and about 451 million

customers served.

352 Baldrige examiners volunteered

roughly $7.9 million in

services in 2018.

State Baldrige-based examiners

volunteered around $29 million in

services in 2017.

What People Are Saying

I have always envisioned Stellar to be a company that is built to last. . . . And if you ask how we can ensure that we are built to last, I would say the answer is Baldrige.

Celeste Ford CEO and FounderStellar Solutions Palo Alto, CA Baldrige Award recipient

We believe that government can be great. We believe that local government can be great. And we believe that the Baldrige framework is ideally suited to help local government go from here to here[low to high].

Darin AtteberryCity ManagerCity of Fort Collins Fort Collins, CO Baldrige Award recipient

CONNECT WITH BALDRIGE@BaldrigeProgram #Baldrige

NIST Training Draft

Baldrige Performance Excellence Program Created by Congress in 1987, the Baldrige Program is managed by the National Institute of Standards andTechnology (NIST), an agency of the U.S. Departmentof Commerce. This unique public-private partnershipis dedicated to helping organizations improve their performance and succeed in the global marketplace. The program administers the Presidential Malcolm Baldrige National Quality Award. In collaboration with the greater Baldrige community, we addresscritical national needs through

• a systems approach to achieving organizational excellence;

• organizational self-assessment tools and analysis of organizational strengths and opportunities for improvement by a team of trained experts;

• training, executive education, conferences, and workshops on proven best management practices and on using the Baldrige Excellence Framework to improve; and

• Baldrige-based approaches to cybersecurity risk management and community excellence.

Foundation for the Malcolm Baldrige National Quality AwardThe mission of the Baldrige Foundation is to ensure the long-term financial growth and viability of the Baldrige Performance Excellence Program and to support organizational performance excellence in the United States and throughout the world. To learn more about the Baldrige Foundation, see www.baldrigefoundation.org.

Alliance for Performance ExcellenceThe Alliance (www.baldrigealliance.org) is a national network of Baldrige-based organizations and supporting members with a mission to grow performance excellence in support of a thriving Baldrige community. Members contribute nearly 300,000 volunteer hours and more than $30 million per year in tools, resources, and expertise to assist organizations on their journeys to excellence. This includes annually evaluating and recognizing over 1,000 organizations that use the Baldrige Excellence Framework and serving as the feeder system for the national Baldrige Award.

American Society for QualityThe American Society for Quality (ASQ; https://asq.org) assists in administering the award program under contract to NIST. ASQ’s vision is to make quality a global priority, an organizational imperative, and a personal ethic and, in the process, to become the community for all who seek quality concepts, technology, or tools to improve themselves and their world.

For more information:www.nist.gov/baldrige | 301.975.2036 | [email protected]

Baldrige Performance Excellence ProgramNational Institute of Standards and Technology (NIST) • United States Department of Commerce

July 2019

To order copies of this publication or obtain other Baldrige Program products and services, contact

Baldrige Performance Excellence ProgramAdministration Building, Room A600, 100 Bureau Drive, Stop 1020, Gaithersburg, MD 20899-1020 www.nist.gov/baldrige | 301.975.2036 | [email protected]

The Baldrige Program welcomes your comments on Baldrige products and services. Please direct your comments to the address above.

The Baldrige Program is very grateful to an actual organ procurement organization that allowed its own Baldrige-based award application to be the basis for this case study. From that real application, names and data have been fictionalized, and elements have been intentionally edited to be less mature, less beneficial, and missing in order for this case study to score lower than the real application. Such editing was done so that Baldrige examiners being trained using the case study can more easily identify opportunities for improvement and general feedback.

The LifeBridge Organ and Tissue Sharing Case Study is a fictitious Baldrige Award application prepared for use in the 2019 Malcolm Baldrige National Quality Award Examiner Preparation Course. The fictitious case study organization is intended to be a regional organ and tissue procurement organization for people living in a federally assigned territory within the made-up states of North and South Takoma. The case study illustrates the format and general content of an award application. However, since the case study serves primarily as a tool for training examiners to evaluate organizations against the 2019–2020 Baldrige Excellence Framework and its Criteria for Performance Excellence, it may not address all Criteria requirements or demonstrate role-model responses in all Criteria areas. Please refer to the LifeBridge Organ and Tissue Sharing Feedback Report to learn how the organization scored and to see its strengths and opportunities for improvement.

This case study is a work of fiction, created and produced for the sole purpose of training regarding the use of the Baldrige Excellence Framework. There is no connection between the fictitious LifeBridge Organ and Tissue Sharing and any other organization, named either LifeBridge Organ and Tissue Sharing or otherwise. The names of several national and government organizations are included to promote the realism of the case study as a training tool, but any data and content about them may have been fictionalized, as appropriate; all other organizations cited in the case study are fictitious or have been fictionalized.

BALDRIGE EXCELLENCE FRAMEWORK®, BALDRIGE CRITERIA FOR PERFORMANCE EXCELLENCE®, BALDRIGE PERFORMANCE EXCELLENCE PROGRAM®, BALDRIGE COLLABORATIVE ASSESSMENT®, BALDRIGE EXAMINER®, BALDRIGE EXCELLENCE BUILDER®, PERFORMANCE EXCELLENCE®, THE QUEST FOR EXCELLENCE®, and the MALCOLM BALDRIGE NATIONAL QUALITY AWARD® medal and depictions or representations thereof are federally registered trademarks and service marks of the U.S. Department of Commerce, National Institute of Standards and Technology. The unauthorized use of these trademarks and service marks is prohibited.

NIST, an agency of the U.S. Department of Commerce, manages the Baldrige Program. NIST has a 100-plus-year track record of serving U.S. industry, science, and the public with the mission to promote U.S. innovation and industrial competitiveness by advancing measurement science, standards, and technology in ways that enhance economic security and improve our quality of life. NIST carries out its mission in three cooperative programs, including the Baldrige Program. The other two are the NIST laboratories, conducting research that advances the nation’s technology infrastructure and is needed by U.S. industry to continually improve products and services; and the Hollings Manufacturing Extension Partnership, a nationwide network of local centers offering technical and business assistance to small manufacturers.

Suggested citation: Baldrige Performance Excellence Program. 2019. 2019 Baldrige Case Study: LifeBridge Organ and Tissue Sharing. Gaithersburg, MD: U.S. Department of Commerce, National Institute of Standards and Technology. https://www.nist.gov/baldrige.

knockout for glue .4375 for .1875 spine

The Annual Quest for Excellence® ConferenceOfficial conference of the Malcolm Baldrige National Quality Award

www.nist.gov/baldrige/qe

Gaylord National HarborNational Harbor, Maryland (near Washington, D.C.)

April 7–10, 2019March 24–27, 2020April 11–14, 2021

Each year at The Quest for Excellence Conference, Baldrige Award recipients share their exceptional performance practices with leaders of business, education, health care, and nonprofit organizations and inspire attendees to apply the insights they gain within their own organizations.

Plan to attend and learn about the recipients’ best management practices, participate in educational presentations on the Baldrige Excellence Framework, and network with Baldrige Award recipients and other attendees.

The Malcolm Baldrige National Quality Award www.nist.gov/baldrige/baldrige-award

The Malcolm Baldrige National Quality Award, created by Public Law 100-107 in 1987, is the highest level of national recognition for performance excellence that a U.S. organization can receive. The award promotes

• awareness of performance excellence as an increasingly important element in U.S.competitiveness and

• the sharing of successful performance strategies and information on the benefits of using these strategies.

The President of the United States traditionally presents the award. A 22-karat, gold-plated medallion that bears the name of the award and “The Quest for Excellence” on one side and the Presidential Seal on the other.

Organizations apply for the award in one of six eligibility categories: manufacturing, service, small business, education, health care, and nonprofit.Up to 18 awards may be given annually across the six categories.

NIST Training Draft

CONTENTS

O1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A1

2019Intent to ApplyForm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I1OrganizationChart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2019AwardApplicationForm.GlossaryofTermsandAbbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G1

Preface: Organizational ProfileP.1 OrganizationalDescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iP.2 OrganizationalSituation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Category 1: Leadership1.1 SeniorLeadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.2 GovernanceandSocietalContributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Category 2: Strategy2.1 StrategyDevelopment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62.2 StrategyImplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Category 3: Customers3.1 CustomerExpectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103.2 CustomerEngagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Category 4: Measurement, Analysis, and Knowledge Management4.1 Measurement,Analysis,andImprovementofOrganizationalPerformance . . . . . . . .144.2 InformationandKnowledgeManagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Category 5: Workforce5.1 WorkforceEnvironment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .195.2 WorkforceEngagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Category 6: Operations6.1 WorkProcesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .256.2 OperationalEffectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

Category 7: Results7.1 ProductandProcessResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .307.2 CustomerResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .377.3 WorkforceResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .407.4 LeadershipandGovernanceResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .447.5 Financial,Market,andStrategyResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

NIST Training Draft

2019

INTENT TO APPLY FORM

Intent to Apply/Eligibility Form Tennessee Center for Performance Excellence Award Program

You may download this form from the TNCPE website: www.TNCPE.org/awards/apply.

Before you apply for a Level 2, 3, or 4 Award, TNCPE must determine your organization’s eligibility. Please send the $250 Intent to Apply Fee and one copy of the Intent to Apply/Eligibil-ity Form, electronically or postmarked by the date noted above.

Please type or print 1. Applicant

____________________________________________________________ Applicant organization’s official name

____________________________________________________________ Address

____________________________________________________________ City State Zip

2. Size and Locations

Total # of employees (full-time equivalent) _______

Total # of sites _______

3. Industry SectorPlease check the sector that best describes your organizationo Manufacturing o Education o Serviceo Government o Health Care o Nonprofit

4. IndustrialClassificationList up to three NAICS codes that best describe yourorganization.

______________ ______________ ______________

5. How did you hear about TNCPE?

____________________________________________________________

6. OfficialContact

____________________________________________________________ Name

____________________________________________________________ Title

____________________________________________________________ Mailing address

____________________________________________________________ Street address (no PO Box)

____________________________________________________________ City State Zip

____________________________________________________________ Telephone

____________________________________________________________ Email

SUBMITTED By 2019 cycle: APRIL 152020 cycle: aPril 15

Intent to Apply/Eligibilty Form

7. AlternateOfficialContact

____________________________________________________________ Name

____________________________________________________________ Telephone

____________________________________________________________ Email

8. Return Applicant? Yes _____ No _____

Application year(s): ______________________________________

9. Application Level(See award level descriptions on pages vi-vii)Check One: o 2 o 3 o 4

10. Assurance and AuthorizationWe understand this Intent to Apply/Eligibility Form andsubsequent application to TNCPE will be reviewed bymembers of the TNCPE Board of Examiners. We furtherunderstand that all examiners are required to follow theTNCPE Code of Ethics and Standards of Conduct to ensureconfidentiality and avoid possible conflict of interest.

____________________________________________________________ Authorized signature - Highest ranking official of applicant organization

____________________________________________________________ Name (please type or print) Date

____________________________________________________________ Title

____________________________________________________________ Address

____________________________________________________________ City State Zip

____________________________________________________________ Telephone

____________________________________________________________ Email

Intent to Apply/Eligibility Form is continued on next page

I1

I2

11. Participation on the Board of Examiners_____ Our organization wishes to send one employee toTNCPE examiner training free of charge. We understandthat if the examiner attends training but is unableto complete the entire training and review cycle, ourorganization will be invoiced for $595, the value ofexaminer training.

____________________________________________________________ Name of examiner

____________________________________________________________ Title

____________________________________________________________ Telephone

____________________________________________________________ Email

_____ We prefer not to participate on the Board of Examiners this calendar year.

12. Business FactorsIn addition to determining eligibility, this information isused by TNCPE to screen and assign examiner teams toavoid conflict of interest in application reviews.

Please attach a line and box organizational chart or charts for your organization along with the following information:

Business/Organization Description: Provide a briefdescription of the nature of your business or organization (products and services, programs, or technologies). Conclude with a list of key competitors or indicate if no direct competitors exist.

Market and Customers: Provide a brief description ofthe nature of major markets (local, regional, national, international). Conclude with a list of key customers.

Suppliers, Partners and Collaborators: Provide a briefdescription of the importance of suppliers, partners, and collaborators. Conclude with a list of key suppliers/partners and the type of products or services each provides.

13. SubunitsComplete only if the applicant organization is a unit ordivision of a larger (or parent) company. If this is the case,attach a line and box organizational chart showing yourorganization’s relationship to the highest managementlevel of the parent organization.

A. Is the applicant ________ a larger parent or system?(Check all that apply.)

o a subsidiary of o a like organization ofo a division of o administered byo controlled by o a school ofo a unit of o owned by

B. Parent organization

____________________________________________________________ Name


____________________________________________________________ City State Zip

Highest ranking official of parent organization

____________________________________________________________ Name

____________________________________________________________ Title

C. Is the applicant the only subunit of the parentorganization intending to apply?

_____ Yes _____ No _____ Do not know

D. Briefly describe the major functions provided to theapplicant by the parent or by other subunits of theparent. Examples of such functions include but are notlimited to strategic planning, research and development,data gathering and analysis, human resources, legalservices, finance or accounting, sales and marketing,supply chain management, global expansion,information and knowledge management, educationand training programs, information systems andtechnology support, curriculum and instruction, andacademic program coordination/development.

E. Is the applicant self-sufficient enough to respond to allseven Baldrige Excellence Framework categories?

_____ Yes _____ No (if no, briefly explain)

14. Intent to Apply FeeSubmit the $250 Intent Fee (non-refundable) made payable to TNCPE to cover initial processing and eligibility determination. A check may be mailed to the address below or call to make a credit card payment. In addition to your Intent to Apply Fee, submit one copy of your Intent to Apply/Eligibility Form and supplementary attachments electronically [email protected].

Tennessee Center for Performance Excellence 2525 Perimeter Place Drive, Suite 122 Nashville, TN 37214-3773(800) 453-6474

ORGANIZATIONCHART

NIST Training Draft

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NIST Training Draft

2019 APPLICATION

FORM

Level 2, 3, and 4 Application Form Tennessee Center for Performance Excellence Award Program

You may download this form from the TNCPE website: www.TNCPE.org/awards/apply.

Please submit TNCPE this Application Form accompanied byone electronic copy of your Organizational Profile and Criteria response, and the appropriate Application Fee. These items should be submitted to the TNCPE office by the date notedabove.

Please type or print.

1. Applicant

____________________________________________________________ Organization name as it will appear on award

____________________________________________________________ Address

____________________________________________________________ City State Zip

2. Size and Locations

Total # of employees (full-time equivalent) _______

Total # of sites _______

3. OfficialContact

____________________________________________________________ Name

____________________________________________________________ Title

____________________________________________________________ Mailing address


____________________________________________________________ City State Zip

____________________________________________________________ Telephone

____________________________________________________________ Email

4. AlternateOfficialContact

____________________________________________________________ Name

____________________________________________________________ Telephone

____________________________________________________________ Email

SUBMITTED By 2019 cycle: july 152020 cycle: july 15

Level 2, 3, and 4 Application Form

5. Application Level and Criteria Response

A. Identify the application level for which you are applying.Check One: o 2 o 3 o 4(See Award level descriptions on pages vi - vii)

B. Attach Organizational Profile and Criteria response toApplication Form

C. Check the Criteria you have used to write your responseo Business/Nonprofit o Health Care o Education

D. Application FeeAn Application Fee is required for all award levels basedon workforce size and TNCPE Membership status.

Please refer to the table on page 5 to determine your application fee. Go to TNCPE.org/members for TNCPE membership information.

Total Application Fee

7. One-Sentence Organization DescriptionPlease provide a brief description of your organization to beused for publicity and recognition.

8. Release Statement and SignatureofHighestRankingOfficial

My signature states and attests that: I have reviewed the information provided in this application packet. To the best of my knowledge, no untrue statement or omission of a material fact that is legally disclosable and affects organizational ethical and legal practices has been made in this application packet. I understand that if information is found that could be embarrassing to TNCPE or its Award Program my organization will no longer receive consideration for an award and will only receive a Feedback Report.

____________________________________________________________ Signature Date

____________________________________________________________Name/Title

Submit the appropriate Application Fee to the address below or call to make a credit card payment. In addition to your application fee, submit one copy of your Application Form and one copy of your Organizational Profile and Criteria response saved in one PDF file to [email protected].

Tennessee Center for Performance Excellence 2525 Perimeter Place Drive, Suite 122 Nashville, TN 37214-3773 (800) 453-6474

TNCPECriteriaBook-pages1-74.indd 65 1/26/17 4:14 PM

A1

http://www.TNCPE.org/awards/apply.Please

http://www.TNCPE.org/awards/apply.Please

mailto:[email protected]

GLOSSARYOFTERMSAND

ABBREVIATIONS

NIST Training Draft

G1

Glossary of Terms and Abbreviations

24/7 CMO 24HoursaDay/7DaysaWeek ChiefMedicalOfficer

CMSA CentersforMedicareandMedicaidServicesAATB COIAmericanAssociationofTissueBanks ConflictofinterestADA Conversion RateAmericanswithDisabilitiesAct PercentageofactualdonorsdividedbypotentialdonorsAED COOAutomatedExternalDefibrillators ChiefOperatingOfficerAOPOAssociationofOrganProcurementOrganizations DAOS DART RateAvailableOn-Site Daysaway,restricted,ortransferred(OSHAForm300a)

AP(s) Data MallActionPlan(s) Repositoryofpredefinedreportsthatallowtheusertoaccess

valuableorganizationaldatafordecisionmakingAuthorizationPermissionorpowergrantedbyanauthority(firstperson DCDornext-of-kin)fororganand/ortissuedonation DonationafterCardiacDeath-typeofdonationfororgan

procurementthatoccursaftercardiaccessation

B DHSSBOD U.S.DepartmentofHealthandHumanServicesBoardofDirectors DMV

DepartmentofMotorVehiclesC DoLCAPA DepartmentofLaborCorrectiveActionPreventiveAction DonorNetC&C FacilitatesorganplacementandacceptancebyrapidlyandCapabilityandCapacity efficientlyprovidingkeyinformationtoorgantransplant

centersCCCoreCompetency:Mission-drivenworkforce DOR

DepartmentofRevenue(forstateofNT)CCPCorporateComplianceProgram DSA

DesignatedServiceAreaCDCCentersforDiseaseControlandPrevention

ECEOChiefExecutiveOfficer EBAA

EyeBankAssociationofAmericaCFO ChiefFinancialOfficer EEOC

EqualEmploymentOpportunityCommissionCHROChiefHumanResourcesOfficer EKR

EmployeeKeyRequirementCLIAClinicalLaboratoryImprovementAmendments

NIST Training Draft

G2

ELT LExecutiveLeadershipTeamconsistingoftheCEO,CMO, LDSCHRO,CFO,andCOO LearningandDevelopmentSystemEMB LOTSExtendedMedicalBank-employeebenefittocoverextended LifeBridgeOrganandTissueSharingillnesses

LSEMR LeadershipSystemElectronicMedicalRecord

LTERP LeadershipTeamEmergencyResponsePlan

MF

MEFDA MedicalExaminerFoodandDrugAdministration

FLSA OFairLaborStandardsAct

OAC(s)Four As OrganAcquisitionCharge(s),thecostthatisbilledtotheComplaintResolutionProcess:Acknowledge,Apologize, transplantcentersfortheprocurementoforgans;includesallAsk,Act directandindirectcosts

FSS OD(s)FamilySupportServices OperationalDiscussions

FTE OMPFull-TimeEmployee OperationalManagementProcess

OPCG OrganProcurementCoordinatorGift of Life OPOOrgansandtissuesdonatedbydonorfamilies OrganProcurementOrganizationGPR OPTNNationalorganizationprovidingcomparativesatisfaction OrganProcurementandTransplantationNetworkandengagementdata.

OROperatingRoom

HOrganHLAReferstokidneys,lungs,liver,heart,intestines,andpancreasHumanLeukocyteAntigenOrgan ConversionHRPercentageofactualorgandonorsdividedbypotentialorganHumanResourcesdonors

HRSAOrgan YieldHealthResourcesandServicesAdministrationOrganstransplantedperdonor

OSHAIOccupationalSafetyandHealthAdministration

ICUIntensiveCareUnit OWS

OrganWorkSystemIndividual ScorecardsMeasurementsystemtooltrackedattheindividuallevel

IT/IS InformationTechnology/InformationSystems

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P SPPStrategicPlanningProcessPDSA

Plan-Do-Study-Actproblem-solvingperformance SQAimprovementtool/methodology StateQualityAward

PEP SRTR PerformanceEvaluationProcess ScientificRegistryofTransplantRecipients

PHI SWOTPersonalHealthInformation Strengths,Weaknesses,Opportunities,Threatsanalysis,partof

environmentalscanningPHSPublicHealthServices

TPIPerformanceImprovement Tissue

Referstomusculoskeletal,skin,cardiovascular,andeyePIIPersonallyIdentifiableInformation Tissue Yield

TissueprocuredperdonorPMSPerformanceMeasurementSystem TOPC

TissueOcularProcurementCoordinatorsPTOPaid/PersonalTimeOff Topline Scorecard

PerformancemeasurementtoolreflectingstatusofkeyorganizationalmetricsQTTQAPITitanTechnologyQualityAssessmentandPerformanceImprovementTWSQSTissueWorkSystemQualitySystems

URUAGARFOUniformAnatomicalGiftActRoundingforOutcomesUNOSROIUnitedNetworkforOrganSharingReturnonInvestment

VSV/MSA(s)Vision/MissionStrategicAdvantage(s)V/M/VSaaS Vision/Mission/ValuesSoftwareasaServiceVOCSC(s)VoiceoftheCustomerStrategicChallenge(s)VOSSD(s)VoiceoftheStakeholderStrategicDiscussion(s)YieldSO(s)OutcomesofdonationactivitiesStrategicObjective(s)YTDSOP(s)YeartoDateStandardOperatingProcedure(s)

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Organizational Profile

Picture Sally, who is only 16 years old, a typical teenager who loves her friends, family, and dog, Spot, and is a beloved daughter, sister, and friend. Following a critical injury during a car accident, she is now in the intensive care unit. After evaluating Sally’s injuries and performing life-saving measures, doctors have diagnosed conclusively that Sally is brain-dead. Machines keep her organs functioning, while a team from LifeBridge Organ and Tissue Sharing (LOTS) talks compassionately to Sally’s family about donating her organs and tissues. On the most agonizing day of this family’s life, family members find the courage to say “yes.” Sally saved multiple lives that day, including a three-year-old boy from North Takoma who received Sally’s left kidney and was then excited to go home with his family after being in the hospital since birth; a 56-year-old father, a factory worker from South Takoma, who had been waiting for a liver for four years; and a nine-year-old fire victim who was airlifted to a state hospital with burns on over 50 percent of her body who received Sally’s skin tissue that helped keep out infection while the victim’s skin regenerated. The ability to impact countless lives motivated Sally’s family to provide the literal “Gift of Life” to waiting recipients. The ability to provide the connection between life and death is the reason LOTS staff members come to work every day—to achieve the organization’s mission to save and improve lives.

P.1 Organizational DescriptionP.1a Organizational EnvironmentP.1a(1) Formorethan25years,LOTShasservedastheregionalorganandtissueprocurementorganization(OPO)for3.2millionpeoplelivingwithinafederallyassignedterritoryinclusiveof62countieslocatedwithinthestatesofNorthTakoma(NT)andSouthTakoma(ST).Fromitsfoundinggoaltoassistinthecoordinationoforgandonations,LOTShasgrowntobecomeamultifaceted,nonprofitorgani-zationdedicatedtosavingandimprovinglives(Figure P.1-1).LocatedinColumbia,NT,LOTSisoneofthe58federallydesignatedorganizationsofitskindintheUnitedStates.

LOTS’smainserviceofferingisthefacilitationoforganandtissuedonation,accomplishedthroughtheorganization’stwoworksystems:OrganandTissue.Thedeliveryofservicesforbothworksystemsrequiresthecarefulcoordinationofpartners,collaborators,andkeysupplierstoensurethatorgansandtissuesareavailableforusebytheorganization’skeycustomergroups(Figure P.1-6).Bothservicelines(organandtissue)arecriticaltoLOTS’ssuccess,whichismeasuredbythenumberoflivessavedandimproved.ThePartnershipModel(Figure P.1-2)highlightstheorganization’scoordina-tionofpartners,collaborators,andsupplierstoensurethatorgansandtissuesarealwaysavailablefortheorganization’skeycustomers.

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DonorfamiliescomefromthecommunityatlargeandareidentifiedaspotentialcollaboratorsonceapartnernotifiesLOTSofapatient’sdeath.Atthispoint,assumingthepatientismedicallysuitablefordonation,thefamilyispresentedwiththeopportunityfordonationbyamemberoftheLOTS’sworkforce.Duetothelimitingcriteriagoverningorganandtissuedonation,eachdonationopportunitymustbemaximizedtoitsfullestpotential.Oftheapproximately15,000deathsoccurringannuallywithinLOTS’sdesignatedservicearea(DSA),approximately100patientshavetheopportunitytobecomeorgandonorsduetothespecialcircumstancesofbraindeathunderwhichanorgandonormustdie.Tissuedonationopportunitiesoccurapproximately2,000timesannually(Figure P.1-3).

LOTSpartnerswiththe80hospitalsandseveralnonhospitalreferralorganizations(medicalexaminer[ME]andhospiceoffices)locatedwithinitsDSAtogainaccesstopotentialdonorfamilycollaborators,acriticalcontrolpointofthe

Picture Sally, who is only 16 years old, a typical teenager who loves her friends, family, and dog, Spot, and is a beloved daughter, sister, and friend. Following a critical injury during a car accident, she is now in the intensive care unit. After evaluating Sally’s injuries and performing life-saving measures, doctors have diagnosed conclusively that Sally is brain-dead. Machines keep her organs functioning, while a team from LifeBridge Organ and Tissue Sharing (LOTS) talks compassionately to Sally’s family about donating her organs and tissues. On the most agonizing day of this family’s life, family members find the courage to say “yes.” Sally saved multiple lives that day, including a three-year-old boy from North Takoma who received Sally’s left kidney and was then excited to go home with his family after being in the hospital since birth; a 56-year-old father, a factory worker from South Takoma, who had been waiting for a liver for four years; and a nine-year-old fire victim who was airlifted to a state hospital with burns on over 50 percent of her body who received Sally’s skin tissue that helped keep out infection while the victim’s skin regenerated. The ability to impact countless lives motivated Sally’s family to provide the literal “Gift of Life” to waiting recipients. The ability to provide the connection between life and death is the reason LOTS staff members come to work every day—to achieve the organiza-tion’s mission to save and improve lives.



Figure P.1-1: Vision, Mission, Values

VISION Organs and tissues are always available

MISSION We save and improve lives

VALUES Compassion Teamwork Honesty Quality Improvement

LifeBridgeOrgan and

Tissue Sharing

Partners CustomersC

olla

bora

tors Key SuppliersLIVES

SAVED

Figure P.1-2: Partnership Model

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Picture Sally, who is only 16 years old, a typical teenager who loves her friends, family, and dog, Spot, and is a beloved daughter, sister, and friend. Following a critical injury during a car accident, she is now in the intensive care unit. After evaluating Sally’s injuries and performing life-saving measures, doctors have diagnosed conclusively that Sally is brain-dead. Machines keep her organs functioning, while a team from LifeBridge Organ and Tissue Sharing (LOTS) talks compassionately to Sally’s family about donating her organs and tissues. On the most agonizing day of this family’s life, family members find the courage to say “yes.” Sally saved multiple lives that day, including a three-year-old boy from North Takoma who received Sally’s left kidney and was then excited to go home with his family after being in the hospital since birth; a 56-year-old father, a factory worker from South Takoma, who had been waiting for a liver for four years; and a nine-year-old fire victim who was airlifted to a state hospital with burns on over 50 percent of her body who received Sally’s skin tissue that helped keep out infection while the victim’s skin regenerated. The ability to impact countless lives motivated Sally’s family to provide the literal “Gift of Life” to waiting recipients. The ability to provide the connection between life and death is the reason LOTS staff members come to work every day—to achieve the organiza-tion’s mission to save and improve lives.



Figure P.1-1: Vision, Mission, Values

VISION Organs and tissues are always available

MISSION We save and improve lives

VALUES Compassion Teamwork Honesty Quality Improvement

LifeBridgeOrgan and

Tissue Sharing

Partners CustomersC

olla

bora

tors Key SuppliersLIVES

SAVED

Figure P.1-2: Partnership Model



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drivetomeetthemission: We save and improve lives. Bydefinition,themissionaffirmsthatLOTSplaysaroleinthelife-savinggiftofdonation.Whetheritisthe“literallifesave”ofanorganrecipientora“qualityoflifeimprovementtoatissuerecipient,”atitscore,LOTSisallabouttransplantationandsavingandimprovinglives.Valuesofcompassion,improve-ment,honesty,teamwork,andqualityserveasaguid-ingforceforhowtheworkforcelivesthecultureonadailybasis.Thevision,mission,andvalues(V/M/V)ofLOTS,validatedduringtheStrategicPlanningProcess(SPP;Figure 2.1-1),serveasthefounda-tionforthecultureandformthebasisforhowtheorganizationismanaged.ThemissionofLOTScouldnotbeaccomplishedwithouttheorganization’scorecompetency(CC)ofamission-drivenworkforce.

Mission-Driven Workforce: TheworkofLOTS,byitsverynature,requiresalevelofcareandcompas-sionthatcanonlybedeliveredbythe“humantouch.”Therefore,theactionsandbehaviorsdemonstratedbythestaffaredirectlylinkedtocreatingapositivedonationexperienceforthedonorfamily(collabora-tors),whichisessentialtotheaccomplishmentofthemissionandthesuccessoftheorganization.ThisCCwasidentifiedusingseveralcyclesofLOTS’s

workforcesurveyresults,whichnotedthatoverallengagementandoveralljobsatisfactioncontinuetoshowstrongresults(Figures 7.3-12, 7.3-12A, and 7.3-14).

P.1a(3) LOTSisa24/7businessinwhichmanyoftheemployeesaredecentralized.TheWorkforceProfile (Figure P.1-4)reflectstheemployeeprofileandincludesjobtype,tenure,gender,andethnicity.Todate,theorganizationhasnotexperiencedanyreductionsinworkforce.Conversely,astheneedfordonationshasincreased,sohastheneedforexpansionofbothclinicalandnonclinicalstafftosupportoperationalefficiencies.Forthepurposeofreportingand

ProcurementProcess(Figure 2.1-2).LOTSprovidesongoingeducationalofferingstothesepartnerstoensurethatthisintro-ductionoccursinatimelymanner.Onceareferralismade,LOTSprescreensthepotentialdonorformedicaleligibilityfordonation.PatientfamiliesarecompassionatelyapproachedbyFamilySupportServices(FSS)staffintheOrganWorkSystem(OWS)andbytheCommunicationCenterstaffintheTissueWorkSystem(TWS).Duringtheapproach,familiesarepresentedwiththeopportunityfordonationortohonortheirlovedone’spreviousdecisiontobecomeadonor(Figure 3.2-1,Pre-DonationPhase).ClinicalstaffmembersassistthedonorhospitalpartnerswiththemedicalmanagementofthedonoruntiltransportationtotheLOTSfacilityoccursandthedonatedgiftsarerecovered(Figure 3.2-1,DonationPhase).IntheOWS,recoveryisperformedbythetransplantsurgeonassistedbyOrganProcurementCoordinators(OPCs);intheTWS,recoveryisperformedbyTissueProcurementCoordina-tors(TPCs).LOTSactsasaresponsiblestewardofthe“GiftofLife”bycoordinatingtheplacementofdonatedorgansandtissuestoitskeycustomergroups:localorgantransplantcentersandtissueprocessors.Thedonatedorgansandtissuesareusedforthebettermentofthecommunitiesserved,whichincludedonorfamiliesandtransplantrecipientpatientsandtheirfamilies(Figure P.1-6).

P.1a(2) ThemissionofLOTSistosaveandimprovelives(Figure P.1-1).LOTS’svisionisOrgans and tissues are always available. Thevisionwasdevelopedinlightofthebeliefthattheorganization’sultimategoalwillonlybereal-izedwhenorgansandtissuearereadilyavailabletopatientswhentheyneedthem.CentraltotheLOTScultureisastrong

Figure P.1-4: Workforce Profile (Employees)

Leadership Team 10%

Staff 90%

Male 35%

Female 65%

1 Year 20%

2–5 Years 41%

6–10 Years 21%

11+ Years 18%

African American 20% (DSA 25%*)

White 70% (DSA 70%*)

Other 10% (DSA 5%*)

*Based on 2010 Census

Job TypeTenure

GenderEthnicity

Figure P.1-3: Finding the Heroes

Deaths Reported

Referrals

Eligible

Authorization

Donors

ORGAN TISSU

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Figure P.1-4: Workforce Profile (Employees)

Leadership Team 10%

Staff 90%

Male 35%

Female 65%

1 Year 20%

2–5 Years 41%

6–10 Years 21%

11+ Years 18%

African American 20% (DSA 25%*)

White 70% (DSA 70%*)

Other 10% (DSA 5%*)

*Based on 2010 Census

Job TypeTenure

GenderEthnicity

Figure P.1-3: Finding the Heroes

Deaths Reported

Referrals

Eligible

Authorization

Donors

ORGAN TISSU

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comparingdata,theworkforceissegmentedbyworksystemanddepartment.TheOWSmanagestheProcurementProcessfororgans,theTWSmanagestheProcurementProcessfortissues,andthesupportdepartmentsprovidetheinfrastructuretomaximizeorganizationalperformance(Figure 2.1-2).Theorganizationdoesnotutilizetheassistanceofvolunteers.Workforceeducationalrequirements,includingapplicablecertifications,mayvarybyworksystemanddepartmentandareincludedinalljobdescriptions.Inaddition,theLearningandDevelopmentSystem(LDS;Figure 5.2-2)includescomponentsthatallowthetrackingofpersonalgoalsandcertificationsintheonlinePerformanceEvaluationProcess(PEP;Figure 5.1-2).UtilizingtheCommunicationProcess(Figure 1.1-3),LOTSroutinelyunderscoresthateveryroleintheorganizationcontributestothesuccessofthemission.Multiplestaffsurveycycleshavevalidatedthreeofthehighest-scoringsurveyattributes:thestaffconnectiontothemission,followedcloselybyemployeebenefitsandrelation-shipswithcoworkers.

LOTShasnoorganizedbargainingunits.Allemployeesrequireahealthy,safe,andsecureworkenvironment.LOTS’sapproachestoaddresstheserequirementsincludesystem-wideprogramsfocusingonrisksinparticularsettings.Manymem-bersoftheworkforcecarryoutclinicaldutiesinahospital,ratherthanperformworkinanoffice.Healthandsafetyissuesrelatedtostaffworkinginhospitalsalsoapplytononclinicalstaff.Similarly,typicaloffice-relatedsafetyrequirementsapplytononclinicalstaff.AtLOTS,suchissuesareaddressedthroughannualtrainingandstandardoperatingprocedures(SOPs).Duetothe24-hournatureofsomework,for“after-hours”staffmembers,specialsafetyrequirementsexistthatincludereservedofficeparkingspots,securedparking,andsensorlighting(5.1b[1]).

P.1a(4) LOTSownsacustom-builtfacilityinColumbia,NT,whichhousesacriticalcareunitwhereorgandonormanage-mentoccursandwithafullyequippedoperatingroom(OR).Thekeyclinicaltechnologiesandequipmentincludex-ray,ultrasound,andtypicalORequipment.LOTSleasesatwin-engineturbopropplaneequippedwithmedicalequipmenttotransportdonorstotheLOTSfacilityfororganandtissuerecovery.Utilizingtechnology,LOTSprovidesstaffwithcollaborativetools,real-timeaccesstokeydataincludinganelectronicmedicalrecord(EMR)system,andreportingservicesthatprovidecustomizedreports.

P.1a(5) LOTSoperatesunderahighlyregulatedenviron-mentandidentifieskeyregulatoryrequirementsinQualityComplianceManagement(Figure P.1-5).Inaddition,localenvironmentalandregulatoryinitiativesapplyforfireandsanitationmeasures;biohazardtrashdisposalmeetsalllocalandstateregulations.

P.1b Organizational RelationshipsP.1b(1) IncorporatedinthestateofNorthTakoma,LOTSisaprivate,nonprofit501(c)(3)organization.Avoluntary,commu-nity-basedgovernanceBoardofDirectors(BOD)setspolicy

fortheorganizationandiscomposedofhospitalexecutives,physicians,anddonorfamilymembers.RepresentativesfromLOTS’skeydonorhospitals(partners)andtransplantcenters(customers)areappointed,allowingtheseseniorleaderstorepresentcustomerandpartnerrequirements.Reportingtothegovernanceboard,theChiefExecutiveOfficer(CEO)directsanExecutiveLeadershipTeam(ELT)composedoftheChiefMedicalOfficer(CMO),ChiefHumanResourcesOfficer(CHRO),ChiefFinancialOfficer(CFO),andChiefOperatingOfficer(COO).TheLeadershipTeam(LT)consistsoftheELTandthedirectors,managers,andsupervisors.

TheBODevaluatestheperformanceoftheCEOutilizingongoingmonitoringofperformancemeasuresasoutlinedintheScorecardReviewProcessnotedin1.2a(2).TheCEOevaluatestheperformanceofherdirectreports,andthosereportsevaluatetheperformanceofthedirectors,who,inturn,evaluatemanagersandothermembersofthestaff.

P.1b(2) Figure P.1-6 outlinesLOTS’skeycustomers,partners,andstakeholders,aswellastherequirementsandexpectationsfortheorganization’sservicesandoperationsforeachgroup.LOTS’skeymarketsegmentistheorganization’sDSA,whichisassignedbythefederalgovernment.Localorgantransplantcenters(PremierHealth,ColumbiaUniver-sityHospital,PremierChildren’sHospital,andColumbiaChildren’sHospital)andtissueprocessors(TissueTrans-formations,LifeBank,andAdvantageLife)areLOTS’skeycustomergroups.LOTScollaborateswiththedonorfamilies

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comparingdata,theworkforceissegmentedbyworksystemanddepartment.TheOWSmanagestheProcure-mentProcessfororgans,theTWSmanagestheProcure-mentProcessfortissues,andthesupportdepartmentsprovidetheinfrastructuretomaximizeorganizationalperformance(Figure 2.1-2).Theorganizationdoesnotutilizetheassistanceofvolunteers.Workforceeducationalrequirements,includingapplicablecertifications,mayvarybyworksystemanddepartmentandareincludedinalljobdescriptions.Inaddition,theLearningandDevelopmentSystem(LDS;Figure 5.2-2)includescomponentsthatallowthetrackingofpersonalgoalsandcertificationsintheonlinePerformanceEvaluationProcess(PEP;Figure 5.1-2). UtilizingtheCommunicationProcess(Figure 1.1-3),LOTSroutinelyunderscoresthateveryroleintheorganiza-tioncontributestothesuccessofthemission.Multiplestaffsurveycycleshavevalidatedthreeofthehighest-scoringsurveyattributes:thestaffconnectiontothemission,fol-lowedcloselybyemployeebenefitsandrelationshipswithcoworkers.

LOTShasnoorganizedbargainingunits.Allemployeesrequireahealthy,safe,andsecureworkenvironment.LOTS’sapproachestoaddresstheserequirementsincludesystem-wideprogramsfocusingonrisksinparticularsettings.Manymembersoftheworkforcecarryoutclinicaldutiesinahospital,ratherthanperformworkinanoffice.Healthandsafetyissuesrelatedtostaffworkinginhospitalsalsoapplytononclinicalstaff.Similarly,typicaloffice-relatedsafetyrequirementsapplytononclinicalstaff.AtLOTS,suchissuesareaddressedthroughannualtrainingandstandardoperatingprocedures(SOPs).Duetothe24-hournatureofsomework,for“after-hours”staffmembers,specialsafetyrequirementsexistthatincludereservedofficeparkingspots,securedparking,andsensorlighting(5.1b[1]).

P.1a(4) LOTSownsacustom-builtfacilityinColumbia,NT,whichhousesacriticalcareunitwhereorgandonormanage-mentoccursandwithafullyequippedoperatingroom(OR).Thekeyclinicaltechnologiesandequipmentincludex-ray,ultrasound,andtypicalORequipment.LOTSleasesatwin-engineturbopropplaneequippedwithmedicalequipmenttotransportdonorstotheLOTSfacilityfororganandtissuerecovery.Utilizingtechnology,LOTSprovidesstaffwithcollaborativetools,real-timeaccesstokeydataincludinganelectronicmedicalrecord(EMR)system,andreportingservicesthatprovidecustomizedreports.

P.1a(5) LOTSoperatesunderahighlyregulatedenviron-mentandidentifieskeyregulatoryrequirementsinQualityComplianceManagement(Figure P.1-5).Inaddition,localenvironmentalandregulatoryinitiativesapplyforfireandsanitationmeasures;biohazardtrashdisposalmeetsalllocalandstateregulations.

P.1b Organizational RelationshipsP.1b(1) IncorporatedinthestateofNorthTakoma,LOTSisaprivate,nonprofit501(c)(3)organization.Avoluntary,

community-basedgovernanceBoardofDirectors(BOD)setspolicyfortheorganizationandiscomposedofhospitalexecu-tives,physicians,anddonorfamilymembers.RepresentativesfromLOTS’skeydonorhospitals(partners)andtransplantcenters(customers)areappointed,allowingtheseseniorlead-erstorepresentcustomerandpartnerrequirements.Reportingtothegovernanceboard,theChiefExecutiveOfficer(CEO)directsanExecutiveLeadershipTeam(ELT)composedoftheChiefMedicalOfficer(CMO),ChiefHumanResourcesOfficer(CHRO),ChiefFinancialOfficer(CFO),andChiefOperatingOfficer(COO).TheLeadershipTeam(LT)consistsoftheELTandthedirectors,managers,andsupervisors.

TheBODevaluatestheperformanceoftheCEOutilizingongoingmonitoringofperformancemeasuresasoutlinedintheScorecardReviewProcessnotedin1.2a(2).TheCEOevaluatestheperformanceofherdirectreports,andthosereportsevaluatetheperformanceofthedirectors,who,inturn,evaluatemanagersandothermembersofthestaff.

P.1b(2) Figure P.1-6 outlinesLOTS’skeycustomers,partners,andstakeholders,aswellastherequirementsandexpectationsfortheorganization’sservicesandoperationsforeachgroup.LOTS’skeymarketsegmentistheorganization’sDSA,whichisassignedbythefederalgovernment.Localorgantransplantcenters(PremierHealth,ColumbiaUniversityHospital,PremierChildren’sHospital,andColumbiaChildren’sHospital)andtissueprocessors(TissueTrans-formations,LifeBank,andAdvantageLife)areLOTS’skey

Figure P.1-5: Quality Compliance Management

Regulatory AgencyMandatory/ Voluntary

CAP SafeLaboratoryPractices Mandatory

CMS BillingandPerformanceRequirements

Mandatory

EEOC EmploymentPractices Mandatory

FDA CompliancewithRequirements Mandatory

DoL EmploymentPractices Mandatory

IRS NonprofitRequirements Mandatory

UNOS/OPTN

OrganAllocation/OperationalOversight

Voluntary

Occupational Health and Safety

OSHA WorkplaceSafety Mandatory

Accreditation

AATB StandardsforTissueBankingAccreditation

Voluntary

AOPO StandardsforOrganProcurementAccreditation

Voluntary

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tohonortheirlovedones’decisionstobedonorsoronbehalfoftheirlovedones;donorfamilyrequirementsarethesameregardlessofdonationtype.

P.1b(3) LOTSrecognizesthatkeysuppliers,partners,andcollaboratorsplayanimportantroleinsupportingitinachievingitsvision,mission,andstrategicobjectives(SOs).KeysuppliersincludeGuardianAmbulance,WrightBrothersCharter,TitanTechnology(TT),TransplantTechnologies,andColumbiaCremation(Figure P.1-6).Theseorganizationshavemadesignificantbusinessmodelaccommodationstoprovide24/7availabilitytoensurethatthedonationcanproceedsmoothly.GuardianAmbulance,WrightBrothersCharter,andColumbiaCremationprovideairandgroundtransportationservicesforstaff,aswellasorganandtissuedonors,ensuringthatthedonationisexpedited.TTprovidesallroutinemain-tenanceandinfrastructuresupportofinformationtechnology(IT),allowingtheinternalITstaffemployedbyLOTStofocusontechnologiesspecifictotheOPOindustry.TransplantTech-nologiesprovidestheEMRsystem,includingtheplatformthatallowssequelreportingfunctions,whichareacriticalpartofthePerformanceMeasurementSystem(PMS;Figure 4.1-1).TransplantTechnologiesalsoaffordstheorganizationtheabilitytouploadtissuedonorrecordstotheprocessorstoensuretimelyreleaseoftissue.Thesesuppliers,partners,andcollaboratorsprovideLOTSwiththeabilitytoassessprocessperformanceandenhancecompetitivenessbyexceedingcus-tomerrequirements.AsLOTS’skeypartnersandmainreferralsources,donorhospitalsandnonhospitalreferralsourcesareessentialtogainingaccesstopotentialdonorfamilies.Throughongoingtraining,theHospitalServicesstaffassistswiththeestablishmentofsystemsthatinitiatethepre-donationAuthorizationProcess(throughtheReferralManagementProcess)andsupportthedonationdecision.OnceareferraltoLOTSismade,aLOTSstaffmemberpresentstheoptionofdonationtothepotentialdonorfamily.Ascollaborators,donorfamilymembersprovideauthorizationfordonationonbehalfoftheirlovedonesortohonortheirlovedones’documentedauthorizationtobeanorganand/ortissuedonor.Fordonorfamilycollaborators,two-waycommunicationoccursduringthePre-DonationPhaseviaface-to-faceconversations(OWS)andbyphone(TWS).Theprimarymethodsforknowledgesharingandcommunicationwithsuppliers,collaborators,andpartnersarenotedinVoiceoftheStakeholder(VOS;(Figure 4.2-1);primarymethodsforcustomercommunicationarenotedinVoiceoftheCustomer(VOC;Figure 3.1-1).Supplierandpartnercommunicationismainlyconductedviatwo-waycommunicationandface-to-facemeetingswithfollow-upcommunicationviaphoneandemail.Inputsfrompartnersandcollaborators,aswellasotherkeystakeholders,feedintotheSPP(Figure 2.1-1)andhelpdriveorganizationalimprovements.LOTS’skeysupply-networkrequirementsforsuppliersincludetimelycommunication,accurateinformation,andservicequality(Figure P.1-6).

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customergroups.LOTScollaborateswiththedonorfamiliestohonortheirlovedones’decisionstobedonorsoronbehalfoftheirlovedones;donorfamilyrequirementsarethesameregardlessofdonationtype.

P.1b(3) LOTSrecognizesthatkeysuppliers,partners,andcollaboratorsplayanimportantroleinsupportingitinachievingitsvision,mission,andstrategicobjectives(SOs).KeysuppliersincludeGuardianAmbulance,WrightBrothersCharter,TitanTechnology(TT),TransplantTechnologies,andColumbiaCremation(Figure P.1-6).Theseorganizationshavemadesignificantbusinessmodelaccommodationstoprovide24/7availabilitytoensurethatthedonationcanproceedsmoothly.GuardianAmbulance,WrightBrothersCharter,andColumbiaCremationprovideairandgroundtransportationservicesforstaff,aswellasorganandtissuedonors,ensuringthatthedonationisexpedited.TTprovidesallroutinemain-tenanceandinfrastructuresupportofinformationtechnology(IT),allowingtheinternalITstaffemployedbyLOTStofocusontechnologiesspecifictotheOPOindustry.TransplantTech-nologiesprovidestheEMRsystem,includingtheplatformthatallowssequelreportingfunctions,whichareacriticalpartofthePerformanceMeasurementSystem(PMS;Figure 4.1-1).TransplantTechnologiesalsoaffordstheorganizationtheabilitytouploadtissuedonorrecordstotheprocessorstoensuretimelyreleaseoftissue.Thesesuppliers,partners,andcollaboratorsprovideLOTSwiththeabilitytoassessprocessperformanceandenhancecompetitivenessbyexceedingcus-tomerrequirements.AsLOTS’skeypartnersandmainreferralsources,donorhospitalsandnonhospitalreferralsourcesareessentialtogainingaccesstopotentialdonorfamilies.Throughongoingtraining,theHospitalServicesstaffassistswiththeestablishmentofsystemsthatinitiatethepre-donationAuthorizationProcess(throughtheReferralManagementProcess)andsupportthedonationdecision.OnceareferraltoLOTSismade,aLOTSstaffmemberpresentstheoptionofdonationtothepotentialdonorfamily.Ascollaborators,donorfamilymembersprovideauthorizationfordonationonbehalfoftheirlovedonesortohonortheirlovedones’documentedauthorizationtobeanorganand/ortissuedonor.Fordonorfamilycollaborators,two-waycommunicationoccursduringthePre-DonationPhaseviaface-to-faceconversations(OWS)andbyphone(TWS).Theprimarymethodsforknowledgesharingandcommunicationwithsuppliers,collaborators,andpartnersarenotedinVoiceoftheStakeholder(VOS;(Figure 4.2-1);primarymethodsforcustomercommunicationarenotedinVoiceoftheCustomer(VOC;Figure 3.1-1).Supplierandpartnercommunicationismainlyconductedviatwo-waycommunicationandface-to-facemeetingswithfollow-upcommunicationviaphoneandemail.Inputsfrompartnersandcollaborators,aswellasotherkeystakeholders,feedintotheSPP(Figure 2.1-1)andhelpdriveorganizationalimprovements.LOTS’skeysupply-networkrequirementsforsuppliersincludetimelycommunication,accurateinformation,andservicequality(Figure P.1-6).

Figure P.1-6: Key Stakeholder Requirements

Customers Requirements

TransplantCenters—Organ • MaximizeDonation• Information• Competence

TissueProcessors • MaximizeDonation• Information• Accountability

Partners

DonorHospitalsMedicalExaminersHospice

• Respect/Sensitivity• Information• ServiceQuality

Collaborators

OrganandTissue DonorFamilies

• Compassion• StewardshipoftheGift• HonortheDonor

FuneralHomes • Communication• Service

Stakeholders

Communitieswithin ServiceArea

• ComplywithLegal,Ethical,andRegulatoryRequirementsWhileProvidingQualityOrgansandTissues

Workforce • ConnectionwithV/M/V• ExcellentBenefits• Coworkers

BoardofDirectors • StrategicPlanning• Administration• FinancialManagement

Suppliers Expectations

GuardianAmbulanceWrightBrothersCharterTTTransplantTechnologiesColumbiaCremation

• AccurateInformation• ServiceQuality• TimelyCommunication

P.2 Organizational SituationP.2a Competitive EnvironmentP.2a(1) AsthefederallydesignatedOPOwithinitsservicearea,LOTSdoesnothavetraditionalorganprocurementcompetitors.Muchlikeautilitycompany,LOTSisaregu-lated“monopoly”thatoperatessolelywithinthebordersofitsDSA;nootherOPOsmayprocureorganswithinthisboundary.Tomaintainthisdesignation,however,OPOsmust

P.2 Organizational SituationP.2a Competitive EnvironmentP.2a(1) AsthefederallydesignatedOPOwithinitsservicearea,LOTSdoesnothavetraditionalorganprocurementcompetitors.Muchlikeautilitycompany,LOTSisaregu-lated“monopoly”thatoperatessolelywithinthebordersofitsDSA;nootherOPOsmayprocureorganswithinthisboundary.Tomaintainthisdesignation,however,OPOsmust

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meetnationalperformancestandardssetbytheCentersforMedicareandMedicaidServices(CMS).Shouldperformanceconsistentlyfallshortofthenationalstandards,CMScouldchoosetoawardtheDSAtoanotherOPO.WhileOPOsdonotcompetefororgans,thereassignmentofpotentialfutureDSAswouldbebasedonperformancetothestandards.FortheTWS,donorhospitalsarerequiredbylawtoreportalldeathstoLOTS;however,theymaycontractwithanothertissuebankattheirowndiscretionfortherecoveryprocess.LOTSmaintainstissuerecoverycontractswith100%ofthe80donorhospitalpartnerswithinitsservicearea.LOTSpartnerswithaneyebank,VisionMax,toensureeyedonationopportunitiesforfamiliesintheDSA.LOTSranks40thamongtheexisting58OPOsintermsofpopulationlivingwithinitsDSA.SinceexpansionoftheDSAisnotallowed,growthindonationmustcomefromincreasesinmedicallyeligiblecandidatesfromwithintheDSA,fromincreasesinthenumberoffamilieswhosay“yes”(authorization)todonation,orfromtheidentifica-tionofnonhospitalreferralsources.Theconstraintsofalimitedserviceareareinforcetheimportanceofmaximizingdonationforeachdonorinordertoachievethemissionofsavinglives(Figure P.1-3).

P.2a(2) BecauseLOTSdoesnothavecompetitorsinthetra-ditionalsense,therearenokeychangestakingplacethataffecttheorganization’scompetitivepositionasanOPO.WhilethechangestotheAffordableCareActwillbeachallengeforthehealthcareindustry,thescopeofitschangestotheOPOindustryisuncertainatthistime.Assuch,theorganizationhasdecidedtofocusonwhatitcancontrol;utilizingLOTS’sdriveandprovenabilitytoimproveandrelyonitsmission-drivenworkforce(CC)toachievecost-effectivenessandefficienciestoplaceitselfinastrongfinancialposition(SA)tomanagefuturechallenges.KeyfactorsinfluencingthesuccessofLOTSinclude

■ Amission-drivenworkforcethatishighlymotivatedandengagedinsaving lives(CC)

■ Strongrelationshipsformedthroughpartneringandcollaboration

Asstatedpreviously,theOWSandTWSdonotcurrentlyhavecompetitors.

P.2a(3) TheComparativeDataProcess(Figure 4.1-4)liststheorganization’skeycomparativedatasources.Theorganindustryhasselectnationalbenchmarksavailablethroughmultiplesources;however,theleadtimebeforesuchresultsbecomeavailablecanbemanymonths.Comparativedataaremorelimitedfortissueoperations,inwhichtissueprocessorsprovidemonthlyfeedbackforselectresultsintheformofscorecards.Tooffsettheselimitations,LOTSreliesonsharingthroughcollaborationwithotherOPOstoobtaincomparativedata.

P.2b Strategic ContextStrategicChallenges(SCs)andAdvantages(SAs;Figure P.2-1)providesasummarythatreflectsthecurrentstrategicstateofLOTS.SCsandSAsarereviewedannuallyduringstep3of

theSPP(Figure 2.1-1);steps5through8ensurethatappropri-ateactionplans(APs)arelinkedtoorganizationalsuccess.

P.2c Performance Improvement SystemTogetherwiththeBOD,theLOTSLTcreatesanenvironmentthatsupportsimprovementthroughthecreationofstrategies,systems,andmethodsforachievingperformanceexcellence.TheLeadershipSystem(LS;Figure 1.1-1)isusedtosetanddeploytheV/M/VandculturetotheworkforceviatheCommunicationProcess(Figure 1.1-3).LOTShasdevelopedanorganizationalstructure,processes,andculturetofocusonactionandachievesustainableperformance,fosterimprove-ment,andseekoutstrategicopportunities.AcontinuousprocessimprovementenvironmentallowsLOTStodeliveradistinctivevaluestreamthatbenefitsboththeperformanceofcustomer-focusedoperationsandthelivesoforganandtissuerecipients.

LOTSusestheBaldrigeCriteriaforPerformanceExcellenceasitsbusinessmodelanditsfoundationforperformanceimprovement(PI).Ultimately,thismodelprovidesongo-ingfeedbackintotheSPP.Additionally,step3oftheLS(Figure 1.1-1)provideskeybusinessprocessmonitoringtoalignbusinessstrategytoorganizationalperformance.OperationalimprovementsareidentifiedandimplementedthroughtheSPPandtheOperationalManagementProcess(OMP;Figure 6.1-1).Bothprocessesbringtotheforefrontkeyinformationtomanagethebusiness,aggregatedata,createactionsthatsynthesizeinformationintoknowledge,andultimatelyfacilitatethesharingofknowledge,bothinternallyandexternally.PerformanceimprovementstaffarepartoftheQuality/Regulatorydepartmentandhelpsupporttheoverarch-ingorganizationalgoalofimprovement.Tomonitorsuccess,thePMS(Figure 4.1-1)isused.Theover-archingapproach,formalandinformal,tosupportprocessimprovementeffortsisthePlan-Do-Study-Act(PDSA)problem-solvingmethodol-ogy.ThismethodologyisembeddedinLOTS’simprovementprocesses.

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meetnationalperformancestandardssetbytheCentersforMedicareandMedicaidServices(CMS).Shouldperformanceconsistentlyfallshortofthenationalstandards,CMScouldchoosetoawardtheDSAtoanotherOPO.WhileOPOsdonotcompetefororgans,thereassignmentofpotentialfutureDSAswouldbebasedonperformancetothestandards.FortheTWS,donorhospitalsarerequiredbylawtoreportalldeathstoLOTS;however,theymaycontractwithanothertissuebankattheirowndiscretionfortherecoveryprocess.LOTSmaintainstissuerecoverycontractswith100%ofthe80donorhospitalpartnerswithinitsservicearea.LOTSpartnerswithaneyebank,VisionMax,toensureeyedonationopportunitiesforfamiliesintheDSA.LOTSranks40thamongtheexisting58OPOsintermsofpopulationlivingwithinitsDSA.SinceexpansionoftheDSAisnotallowed,growthindonationmustcomefromincreasesinmedicallyeligiblecandidatesfromwithintheDSA,fromincreasesinthenumberoffamilieswhosay“yes”(authorization)todonation,orfromtheidentifica-tionofnonhospitalreferralsources.Theconstraintsofalimitedserviceareareinforcetheimportanceofmaximizingdonationforeachdonorinordertoachievethemissionofsavinglives(Figure P.1-3).

P.2a(2) BecauseLOTSdoesnothavecompetitorsinthetra-ditionalsense,therearenokeychangestakingplacethataffecttheorganization’scompetitivepositionasanOPO.WhilethechangestotheAffordableCareActwillbeachallengeforthehealthcareindustry,thescopeofitschangestotheOPOindustryisuncertainatthistime.Assuch,theorganizationhasdecidedtofocusonwhatitcancontrol;utilizingLOTS’sdriveandprovenabilitytoimproveandrelyonitsmission-drivenworkforce(CC)toachievecost-effectivenessandefficienciestoplaceitselfinastrongfinancialposition(SA)tomanagefuturechallenges.KeyfactorsinfluencingthesuccessofLOTSinclude

■ Amission-drivenworkforcethatishighlymotivatedandengagedinsaving lives(CC)

■ Strongrelationshipsformedthroughpartneringandcollaboration

Asstatedpreviously,theOWSandTWSdonotcurrentlyhavecompetitors.

P.2a(3) TheComparativeDataProcess(Figure 4.1-4)liststheorganization’skeycomparativedatasources.Theorganindustryhasselectnationalbenchmarksavailablethroughmultiplesources;however,theleadtimebeforesuchresultsbecomeavailablecanbemanymonths.Comparativedataaremorelimitedfortissueoperations,inwhichtissueprocessorsprovidemonthlyfeedbackforselectresultsintheformofscorecards.Tooffsettheselimitations,LOTSreliesonsharingthroughcollaborationwithotherOPOstoobtaincomparativedata.

P.2b Strategic ContextStrategicChallenges(SCs)andAdvantages(SAs;Figure P.2-1)providesasummarythatreflectsthecurrentstrategicstateofLOTS.SCsandSAsarereviewedannuallyduringstep3of

theSPP(Figure 2.1-1);steps5through8ensurethatappropri-ateactionplans(APs)arelinkedtoorganizationalsuccess.

P.2c Performance Improvement SystemTogetherwiththeBOD,theLOTSLTcreatesanenvironmentthatsupportsimprovementthroughthecreationofstrategies,systems,andmethodsforachievingperformanceexcellence.TheLeadershipSystem(LS;Figure 1.1-1)isusedtosetanddeploytheV/M/VandculturetotheworkforceviatheCommunicationProcess(Figure 1.1-3).LOTShasdevelopedanorganizationalstructure,processes,andculturetofocusonactionandachievesustainableperformance,fosterimprove-ment,andseekoutstrategicopportunities.AcontinuousprocessimprovementenvironmentallowsLOTStodeliveradistinctivevaluestreamthatbenefitsboththeperformanceofcustomer-focusedoperationsandthelivesoforganandtissuerecipients.

LOTSusestheBaldrigeCriteriaforPerformanceExcellenceasitsbusinessmodelanditsfoundationforperformanceimprovement(PI).Ultimately,thismodelprovidesongo-ingfeedbackintotheSPP.Additionally,step3oftheLS(Figure 1.1-1)provideskeybusinessprocessmonitoringtoalignbusinessstrategytoorganizationalperformance.OperationalimprovementsareidentifiedandimplementedthroughtheSPPandtheOperationalManagementProcess(OMP;Figure 6.1-1).Bothprocessesbringtotheforefrontkeyinformationtomanagethebusiness,aggregatedata,createactionsthatsynthesizeinformationintoknowledge,andultimatelyfacilitatethesharingofknowledge,bothinternallyandexternally.PerformanceimprovementstaffarepartoftheQuality/Regulatorydepartmentandhelpsupporttheoverarch-ingorganizationalgoalofimprovement.Tomonitorsuccess,thePMS(Figure 4.1-1)isused.Theover-archingapproach,formalandinformal,tosupportprocessimprovementeffortsisthePlan-Do-Study-Act(PDSA)problem-solvingmethodol-ogy.ThismethodologyisembeddedinLOTS’simprovementprocesses.

Figure P.2-1: Strategic Challenges and Advantages

Challenges

Business • IndustryChanges

Operational • Authorization

SocietalResponsibility • IncreaseRegistry

Workforce • Retention

Advantages

Business • StakeholderSatisfaction

Operational • FacilitiesandEquipment

SocietalResponsibility • BaldrigeBusinessModel

Workforce • SupportiveCulture

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RESPONSESADDRESSINGALLCRITERIAITEMS

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Category 1: Leadership

1.1 Senior Leadership1.1a Vision and Values1.1a(1) LOTSLS(Figure 1.1-1)providesdirectionforanengagedworkforcethatsuccessfullyfacilitatesorganandtissuedonationinalignmentwiththeVisionandValues (V/V;Figure P.1-1).DuringarecentSPPsession,LOTSreviewedtheV/Voftheorganization.Thisrevalidationprocessincorporatedemployeeinputusinganinternalsurvey.TheV/Vwereupdated,vetted,andratifiedbytheBOD.

TheLTdeploystheV/Vandculturetotheworkforce,aswellastocustomers,stakeholders,partners,andsuppliers,viamultiplecommunicationmechanismsasmanagedbytheCommunicationProcess(Figure 1.1-3).Examplesinclude■ ReviewingandemphasizingtheV/M/Vduringboard,staff,

anddepartmentmeetings■ Incorporatingthestoriesofdonorfamilies,recipients,

andpatientswaitingforatransplantintomultiplecommunicationmethods

TheLTmembersserveasrolemodelsanddemonstratetheircommitmenttothecorevaluesbysettingthecultureviatheLS,includingthroughdailypracticeandduringstaffmeetings,duringdepartmentmeetings,andinconversationsinRoundingforOutcomes(RFO).Leadersprovidepersonalacknowledge-menttoemployeesfordemonstratingbehaviorsconsistentwiththeorganization’scorevalues.TheLTusesa360-degreereviewtoprovidesystematicfeedbacktoallLTmembersfrompeersanddirectreportspertainingtotheleader’sindividualeffectiveness,includingexhibitingbehaviorsconsistentwiththeV/V.ThisreviewprocessalsoprovidestheLTwithindividualopportunitiesforimprovementandisusedtoassesstheeffectivenessoftheLS.TheBODevaluatestheCEO’seffectivenesswithoperatingtheorganizationinalignmentwiththeV/V.

1.1a(2) TheLT’sactionspersonallydemonstratethehigheststandardsofethicalbehaviorbypromotingtheprinciplesandideasreflectedintheV/Vatstaff,worksystem,anddepartmentmeetings,aswellasregularlythroughRFOconversations.TheLTadherestoworkplacepoliciesincludingtheCodeofProfessionalConduct,Donor/RecipientConfi-dentiality,andConflictofInterest(COI)withasignedannualdisclosure.

ThroughtheLOTSCorporateComplianceProgram(CCP;Figure 1.1-2),leaderspromoteanatmospherethatencouragesemployeesandstakeholderstoreportanyquestionablebehav-ior.Ananonymoushotlinereportingsystemisinplacetoensureconfidentiality.TheentireLOTSworkforce,includingtheLTandBOD,istrainedannuallyontheCCPpolicy.Inaddition,compliancepoliciesarereviewedbyLOTSQualitystaff.

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Category 1: Leadership

1.1b Communication TheLTcommunicateswithandengagestheworkforceusingtheCommunicationProcess(Figure 1.1-3).AsLOTShasgrown,theCommunicationProcesshasgonethroughmodificationstostaycurrentwithorganizationalneeds.Keydecisionsaredisseminatedtotheentireworkforcethroughvariousmeetingsorelectroniccommunications.Forexample,workforcesurveyfeedbackaboutthemonthlystaffmeetingsresultedinanewformat,anewschedule,andinformation-sharingmechanismsthatwerethensharedviatheCommuni-cationProcess(Figure 1.1-3).CompletionoftheCommunica-tionProcessisaccomplishedthroughknowledgesharingandfeedback,ensuringaclosedcommunicationloop.

Topromotefrank,two-waycommunicationwithemployees,theLTusestheCommunicationProcess,whichsupportsanopen-doorpolicy,andRFO,theconsistentpracticeofaskingspecificquestionstoobtainactionableinformation.LTmem-bers“round”witheachoftheirdirectreportstogainknowl-edge,includingthesupportneededtohelpthestaffmemberachievehis/hergoals,additionalresourceneeds,andpeerrecognition.Thispracticeisalsobeneficialinbuildingrela-tionshipsamongleadersandtheirdirectreportsandensuringthatcommunicationiseffective.Toclosethecommunicationloop,feedbackisprovidedatstaffmeetingsviatheStoplightReport,whichisareportthatcollectsinformationobtainedinroundingandidentifiessuggestions,actionsinprogress,or

1.1 Senior Leadership1.1a Vision and Values1.1a(1) LOTSLS(Figure 1.1-1)providesdirectionforanengagedworkforcethatsuccessfullyfacilitatesorganandtissuedonationinalignmentwiththeVisionandValues (V/V;Figure P.1-1).DuringarecentSPPsession,LOTSreviewedtheV/Voftheorganization.Thisrevalidationprocessincorporatedemployeeinputusinganinternalsurvey.TheV/Vwereupdated,vetted,andratifiedbytheBOD.

TheLTdeploystheV/Vandculturetotheworkforce,aswellastocustomers,stakeholders,partners,andsuppliers,viamultiplecommunicationmechanismsasmanagedbytheCommunicationProcess(Figure 1.1-3).Examplesinclude■ ReviewingandemphasizingtheV/M/Vduringboard,staff,

anddepartmentmeetings■ Incorporatingthestoriesofdonorfamilies,recipients,

andpatientswaitingforatransplantintomultiplecommunicationmethods

TheLTmembersserveasrolemodelsanddemonstratetheircommitmenttothecorevaluesbysettingthecultureviatheLS,includingthroughdailypracticeandduringstaffmeetings,duringdepartmentmeetings,andinconversationsinRoundingforOutcomes(RFO).Leadersprovidepersonalacknowledge-menttoemployeesfordemonstratingbehaviorsconsistentwiththeorganization’scorevalues.TheLTusesa360-degreereviewtoprovidesystematicfeedbacktoallLTmembersfrompeersanddirectreportspertainingtotheleader’sindividualeffectiveness,includingexhibitingbehaviorsconsistentwiththeV/V.ThisreviewprocessalsoprovidestheLTwithindividualopportunitiesforimprovementandisusedtoassesstheeffectivenessoftheLS.TheBODevaluatestheCEO’seffectivenesswithoperatingtheorganizationinalignmentwiththeV/V.

1.1a(2) TheLT’sactionspersonallydemonstratethehigheststandardsofethicalbehaviorbypromotingtheprinciplesandideasreflectedintheV/Vatstaff,worksystem,anddepartmentmeetings,aswellasregularlythroughRFOconversations.TheLTadherestoworkplacepoliciesincludingtheCodeofProfessionalConduct,Donor/RecipientConfi-dentiality,andConflictofInterest(COI)withasignedannualdisclosure.

ThroughtheLOTSCorporateComplianceProgram(CCP;Figure 1.1-2),leaderspromoteanatmospherethatencouragesemployeesandstakeholderstoreportanyquestionablebehav-ior.Ananonymoushotlinereportingsystemisinplacetoensureconfidentiality.TheentireLOTSworkforce,includingtheLTandBOD,istrainedannuallyontheCCPpolicy.Inaddition,compliancepoliciesarereviewedbyLOTSQualitystaff.

Figure 1.1-1: Leadership System (LS)

Enab

led b

y Org

aniza

tiona

l Stru

ctur

e (F

igure

1.2

-2)

Monitor the Performance • Performance Measurement System (Figure 4.1-1)

• Performance Evaluation Process (Figure 5.1-2)

3

Operationalize the Strategy • Communication Process (Figure 1.1-3) • Strategic Planning Process (Figure 2.1-1) • Learning and Development System (Figure 5.2-2) • Operational Management Process (Figure 6.1-1)

2

Create the Environment • V/M/V (Figure P.1-1) • VOC (Figure 3.1-1)

1

1.1b Communication TheLTcommunicateswithandengagestheworkforceusingtheCommunicationProcess(Figure 1.1-3).AsLOTShasgrown,theCommunicationProcesshasgonethroughmodificationstostaycurrentwithorganizationalneeds.Keydecisionsaredisseminatedtotheentireworkforcethroughvariousmeetingsorelectroniccommunications.Forexample,workforcesurveyfeedbackaboutthemonthlystaffmeetingsresultedinanewformat,anewschedule,andinformation-sharingmechanismsthatwerethensharedviatheCommuni-cationProcess(Figure 1.1-3).CompletionoftheCommunica-tionProcessisaccomplishedthroughknowledgesharingandfeedback,ensuringaclosedcommunicationloop.

Topromotefrank,two-waycommunicationwithemployees,theLTusestheCommunicationProcess,whichsupportsanopen-doorpolicy,andRFO,theconsistentpracticeofaskingspecificquestionstoobtainactionableinformation.LTmem-bers“round”witheachoftheirdirectreportstogainknowl-edge,includingthesupportneededtohelpthestaffmemberachievehis/hergoals,additionalresourceneeds,andpeerrecognition.Thispracticeisalsobeneficialinbuildingrela-tionshipsamongleadersandtheirdirectreportsandensuringthatcommunicationiseffective.Toclosethecommunicationloop,feedbackisprovidedatstaffmeetingsviatheStoplightReport,whichisareportthatcollectsinformationobtainedinroundingandidentifiessuggestions,actionsinprogress,or

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suggestionsnottaken.MembersoftheLTreinforcehighperformanceandacustomerandbusinessfocusinmultipleways(Figure 5.2-1, Rewards and Recognition).PersonalnotesofrecognitioncanbewrittenbyanymemberoftheLT,includingtheCEO,toacknowledgespecialachieve-ment.AcustomerandbusinessfocusandmotivationforhighperformancearealsoaccomplishedusingtheCom-municationProcess(Figure 1.1-3).

LocalorgantransplantcentersandtissueprocessorsareLOTS’skeycustomers.TheLTcommunicatesandengageswithitscustomerspertheVOC(Figure 3.1-1).Commu-nicationwithkeycustomersisbasedonone-andtwo-waycommunicationandoccursinallphasesofthecustomerlifecycle.Duetotheconfidentialnatureofdonation,socialmediaarenotusedforoperationalcommunication.Socialmediaareusedforinternalandexternalcommunicationforbroadernonconfidentialmessagingthatdoesnotincorpo-ratedonorinformation.Inaddition,socialmediaareusedtocommunicateandhighlightdonorfamilyandrecipientstoriesviaFacebook,Instagram,andTwitter,reinforcingthemissionofsaving and improving lives .

1.1c Mission and Organizational Performance 1.1c(1) TheLTcreatesasuccessfulorganizationnowandinthefuturethroughtheSPP(Figure 2.1-1)andtheLS (Figure 1.1-1),whichallowafocusontheorganization’splanningandkeyprocessestocreateintegratedworksys-tems.Toensuresustainability,processesaremappedanddocumented,andsuccessionplansaredeveloped;therebyensuringtheenvironmenttoaccomplishLOTS’slife-sav-ingmission.Step1oftheLS(Figure 1.1-1)ensuresthat

Figure 1.1-2: Corporate Compliance Program (CCP)An

nual

Revie

w/Fe

edba

ck R

epor

t

Legend:“1” 5 Proactive; “2” 5 Reactive

CommunitiesWithin DSA

2 Website

Key Suppliers 1 Contracts 2 Anonymous Hotline

Donor Families VOS (Figure 4.2-1)2 Anonymous Hotline

Hospital/Non-Hospital Partners 1 Contract Expectation 2 Anonymous Hotline 2 Website

Transplant Center, Tissue Processor

1 Contract Expectation 1 Physician Code of Professional Conduct 2 Anonymous Hotline 2 Website

BOD, WFAnnual Review & Acknowledgement: 1 Code of Professional Conduct (WF Only) 1 Conflict of Interest 1 Corporate Compliance Training 2 Anonymous Email & 24-Hour Hotline

Core Value: Honesty

Communication Process (1.1-3)


Figure 1.1-3: Communication Process

Staff Meetings Electronic Means

PublicationsOne-Way Communication

2Work System Meetings Operations Meetings Department Meetings

Two-Way Communication

3

Strategic Operational Discussions Discussions SPP (Figure 2.1-1) OMP (Figure 6.1-1)

Key Decisions

Knowledge Sharing & FeedbackRounding for Outcomes

Electronic Means Relationship Management

VOC (Figure 3.1-1)VOS (Figure 4.2-1)

Two-Way Communications

4

1

2




Figure 1.1-2: Corporate Compliance Program (CCP)An

nual

Revie

w/Fe

edba

ck R

epor

t

Legend:“1” 5 Proactive; “2” 5 Reactive

CommunitiesWithin DSA

2 Website

Key Suppliers 1 Contracts 2 Anonymous Hotline

Donor Families VOS (Figure 4.2-1)2 Anonymous Hotline

Hospital/Non-Hospital Partners 1 Contract Expectation 2 Anonymous Hotline 2 Website

Transplant Center, Tissue Processor

1 Contract Expectation 1 Physician Code of Professional Conduct 2 Anonymous Hotline 2 Website

BOD, WFAnnual Review & Acknowledgement: 1 Code of Professional Conduct (WF Only) 1 Conflict of Interest 1 Corporate Compliance Training 2 Anonymous Email & 24-Hour Hotline

Core Value: Honesty



Figure 1.1-3: Communication Process

Staff Meetings Electronic Means

PublicationsOne-Way Communication

2Work System Meetings Operations Meetings Department Meetings

Two-Way Communication

3

Strategic Operational Discussions Discussions SPP (Figure 2.1-1) OMP (Figure 6.1-1)

Key Decisions

Knowledge Sharing & FeedbackRounding for Outcomes

Electronic Means Relationship Management

VOC (Figure 3.1-1)VOS (Figure 4.2-1)

Two-Way Communications

4

1




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LOTSisabletocreateandreinforceanorganizationalculture andincorporatedintotheweb-basedPMS,areakeypiecethatfostersworkforceandcustomerengagement,utilizingthe ofthePMSandarereviewedateachworksystemmeetingCommunicationProcess(Figure 1.1-3)andtheVOCProcess (Figures 4.1-1 and 4.1-2).Seniorleaderaccountabilityforthe(Figure 3.1-1). organization’sactionsisaccomplishedthroughannualgoal

plansreflectedinthePEP(Figure 5.1-2).ReviewoftheworkLOTS’sstrategyisoperationalizedviatheSPP(Figure 2.1-1),systemscorecardsoccursattheworksystemmeetingsandOMP(Figure 6.1-1),andCommunicationProcessensurestheabilitytorecognizetheneedtomodifyorimple-(Figure 1.1-3).TheSPPestablishesstrategicorganizationalmentAPsasprioritieschange.APprogressforalldepartmentsdirection,fromwhichAPsaredeveloped,implemented,andisreviewedatLTmeetings.SystematicreviewsoftheAPs,viamodifiedasneeded.TheOMPisutilizedtoreview,analyze,one-on-onemeetingswithmanagers,providestaffaccount-improve,andprioritizetheorganization’sinternalandabilityandopportunitiestoensurethatorganizationalper-externalprocesses;keystrategicandoperationaldecisionsformanceisprogressingtoplanandthatLOTSisultimatelyarecommunicatedtotheworkforceandkeypartnersviatheattainingitsvision.Forexample,theTissueProcurementCommunicationProcess.Theorganization’sperformanceisDepartmentandthePIstaffworkedcollaborativelyin2018tomonitoredbytheLTusingthePMS(Figure 4.1-1);leader-address“redboxes”fordocumentationcompliance.SeveralshipandemployeeperformanceismonitoredviathePEPinitiativeswerecreatedandimplemented,resultinginprocess(Figure 5.1-2).TheLOTSculture,theV/M/V,andtheLDSandprocedureimprovementsthatresultedinimproved(Figure 5.2-2)createanenvironmentamenabletoemployeedocumentationmetricsthatdidachievetarget.andorganizationallearning.Thecommitmenttothemissionof

saving and improving lives,alongwiththevalueofimprove- Step1oftheannualSPPhelpstheorganizationfocusonment,drivesLOTStostayawareofindustryknowledgeand balancingtheneedsofcustomers,partners,andstakeholders.bestpractices.Individualtraininganddevelopmentgoals ExpectationsarevalidatedbyperiodicsurveysandfocusareaddressedthroughtheongoingPEP.Asdescribedin groups.PerformancemetricsinthePMSrepresentkeyP.1a(2),theLOTScultureencouragesanenvironmentwhere performancemeasuresoftheorganizationandensurebalanceemployeescontinuouslyseekimprovementinordertosave forkeycustomersandstakeholders.andimprovemorelives.

1.2 Governance and Societal ContributionsTheLTcreatesanenvironmentthatencouragesandsupportsimprovement,andthisimprovementismeasuredovertime 1.2a Organizational GovernancewiththekeymetricsontheToplineScorecard(Figure 4.1-2). 1.2a(1) GovernanceoftheorganizationisprovidedbyaIfametricis“inthered”forthreemonths,theresponsible 15-memberBODthatstrategicallyreviewsorganizationalleadermustanalyzeandunderstandwhy,andifthemetric resultstoachievefiscalandmanagementaccountability.continuesbelowthetarget,anewormodifiedAPmustbe TransparencyinoperationsensuresthatLOTSaddressesitsdevelopedtoaddresstheshortfall. responsibilitytothecommunity,exhibitsethicalbehavior,

practicesgoodcitizenship,andprotectsstakeholderinterests.LTmembers,includingtheCEO,developsuccessionplansforLOTS’sdiverseboardreflectskeycustomers,stakeholders,theirpositionstoensurethatappropriateinterimleadershipisandpartnersandisbalancedtopromoteadiversityofinsightsavailableshouldavacancyoccur,aswellasplansforfutureandperspectives.PracticesoftheLOTS’sBODtoreviewandleaderstogrowwithintheorganization.Successionplansareachievekeyaspectsandaccountabilityofgovernanceincludealignedwiththeannualperformanceevaluationstoensurethat

currentandfutureleadersarereceivingtheneededleadership ■ Holdingmanagementaccountableforoperationalresultstrainingtosupporttheirindividualgrowthanddevelopment. throughevaluationofthemonthlyStatusReport,whichA360-degreefeedbackreviewisusedtoidentifyspecific showsSOtargetprogressimprovementopportunitiesforallcurrentleaders.LT ■ Reviewingandapprovingthestrategicplan,budget,Qual-developmenthasincludedtrainingthroughLearningDevel- ityAssessmentandPerformanceImprovement(QAPI),andopmentInstitutes,attendanceatstateandnationalindustry toplinemetricsannuallyconferences,andattendanceatnation-widenon-industry ■ Achievingfiscalaccountabilitybyreviewoffinancialconferences. reports,whicharereviewedindetailatboardmeetings

■ Ensuringtransparencyoftheboardandcommitteeopera-1.1c(2) ThroughtheLS(Figure 1.1-1),theLTcreatesationsthroughtheavailabilityofminutes,presentations,focusonaccomplishingtheorganization’sobjectives,improv-andreportsthatincludequality/regulatoryoutcomes.ingperformance,andachievingtheV/M/V.Step1oftheLSTransparentselectionofgovernanceboardmembersisiscreatingtheenvironment,akeypartoftheorganization’saccomplishedbyactivelysolicitingnominationsfromsuccess.Thisincludesusingthecustomer-focusedandsourcesincludingkeymembersofthecommunityandmission-drivenculturetoseekcontinuousimprovement.membersoftheMedicalAdvisoryBoard,inadditiontoStep2oftheLS(OperationalizetheStrategy)establishesanominationsfromexistingBODmembersandseniorfocusonactions,whicharemonitoredinstep3(Monitortheleaders.COI,corporatecompliancetraining,anddisclosurePerformance).Cascadingscorecards,integratedintoworkstatementsaresignedannuallybyallboardmembers.systems,departments,andmanyindividualmetriclevels

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■ Maintainingindependenceandeffectivenessinaudits ACrisisCommunicationPlanhasbeendevelopedtoensureanthroughanannualexternalaudit.Theauditfirmisengaged appropriateresponsetopublicconcerns,ifneeded.bytheboardAuditCommittee,whichcomprisesinde- Conservationofnaturalresourcesisconsideredthroughpendentboardmembers.Auditresultsarereportedtothe greenbuildingpractices,temperatureandlightconservation,committeealongwithanyrecommendations. recyclingprograms,andassurancethattheenvironmentis

■ Developingandapprovingaformalsuccessionplanfor protectedthrougheffectivebiohazardouswastedisposal.AstheCEO.AuthorityhasbeendelegatedbytheBODtothe anexample,multipleeffortsaremadeacrosstheorganizationCEOtooverseesuccessionplandevelopmentforotherELT toreducepaperusage,includingtheuseofaboardportalmembers. andscreenprojectionofallmeetingdataandthetransitionof

1.2a(2) AsystematicreviewprocessisutilizedbytheBOD’s severalsupportdepartmentstousepaperlesssystems.LOTSCompensationCommitteetoconductanannualreviewofthe preparesforimpactsandconcernsproactivelythrougheffec-CEO’sperformance.Theprocessinputsincludeaself-eval- tivesupply-networkmanagementprocesses,whichincludeauationbytheCEO,areviewoforganizationalperformance secureelectronicdatabaseandestablishedparlevels.metrics,andanonlineevaluationoftheCEObytheBOD.

DuetoLOTS’slife-savingmission,allvoluntaryindustryTheseinputsareusedbytheCompensationCommitteetoaccreditationsaresoughttohelpensureregulatoryandlegaldeveloptheCEO’sperformancereviewand,incollaborationcompliance(Figure P.1-5),aswellasethicalbehavior.ThesewiththeCEO,tosetnewgoalsfortheupcomingyear.ThevoluntaryaccreditationshelpLOTSensurethatprocessesCompensationCommitteeengagesanexternalconsultingfirmmeetorexceedcurrentstandardsandassisttheorganizationtoconductasalarysurvey.Inconjunctionwiththesalarysur-withproactivelyidentifyinganypotentialopportunitiesforveyinformation,acompensationphilosophyandsalaryrangeimprovingprocesses.FeedbackfromtheseaccreditationsisfortheCEOareestablishedbytheCompensationCommittee.incorporatedintotheorganization’sPIprocesses.LOTShasFeedbackfromtheBODandassessmentofthecommitteearereceivedfullaccreditationfromAOPOandAATB.Inaddition,utilizedtoadjustsalarybasedonperformance.LOTShasinternalandexternalauditsscheduledacrossthe

TheCEOconductsannualperformanceevaluationsforthe organizationtoaddressregulatoryrequirementsandtoidentifyELTusingthesamePEPasisusedforevaluationsofthe potentialrisksassociatedwithitsoperations,ensuringthattheLTandtheworkforce.AspartofthePEPprocess,theCEO organizationremainsinastateofreadiness.providestheseleaderswithongoingfeedback,including

Aseriesofinternalandexternalauditsensurecomplianceleadershipeffectivenessandprogresstowardsgoalcompletionwithkeyregulatoryandlegalrequirements,asshownininordertodriveimprovementsinperformance.TheBODFigure 1.2-1.Certainauditfindingsincludeadeviationcompletesself-evaluationsurveysbienniallytodeterminetheformaspartofaformalfeedbackloopandassistLOTSlevelofperformanceofboardmembers,aswellastoidentifywithproactivelyaddressingissuesrelatedtokeycomplianceopportunitiesforimprovement.Thesurveyincludesaself-processes,measures,andgoals.Additionally,theauditspushassessmentoftheirknowledgeandcomfortlevelswithkeytheorganizationtoexceedregulatoryandlegalrequirementsareasofLOTS’soperations;thisfeedbackisusedtodevelopbyservingasmethodsusedforaddressingrisksassociatedaneducationalagendatargetingtheiridentifieddevelopmentwithkeyservicesandoperations(Figures 7.4-4 and 7.4-6).needs(Figure 7.4-2).BoardsurveyresultshelpguideBODAuditfeedbackreportsarereviewedbytheappropriateworkmeetingsandcommunication.groupandsummarizedfortheLTandBOD.Shouldimprove-

1.2b Legal and Ethical Behavior mentsbeidentified,aresponseplanisdevelopedanddeployedviatheOMP(Figure 6.1-1).1.2b(1) Todate,LOTShasnotbeeninvolvedwithany

adverseeventthathadsocietalimpactontheorganization’s 1.2b(2) TheBODandLTpromoteanenvironmentthatservicesandoperations.Historically,nationalindustry fostersandrequireslegalandethicalbehaviorsthroughtheconcernshavefocusedonthesafetyoftheorgansandtissues, CCP (Figure 1.1-2).Furthermore,theorganization’sethicalcoupledwithfairnessintheallocationoforganstorecipients. behaviorstandardsarereflectedinitscorevalueofhonesty.ToLOTSproactivelyapproachesthesepotentialthreatsthrough promoteandensureethicalbehavioracrosstheorganization,strictadherencetopoliciesandprocedures.LOTSleverages allemployeesadheretoaCodeofProfessionalConduct.theOrganizationalStructure(Figure 1.2-2)andutilizesthe LOTS’sCCPisconsistentwithindustrystandards,whichpro-SPP(Figure 2.1-1,Step2)togatherinformationfromavari- videeducation,monitoring,andinvestigationofbreaches.Theetyofsourcestoanticipatelegal,regulatory,andcommunity programprovidesananonymousmechanismfortheworkforceconcerns.Asanexample,theorganizationengagesthegreater andothercustomers,partners,suppliers,andstakeholderstocommunitythroughboardrepresentationofstakeholder reportanynoncomplianceeventsoroccurrences.TheCCPcommunitiesonboththegoverningandadvisoryboards. Officerisresponsibleforinvestigatingcomplaintsandreport-Mediaalertsandpositionstatementscreatedbyindustry ingtotheCEOorBOD’sExecutiveCommittee,ifappropri-organizationsareusedinresponsetonationalnewsstories ate.AlltheelementsoftheCCParereviewedannuallybytheandaredistributedtotheworkforceandBODasappropriate. CorporateGovernance/NominatingCommittee

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society.Thiscanbemeasuredbytheincreaseinthenumberoforganstransplantedandthereductionofdeathsonthelocaltransplantwaitinglist,aswellastheincreasingnumberoftis-suetransplants(Figures 7.1-3 through 7.1-14).Step1oftheannualSPPsessionincludesadiscussionofkeycommunitiestoensurethattheorganizationisresponsivetotheirneedsandrequirements(Figure 2.1-1).

Throughthedesignofitsfacility,whichincludesanenergymanagementsystem,LOTScontributestoenvironmentalwell-being.Theorganizationcontinuestoexplore“green”opportunitiessuggestedbytheworkforce;previousstaffsug-gestionsresultedinaformalizedrecyclingprogramforpaper,plastic,andaluminum,aswellasareductioninhand-outsforstakeholdersbyprovidingdataelectronically.

1.2c(2) TheBODidentifiesLOTS’skeycommunities,andtheLTreviewsandvalidatesthemannuallyaspartoftheSPP(Figure 2.1-1).LOTS’skeycommunitiesincludedonorfami-lies,transplantrecipients,andtheirfamilieswithintheDSA.LOTSsupportsandstrengthenskeycommunitiesinmultipleways.Tosupportdonorfamilies,LOTSconstructedaDonorMemorialMonumentandparkfordonorandrecipientfamiliestogather,remember,andhonortheirlovedones.Inaddition,moreformalwaystohonoradonorfamily’slovedonearememorialeventsinwhichstaffmembersactivelyparticipateateventshostedacrosstheorganization’sDSA.

Figure 1.2-2: Organizational StructureLevel Roles Outcomes

BOD

• ValidateV/M/V• Establishaccountability

• Long-termstrategicdirection

• Organizationalsustainability

Leadership Team

(ELT and LT)

• Createtheenvironment

• Operationalize thestrategy

• Monitortheperformance

• Organizationalculture

• Strategicplandeployment

• People&performancemanagement

Workforce• Supportandfacilitateorgan&tissuedonation

• Maximizedonation

1

2

3

Feed

back

Feed

back

Figure 1.2-1: Key Regulatory and Legal Requirements

Key Regulatory and Legal Requirements

Key Risk Reduction Processes

Measures and Indicators Goals Figures

Compliancewithorganallocation UNOS/OPTNauditsInternalaudits

UNOSorganplacementpolicies

Memberingoodstanding

7.4-5

CompliancewithFDArequirements FDAaudits FDAapproval No adverse findings 7.4-5

Voluntarycompliancetomeetorgandonationindustrystandards

InternalauditsQA/Training

AOPOaccreditation Fullaccreditation 7.4-5

Voluntarycompliancetomeettissuedonationindustrystandards


AATB Fullaccreditation 7.4-5

CompliancewithCMSregulations impactingreimbursement

CMSauditInternalaudit

CMS certification Full certification 7.4-5

CompliancewithIRSregulations impacting not-for-profit organizations

ExternalFinancialaudits Minimalauditadjustments

Unqualified opinion 7.4-4

AOSCorporateComplianceProcess(CCP)

AnnualtrainingacknowledgementReportedhotlineissues

100%CompletionNoEvents

CompliancewithregulationsimpactingHumanResources

EEOCguidelines PolicyCompliance Noeventsoroccurrences

7.4-6

FLSAposted Posting

Safeworkplace Safety officerSafetycommitteeEmployeetraining

OSHAsiteauditsReportableevents

FullcomplianceNoreportableevents

7.4-57.3-7

CompliancewithDORrequirements DORaudit DORapproval No adverse findings 7.4-5

1.2c Societal Contributions1.2c(1) Theaccomplishmentofthemission—we save and improve lives—isLOTS’sgreatestgiftandcontributionto

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Figure 1.2-2: Organizational StructureLevel Roles Outcomes

BOD

• ValidateV/M/V• Establishaccountability

• Long-termstrategicdirection

• Organizationalsustainability

Leadership Team

(ELT and LT)

• Createtheenvironment

• Operationalize thestrategy

• Monitortheperformance

• Organizationalculture

• Strategicplandeployment

• People&performancemanagement

Workforce• Supportandfacilitateorgan&tissuedonation

• Maximizedonation

1

2

3

Feed

back

Feed

back

Figure 1.2-1: Key Regulatory and Legal Requirements

Key Regulatory and Legal Requirements

Key Risk Reduction Processes

Measures and Indicators Goals Figures

Compliancewithorganallocation UNOS/OPTNauditsInternalaudits

UNOSorganplacementpolicies

Memberingoodstanding

7.4-5

CompliancewithFDArequirements FDAaudits FDAapproval No adverse findings 7.4-5

Voluntarycompliancetomeetorgandonationindustrystandards


AOPOaccreditation Fullaccreditation 7.4-5

Voluntarycompliancetomeettissuedonationindustrystandards


AATB Fullaccreditation 7.4-5

CompliancewithCMSregulations impactingreimbursement

CMSauditInternalaudit

CMS certification Full certification 7.4-5

CompliancewithIRSregulations impacting not-for-profit organizations

ExternalFinancialaudits Minimalauditadjustments

Unqualified opinion 7.4-4

AOSCorporateComplianceProcess(CCP)

AnnualtrainingacknowledgementReportedhotlineissues

100%CompletionNoEvents

CompliancewithregulationsimpactingHumanResources

EEOCguidelines PolicyCompliance Noeventsoroccurrences

7.4-6

FLSAposted Posting

Safeworkplace Safety officerSafetycommitteeEmployeetraining

OSHAsiteauditsReportableevents

FullcomplianceNoreportableevents

7.4-57.3-7

CompliancewithDORrequirements DORaudit DORapproval No adverse findings 7.4-5






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Category 2: Strategy

2.1 Strategy Development BoththeBODandLTfocusonastrategictimeframe;short- termtargetsandobjectivesaretobemetinoneyear,and2.1a Strategy Development Processlong-termtargetsandobjectivesaresetfortwoyears.Instep4

2.1a(1) Throughcyclesoflearning,thefocusofstrategic oftheSPP,focusedstrategicdiscussionsaddresstheperfor-planningevolvedfromaprocessbasedondefiningand manceprojectionsfortheone-andtwo-yeartimehorizonsapprovingactionstosupportthebudget,tothesystematicSPP establishedforkeymetrics.occurringthroughouttheyear,supportedbyAPsandgoal

Anychangesand/orprioritizationofchangeorimprove-achievement.TheOPObusinessecosystemisonethatrequiresmentinitiativesareidentifiedandevaluatedwithintheSPPLOTStobeagiletoensureitsabilitytomeetcustomer(Figure 2.1-1).LOTScapitalizesonitsagilityachievedand,ultimately,recipientneeds.TheSPPinvolvesstrategicthroughtheOrganizationalStructure(Figure 1.2-2)toutilizedevelopment,implementation,anddiscussions,eachofwhichacontinuousSPP (Figure 2.1-1),whichhasseenlearningandconsistsofmultiplesteps(Figure 2.1-1).Currently,partici-improvements.TheLTparticipatesinstrategicdiscussionspantsintheSPPincludetheLT,BODmembers,customers,(SDs)thattakeplaceduringleadershipandworksystemmeet-front-linestaff,keypartners,andkeysuppliers.ings,creatingconsistencyacrosstheSPP.DuringtheseSDs,

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Category 2: Strategy

2.1 Strategy Development2.1a Strategy Development Process2.1a(1) Throughcyclesoflearning,thefocusofstrategicplanningevolvedfromaprocessbasedondefiningandapprovingactionstosupportthebudget,tothesystematicSPPoccurringthroughouttheyear,supportedbyAPsandgoalachievement.TheOPObusinessecosystemisonethatrequiresLOTStobeagiletoensureitsabilitytomeetcustomerand,ultimately,recipientneeds.TheSPPinvolvesstrategicdevelopment,implementation,anddiscussions,eachofwhichconsistsofmultiplesteps(Figure 2.1-1).Currently,partici-pantsintheSPPincludetheLT,BODmembers,customers,front-linestaff,keypartners,andkeysuppliers.

BoththeBODandLTfocusonastrategictimeframe;short- termtargetsandobjectivesaretobemetinoneyear,andlong-termtargetsandobjectivesaresetfortwoyears.Instep4oftheSPP,focusedstrategicdiscussionsaddresstheperfor-manceprojectionsfortheone-andtwo-yeartimehorizonsestablishedforkeymetrics.

Anychangesand/orprioritizationofchangeorimprove-mentinitiativesareidentifiedandevaluatedwithintheSPP(Figure 2.1-1).LOTScapitalizesonitsagilityachievedthroughtheOrganizationalStructure(Figure 1.2-2)toutilizeacontinuousSPP (Figure 2.1-1),whichhasseenlearningandimprovements.TheLTparticipatesinstrategicdiscussions(SDs)thattakeplaceduringleadershipandworksystemmeet-ings,creatingconsistencyacrosstheSPP.DuringtheseSDs,

Figure 2.1-1: Strategic Planning Process (SPP)

Strategic Discussions(Occurs annually at SPP and ongoing)

1. DEFINE

Idea Generation

Key Work Process Design Resource Utilization

2. DEP

LOY

Create, Mod

ify, Im

plem

ent,

and3. M

ONITOR

Organizational Performance

(PMS, PEP)

Commun

icate

Actio

ns

Meetings:

• Leadership • Work System

• Other

Strategy Implementation

Assess & ReviewWorkforce/Succession Planning

Financial Impact AP Selection

DevelopPrioritize and Cascade

Organizational Goals into APs, Ensuring Balance for Partners and

Key Stakeholders

Deploy Strategic PlanCommunicate Strategic Direction

(Fig. 1.1-3)

6 75

8

Meetings:

• Leadership• Work System

• Other

Strategic PlanningStrategy Development

Validate/Revalidate1

Analyze2

IdentifyStrategic Challenges, Advantages, & Opportunities

Current/Future Core CompetenciesStrategic Objectives and Organizational Goals

3

ProjectPerformance for 1–3 years

4

Re-validate Performance Projections

Board of Directors Input

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APsmaybecreated,modified,anddeployedasneeded,and customers.Anexampleoflearningandimprovementisthattheprogress-to-planismonitoredandevaluated,ensuringagil- LOTSaddedtheexpansionofformalinputfromkeypartnersityandoperationalflexibility.Thisongoingcycleofstrategy toincludeadditionalrelevantindustrydatagatheredfromdevelopmentanddeploymenthascreatedastrategicLTthat customerandpartnerorganizationsandprovidedinpresenta-fostersanenvironmentforactionandcontinuousimprovement tionstotheLT.ThesedatamaybecollectedfromindustryortosupportLOTS’slife-savingmission.TheSPPundergoesan nonindustryorganizationalconferences(AATB,AOPO,etc.).annualreviewtoensurethatallelementsareaddressedand Duringstep6(Develop),LOTScascadesorganizationalgoalsthatthemethodsutilizedremainagile,flexible,andeffective intoAPstoaccomplishtheSOs,addresstheSCs,andmakeainrespondingtochangesinthedonationenvironment. finaldeterminationaboutthefeasibilityofaccomplishingthe2.1a(2) Thecommitmenttothemissionof saving and SOsduringthedesiredtimeframe.Throughouttheyear,SDsimproving lives,alongwiththevalueofimprovement,drives includeareviewofrelevantchangesimpactingtheorganiza-LOTStostayonthetopofindustryknowledgeandbest tion’sabilitytoexecutethestrategicplan.TheLOTS’spractices.Operationalimprovementsareidentifiedandimple- strategicplanisfluidandprovidesreviewatmanylevels,mentedthroughtheSPPandtheOMP(Figure 6.1-1). Aspart therebyprovidingtheorganizationtheagilitynecessarytobeoftheimprovementapproach,improvementsuggestionsand abletomodifypreviousstrategiesasneeded.Thisconstantideasareidentifiedthroughmultipleinputsandthenvetted evaluation,monitoredbythePMS(Figure 4.1-1)andfacili-throughtheLTandaPDSAcycle.Thismightincludetheuti- tatedbytheCommunicationProcess(Figure 1.1-3),keepslizationofimprovementteams,comprisingmultidisciplinary theorganizationfocusedonexecutingthestrategicplanwithanddiversedepartmentsandstaff.Theteamsperformdata suitableflexibility.OrganizationalresultsarelinkedtotheSPPreview,and,usingPItoolsincludingPDSA,theycomplete (Figure 2.1-1,Step2),andifAPresultsarenotontargetperbrainstormingandprioritizationsessions.Theimprovement thePMS,actionistakentoaddressthegap.systemhasundergoneseveralcyclesoflearningtoensurethat 2.1a(4) ThedecisiontooutsourceaprocessortomanageitallpartsofthePDSAsystemareidentifiedandactedon. internallyisinitiatedthroughtheSPPandincludesassessmentTheSWOT(Strengths,Weaknesses,Opportunities,and ofmanyfactorsincludingcorecompetencies,businesseco-Threats)listisreviewedduringtheSPP(Step2)andvalidated systemchanges,andchangesinregulation.OngoinganalysisthroughongoingSDs (Step8).Strategicopportunitiesare ofkeysupplierandpartnerexpertiseand/orskillsetsviatheidentifiedinstep3oftheSPPandduringongoingSDsthat OMPprovideskeyinformationtoaidinthedeterminationofpromote“out-of-the-box”thinking.Forthe2018planning whichkeyprocesseswillbeaccomplishedinternallyorexter-cycle,thekeystrategicopportunitiesidentifiedareregistry nally.Forexample,LOTStestedabusinesscasestudytobringenrollmentandcustomersatisfaction. laboratorytestingwithintheorganization.Afterreviewingthe

internalskillsetandfinancialcommitmentrequired,LOTS2.1a(3) Duringstep2(Analyze)oftheSPP,LOTSevaluatesdecidedtocontinuetopartnerwiththeColumbiaUniversityitsstrategicposition.Thisstepalsoincludesreviewofkeyper-Hospital’slaboratorytoperformallinfectiousdiseasetestingformancemeasurementresultsandanenvironmentalscanofandHumanLeukocyteAntigen(HLA)typing.Thisallowsthedonationandtransplantationindustry,aswellastheoverallLOTStofocusonsavingandimprovinglives.healthcareclimateofthecommunity.ThereviewincludesThekeyworksystemsaretheOWSandtheTWS(Figure 2.1-2).■ Keyperformancemeasurementresults(Figure 4.1-1)Worksystemdecisionsaremadeviastep8oftheSPP.■ SWOT;SCsandSAs(Figure P.2-1)Incorporationoforganizationalknowledge,newtechnology,■ BODinput(Figure 1.2-2)productexcellence,andagilityarealsoaccomplishedthrough■ Customer,donorfamily(collaborator),andotherkeytheOMP(Figure 6.1-1).Withinstep3oftheSPP,LOTSstakeholderfeedbackandpreferences(Figure 4.2-1)definesandvalidatesitsSAs,SCs,SOs,currentandfuture■ CurrentandproposedchangestoregulatoryrequirementsCCs,andorganizationalgoalsbasedoncurrentperformance(Figure 1.2-1)andtheenvironmentalscanninganalysiscompletedinstep2.

Followinganalysisofthepresentsituation,whichincludesa AllCCsareassessedtoensurethattheyarebasedonareviewofhistoricaldata,step4involvesthecompletionofa strategicassessmentofmeasurableattributes(7.4b).performanceprojectionexercisetoeffectivelyforecastactivitylevelsforkeyorganizationalmetricsforthenexttwoyears. 2.1b Strategic Objectives

Duringstep3(Identify)oftheannualSPP,LOTScollects 2.1b(1) CriticaltoLOTS’ssustainabilityarethetwostrategicandanalyzesrelevantdatatoassistintheidentificationor objectivesthataremostcriticaltosavinglives:maximizevalidationoftheSCsandSAs,usinginformationgleaned donorsandmaximizestakeholderrelationships.Performancefromstep2.ThisprocessvalidatestheSOsandestablishes projectionsreflectingeffortstoaccomplishtheSOsareestab-theappropriategoalscriticaltothefuturesuccessofthe lishedinstep4oftheSPPandarehighlightedinFigure 2.1-3 .organization.Potentialblindspotsthatlimitgoalachievement LOTShasminimalplannedchangeswithcustomers,markets,ortheaccomplishmentoftheorganization’sSOsareidentified suppliers,andpartners.instep2oftheSPPduringtheenvironmentalscanwithkey

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2.1b(2) TheSOsarecomplementarybynaturetoensureappropriatebalancefororganizationalneeds.TheSOofmaximizingstakeholderrelationshipshelpscreateafocusondrivingcustomerandstakeholdersatisfaction.Theculturealsoempowersthemission-drivenworkforce(CC)tomaximizedonationtoachievetheSOofincreasingorganandtissuedonors.LOTSsupportsitsSOswithorganizationalgoalsandresultingAPsthatleverageitsSAsandCCwhiletacklingitsSCs(Figure 2.1-1,Steps4and5)andstrategicopportunities.

AspartoftheSPP,ongoingSDsbasedoninformationfromthePMS(Figure 4.1-1)provideLOTSwithanopportunitytobalanceshort-andlong-termchallengeswithinanevolvingindustrytoensureadaptabilitytosuddenshifts.Theorganiza-tion’sSOsconsiderandbalancetheneedsofstakeholdersbyleveragingtheorganizationalstructure,worksystemdesign,andgoalprioritizationinstep6oftheSPP(Figure 2.1-1).

2.2 Strategy Implementation2.2a Action Plan Development and Deployment2.2a(1) APdevelopmentbeginsinSDsthroughtheSPPandisacooperativeeffortbetweentheLTandemployees.Throughlearningandimprovement,theorganizationhasmovedfromareactivenaturewheretheLTpushedAPstothestafffollowingtheSPP,toaproactivenaturewheretheLTsolicitsstaffparticipationinSDstoprovideinputintoestab-lishingAPs,thusensuringworkforceownership.Figure 2.1-3 outlinesseveralofthekeyshort-andlong-termorganizationalgoalsthatarecascadedtotheworkforce.SomegoalsarecomplexenoughtowarrantmultipleAPs,whileothersaremaintainedthroughcurrentbusinesspracticesandthereforedonotrequireadditionalAPs.

2.2a(2) StrategyandAPdeploymenttotheworkforce,sup-pliers,andpartnersoccurinstep7oftheSPPandthroughtheCommunicationProcess(Figure 1.1-3).LOTSsustainskey

Figure 2.1-3: Strategic Linkages

SO Organizational Goals2018

(Actual)

2019* 1-year

(short-term)

2020* 2-year

(long-term)

Strategic Challenges/ Advantages

(SC/SA) Results

Max

imiz

e D

onor

s O

WS

AchieveOrganDonorsat110 102 110 120 SC 7.1-3

AchieveOrgansTransplantedat360 352 375 400 SC 7.1-5

AchieveTotalBoneDonorsReleasedat750 755 800 850 SC 7.1-6

Opt

imiz

e St

akeh

olde

r R

elat

ions

hips

T

WS

SustainTransplantCenterSatisfaction 4.81 4 .5 4 .5 SA 7.2-1

SustainTissueProcessorSatisfaction 4.8 4 .5 4 .5 SA 7.2-2

StaffRetentionRate 70% 75% 80% SC 7.3-13*Complete list of APs AOS

Figure 2.1-2: Work System AlignmentRelationship Management

Support DepartmentsORGAN WORK SYSTEM

TISSUE WORK SYSTEMSupport Departments

Relationship Management

Authorization Procurement Allocation Post Donation





8





Figure 2.1-3: Strategic Linkages

SO Organizational Goals2018

(Actual)

2019* 1-year

(short-term)

2020* 2-year

(long-term)

Strategic Challenges/ Advantages

(SC/SA) Results

Max

imiz

e D

onor

s O

WS

AchieveOrganDonorsat110 102 110 120 SC 7.1-3

AchieveOrgansTransplantedat360 352 375 400 SC 7.1-5

AchieveTotalBoneDonorsReleasedat750 755 800 850 SC 7.1-6

Opt

imiz

e St

akeh

olde

r R

elat

ions

hips

T

WS

SustainTransplantCenterSatisfaction 4.81 4 .5 4 .5 SA 7.2-1

SustainTissueProcessorSatisfaction 4.8 4 .5 4 .5 SA 7.2-2

StaffRetentionRate 70% 75% 80% SC 7.3-13*Complete list of APs AOS

Figure 2.1-2: Work System AlignmentRelationship Management

Support DepartmentsORGAN WORK SYSTEM

TISSUE WORK SYSTEMSupport Departments

Relationship Management

Authorization Procurement Allocation Post Donation

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outcomesofAPsthroughtrackingandmonitoringviaaweb- 2.2a(5) Keyperformancemeasuresfortrackingtheachieve-basedprogramthatalignsgoalswithindividualperformance mentofAPsandassociatedorganizationalgoalsthatsupportforallmembersoftheworkforcetowardstheaccomplishment theSOsareincludedinthePMSoutputs(Figure 4.1-1).oforganizationalgoals,APs,andalignedSOs.Thestatus TrackingtheeffectivenessofAPsisfurtheraccomplishedofAPsisreviewedbymembersoftheLTandstaffduring throughAPstatusreviewsatLTmeetings.APstatusisalsoroutineone-to-onemeetingsandin-depthattheLTmeetings. reviewedbymanagersintheirrespectiveone-to-onemeetingsThisallowsforstrategyshiftsandresourcere-allocationand withtheirdirectmanagersandwiththeirstaffmembersduringensuresthattheoutcomesofAPscanbesustained.Keyout- RFO.TopromotetransparencyoftheongoingassessmentcomesoftheAPsaremonitoredthroughreviewofthePMS. oforganizationalperformance,APsareupdatedregularlyInaddition,modelingindustrybestpracticesinboththeOWS andarehousedonaweb-basedprogramaccessibletoallandTWS,benchmarkingorganizationalresultstoindustry membersoftheworkforce.Theprioryear’sAPsareassessedhighperformers,andhavingamission-drivenworkforce(CC) forcompletionandeffectivenessandaresummarizedinafurtherdefinetheroadmapforLOTStoaccomplishitsSOs. Q1LTmeeting.ThroughongoingSDs,theLTensuresthat

themeasurementsystem(Figure 4.1-1)coversallkeyareas2.2a(3) Duringstep5oftheSPP,APsarereviewedinofdeploymentandstakeholderrequirements.TheAPsaredetailtoensurealignmentwiththeorganization’sSOsandultimatelymeasuredbytoplineorganizationalperformance.resourceavailability.Workforceplanning(Step5)includesaToplinemeasurescascadethroughoutdepartmentstoansummaryofthecapabilityandcapacity(C&C)discussions,individual’sPEPviaAPstoreinforcealignmentandthewhichprompttheidentificationofadequatecapacityandaccountabilitynecessarytoaccomplishthemissionofLOTSthekeylearninganddevelopmentresourcesneededtodrive(Figure 4.1-2).theaccomplishmentofAPs.Throughadetailedbudgeting

process,amonthlydepartmentalfinancialtrendanalysis,and 2.2a(6) Initialprojectionsareestablishedduringstep4oftheaforecastoffinancialrisk(includinganassessmentofthe SPP,modifiedthroughthebudgetingprocess,andre-validatedfinancialimpactoftheAPsandorganizationalgoals),LOTS withend-of-the-yearoutcomes.Past,present,andprojectedensuresthatadequatefinancialresourcesareavailabletosup- performanceoutcomesandbenchmarksarereviewedthroughportongoingoperationsandnewlydevelopedAPs.Members thePMS.Afterthereview,theLTestablishesone-,two-,andoftheLTparticipateintheprocessofbudgetcreationand three-yearprojectionsthroughtraditionaltrendinganalysis.review;thebudgetisinitiallyapprovedbytheCEO,withfinal Thisassistsintheidentificationofperformancegaps,aidsapprovalbytheBOD. ingoal-setting,andiscriticalgiventhelimitednumberof

publicdatasources.Ifgapsinperformanceareidentified,SDsInstep8(SDs—ongoing)oftheSPP,financialriskandoccur,PItoolsareutilized,APsarecreatedormodified,andviabilityareassessedforcurrentoperationsandobligations.resourcesareallocatedtoaddresstheopportunities.Financialresultsareaffectedbyallocationofcoststhroughthe

CMScostreport.Afinancialstatementispreparedmonthlyfor 2.2b Action Plan ModificationtheLTandBOD.Year-to-datefinancialsarealsopresentedat Systematicreviewsoccurringduringworksystemmeetings,BODmeetings.Riskassessmentincludescostmodelingthe LTmeetings,andongoingSDs(Figure 2.1-1,Step8)providepotentialeffectsofactionsviafinancialstatements,cashflow theopportunitytoidentifyperformancemeasuresthatarelag-projections,andreturnoninvestment(ROI)calculations. gingandtomodifyexistingAPsorcreatenewonesasneeded.2.2a(4) Workforceplansarecapturedwithinstep5(Assess) Scorecardmeasureslaggingoverathree-monthperiodinitiateoftheannualSPPandintheWorkforcePlanningProcess a“red-box”discussionwiththeassociatedLTmembersanda(Figure 5.1-1).Asapartoftheseprocesses,theLTperforms memberfromPI.AdataanalysisandsubsequentAPdeploy-ananalysisofcurrentandfutureneedsandreviewscapacity ment,orAPmodificationforimprovement,maybeperformed,andcapabilityinformationalongwithonboardingandstayand dependingontheoutcomeoftheanalysis.Deploymentofexitinterviewdata.Thesediscussionsdeterminethepotential APsandmodifiedAPsareaccomplishedthroughactionsthatimpactontheworkforce,aswellasworkforceneedsforthe cascadefromtheworksystemordepartmentlevelandmayaccomplishmentoftheshort-andlong-termAPs.Manage- cascadedowntotheindividuallevel.Ongoingmonitoringandmentone-to-onemeetings,RFO,andC&Cdiscussionswith discussionoftheAPsoccurthroughLTmeetings,thePEP,managementrepresentationfromeverydepartmentprovide staffRFO,andworksystemmeetings.ModificationstoAPsLOTSwiththeabilitytoreviewincreasingC&Cneeds,as aretrackedanddiscussedduringLTmeetingstoensurethatwellasanypotentialchangesthatcouldimpacttheworkforce. thedecision-makingprocessiscommunicated.TheabilityTheseongoingSDsandoperationaldiscussions(ODs)aid toeffectivelytrackAPsandtheirmodificationsenablestheinaddressingtraininganddevelopmentneedsrelatedto organizationtoallocateresourceseffectively.workforcecapability,whileassessingthepotentialneedformodificationintheworkforceshoulddemandschange.

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Category 3: Customers

3.1 Customer Expectations asmethodsforlisteningforeachphaseinthecustomerlifecycle,arenotedintheVOCProcess;listeningandlearning3.1a Customer Listeningmethodsarethesameforbothcustomergroups.Learning

3.1a(1) LOTSusesmultipleformalandinformalmechanisms andstrategicimprovementshaveledtoaCustomerSurveytocollect,transfer,andusecustomerinformationtoidentify Process(AOS)thatincorporatesfeedbackreportsandprovidesopportunitiesforimprovementandinnovation.ThisVOC resultstothesurveyparticipantsandthedevelopmentofanyProcess(Figure 3.1-1)incorporatesmethodsforlistening, associatedAPs.LOTSisabletorespondtofeedbackfrominteracting,andobservinglocalorgantransplantcentersand theCustomerSurveyProcessthroughimmediateactionsviatissueprocessorstoobtainactionableinformationthroughout SDsandtheSPP,asillustratedintheCommunicationProcesstheCustomerLifeCycle(Figure 3.2-1).Thevariouslistening (Figure 1.1-3).TheprimarymethodologyusedbyLOTStoandlearningmethodsusedforeachcustomergroup,aswell

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3.1 Customer Expectations3.1a Customer Listening3.1a(1) LOTSusesmultipleformalandinformalmechanismstocollect,transfer,andusecustomerinformationtoidentifyopportunitiesforimprovementandinnovation.ThisVOCProcess(Figure 3.1-1)incorporatesmethodsforlistening,interacting,andobservinglocalorgantransplantcentersandtissueprocessorstoobtainactionableinformationthroughouttheCustomerLifeCycle(Figure 3.2-1).Thevariouslisteningandlearningmethodsusedforeachcustomergroup,aswell

Category 3: Customers

asmethodsforlisteningforeachphaseinthecustomerlifecycle,arenotedintheVOCProcess;listeningandlearningmethodsarethesameforbothcustomergroups.LearningandstrategicimprovementshaveledtoaCustomerSurveyProcess(AOS)thatincorporatesfeedbackreportsandprovidesresultstothesurveyparticipantsandthedevelopmentofanyassociatedAPs.LOTSisabletorespondtofeedbackfromtheCustomerSurveyProcessthroughimmediateactionsviaSDsandtheSPP,asillustratedintheCommunicationProcess(Figure 1.1-3).TheprimarymethodologyusedbyLOTSto

Figure 3.1-1: Voice of the Customer (VOC)

Method

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OperationalDiscussions O • • • •Day-to-DayWork/Interactions/DepartmentMeetings O • • • •ParticipationinSPP(Figure 2.1-1) O • • • •BoardofDirectors Q • • • •MedicalAdvisoryBoard SA • •TransplantCenterMeetings SA • • •Surveys O • • • •Audits,Internal/External O • • • •SocialandElectronicMedia O • • • •Figure 1.1-2 Corporate Compliance Program O • • • •Events/CandlelightMemorial/OpenHouse/Receptions O • • • •CAPA/Deviations O • • • •

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Best-PracticeSharing O • • • •Scorecards/StatusReports/MetricsOn-Demand O • • • •Meetings,ScheduledandAdHoc O • • • •Survey/ProcessorFeedback O • • • •SocialandElectronicMedia(e.g.,EMR,Facebook,Website,DonorNet)

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Figure 2.1-1 SPP O • • • •SurveyFeedback/BaldrigeFeedback/AnnualReport A • • • •CAPA/Deviations Figure 1.1-2 Corporate Compliance Program

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AuditFindings O • • • •Best-PracticeSharing O • • • •

Legend: 5 2-way communication; and 1-way communication, in and out, respectively

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obtaincustomerfeedbackistheonlinesurvey.LOTShasan systems.InformationcollectedintheVOC,alongwiththeestablishedwebsiteandsocialmediapresenceonFacebook, analysiscompletedinthePMS,isusedtoassesspotentialVimeo,Twitter,andInstagram.Giventhehighlyregulated businessgrowthopportunities.TheOMPisusedtodeterminenatureofthedonationandtransplantindustry,thereisno whichcustomergroupstoemphasizeforbusinessgrowth.sharingofconfidentialinformationacrosssocialmedia 3.1b(2) LOTSreliesuponitsVOC(Figure 3.1-1)tosites.LOTSfocusessocialmediaeffortsoncommunication determinecustomerneedsandrequirementsfororganandstrategiesthatstrengthentheorganization’sbrand,reinforce tissuedonationservices(Figure P.1-6).Customerrequire-companyculture,andcelebratestakeholdersuccesses. mentsaresolicitedthroughLOTS’sformalCustomerSurveyLOTSseeksactionablefeedbackonthequalityofservicesand Process(AOS),andresultsarevalidatedduringtheSPPcustomersupportviaVOClisteningandlearningmethods, (Figure 2.1-1).Theserequirementsserveascriticalinputsforincludingsurveys,formalandinformalinteractions,and thedesignofworkprocessesandidentificationofopportuni-meetings(Figure 3.1-1).Learningistransferredviamultiple tiesforimprovement.LOTSfocusesonprocessimprovementcommunicationmechanismsthroughtheCommunication effortstoconsistentlymeetandexceedcustomerneedsandProcess(Figure 1.1-3). expectations.

3.1a(2) AsthefederallydesignatedOPOwithinitsservice LOTSfocusesonFindingtheHeroes(Figure P.1-3)andarea,LOTSdoesnothavetraditionalorganprocurement maximizingeachdonationopportunitytoitsfullestpotentialcompetitorsorpotentialcustomers.Transplantcentersexist tomeettheneedsofitscustomers.FormalandinformalVOCwithintheOPO’sDSA,andorgansareallocatedaccordingto mechanismsensurethatrevisedregulationsandopportunitiesUNOS/OPTNthroughtwo-waycommunication.LOTSkeeps arecapturedinODsandSDs,providingorganizationalagilityabreastofpotentialchangesinorgantransplantcenterstatus toincorporateapplicablechangesinmeetingandexceedingutilizingtheCommunicationProcess(Figure 1.1-3)andVOC customerneedsandexpectations.(Figure 3.1-1).Therestrictionofoperatingwithinafederally LeveragingtherobustCommunicationProcess(Figure 1.1-3)designatedterritoryeliminatescompetitionandencourages andworkingwithitscustomerstoidentifyserviceimprove-collaborativeeffortsamongOPOs. mentsandrefinements,LOTSusestheVOC,PMS,andSPPasRelationshipmanagementwithinthesmall,established inputsintotheOMP(Figure 6.1-1).tissueindustryallowsforcontactwithpotential,future, FortheOWS,serviceofferingsinnewmarketsarenotpos-andcompetitorcustomers.Listeningandinteractionsoccur sibleduetotheassignedDSA.TWSnew-customeropportuni-regularlywithpotentialandformercustomersviaindustry ties,expansionofrelationshipswithcurrentcustomers,orconferencesandwebinars,aswellasthroughsurveydata,as newserviceofferingsareidentifiedviatheSPPortheVOCapplicable(Figure 3.1-1).ThesemechanismsallowLOTS Process.LOTS’scommitmenttoimprovementdifferentiatestoobtainactionableinformationonitsservices,customer itsservicesandcreatesopportunitiestoexpandanddeepensupport,andtransactions.Forexample,twoadditionaltissue relationshipswithcurrentcustomers.processorcustomerswereaddedin2017asaresultofprioreffectiverelationshipmanagementandchangesinthetissue 3.2 Customer Engagementmarketplace.

3.2a Customer Relationships and SupportKnowledgesharingandbenchmarkingwithotherOPOsfor 3.2a(1) LOTS’smission-drivenworkforce(CC)developsbothservicelinesallowfortheidentificationofgapsamong andmanagescustomerrelationshipsasoutlinedintheVOCLOTSandhigh-performingpeers.Usingfeedbackonthe (Figure 3.1-1).InformationiscollectedfromcustomersandservicesprovidedbyotherOPOsservesasindirectfeedback transferredintotheSPPandongoingSDs,wheretrending,onthelevelofservicesprovidedbyLOTS.Thisinforma- analysis,andvalidationtakeplace.Validatedinformationistionsupportsoperationalandstrategicdecisionmakingand utilizedtoimprovethelevelofserviceprovidedtocurrentinnovation(4.1a[2]). customers.LOTSleveragesitsbrand,reputation,andperfor-3.1b Customer Segmentation and Product Offerings mancetoacquiretissueprocessorcustomersandbuildmarket

share.Surveysassessingcustomersatisfactionshowthat3.1b(1) TheSPP(Figure 2.1-1)coordinatesinformationLOTSisworkingtoperformatlevelstoensurethatprocessorleveragedthroughmultipleprocessinputstovalidatecurrentsatisfactionismetorexceeded.Forexample,AdvantageLife,customerandanticipatefuturecustomergroupsandmarketaformertissueprocessor,contactedLOTSin2018toresumesegments.InformationgatheredfromtheVOC(Figure 3.1-1)providingtissuedonorsbasedonLOTS’spriorperformanceisalsousedtoidentifyandanticipatemarketsegments.andeffectiverelationshipmanagement.

InformationgatheredthroughthePMS,includingtheVOCTheprovisionofexceptionalserviceallowsLOTStoretaindata,isintegratedwithintheSPP.Knowledgesharingandcustomerswhilemeetingtheirrequirements,exceedingtheirbenchmarkingforbothservicelinesaidintheidentificationexpectations,andincreasingtheirengagementineverystageofgaps(Figure 4.1-4).Thisactionableinformationsupportsofthecustomerlifecycle.TheCustomerSurveyProcessoperationalandstrategicdecisionmakingforbothwork

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includesassessmentstodriveimprovementsinbothsatisfac-tionandengagement.

LOTSusesdataandinformationgatheredthroughsocialmediatohelpenhancetheorganization’sbrandbyraisingawarenessofdonationandtransplantationand,ultimately,drivingitsvisionoforgans and tissues are always available . Asasupplementtotheenvironmentalscanninganalysisperformedduringstep2oftheSPP(Figure 2.1-1),LOTSfollowsthesocialmediapostingsofitscustomersandkeystakeholderstoensureaccesstothelatestdevelopmentsandtocelebratecustomerandpartnersuccesses.Moreover,theorganizationfollowsappropriateindustrynewssourcestoidentifytrendingstoriesoronesgaininginmediaexposure,togeneratetalkingpoints,andtocreatepreparedresponses,asnecessary.Thisincludessocialmediaalertsforseveralkeywordssuchasorganand/ortissuedonationandtrans-plant.Thisadditionalinsightmayassistintheidentificationofnewservicelinesandmarketsegments,including3Dorganprintingandnewprocessingpartners.Inadditiontoenvironmentalscanningandcrisiscommunication,LOTSsupplementsorganizationalstrategiestoincreaseshareratesandfollowerstoitsownsocialmediaoutletsthroughtheidentificationandsharingofvalue-addedcontent.

3.2a(2) LocalorgantransplantcentersandtissueprocessorsareempoweredtoseekinformationandsupportthroughouttheCustomerLifeCycle(Figure 3.2-1),asillustratedintheVOCProcess(Figure 3.1-1).CustomersareabletoconductbusinesswithLOTSviainputsaslistedintheVOCandbyleveragingtheCommunicationProcess(Figure 1.1-3).

Thekeymeansofcustomersupportinbothworksystemsisthefulfillmentofcustomerrequirements(Figure P.1-6).Keycommunicationmechanisms,includingemail,24/7phonecontact,andwebsiteaccessibility,enablecustomerstoseekinformation,receivesupport,andconductbusiness.Methodsofcustomersupportdonotvarybetweencustomers,customergroups,ormarketsegments.

KeycustomersupportrequirementsaredeterminedthroughtheVOC,validatedthroughtheCustomerSurveyProcess(AOS),anddeployedtoallpeopleandprocessesinvolvedincustomersupportviatheCommunicationProcess.TheCustomerSurveyProcesshasundergonelearningandcyclesofimprovement.

3.2a(3) TheLOTSmission-drivenworkforce(CC)isdedicatedtocomplaintresolution,resultinginhighlevelsofcustomersatisfaction(Figures 7.2-1 A–C; 7.2-2; and 7.2-2A–D).AstheinitialstepintheCustomerComplaintProcess(Figure 3.2-2),allstaffmembersaretrainedinservicerecovery.Front-linestaffmembersareempoweredtoimple-mentimmediatecorrectiveactionatthepointofserviceanduseadditionalresourcesifneededtoquicklyresolvecustomer

complaints.ThisprocessallowstheLOTSworkforcetofol-lowupandprovidereal-timefeedbacktosuccessfullyresolvethecomplaint.Complainttrendscontinuetobelow(Figures 7.2-3 and 7.2-3A–B).Iffront-linestaffmembersormanagersarenotabletoresolvethecomplainttosatisfythecustomer,thecomplaintiselevatedtotheELTforresolution.

Localorgantransplantcenterortissueprocessorcomplaintsorpolicy/proceduredeviationsareroutedthroughthecorrec-tiveactionpreventiveaction(CAPA)systemfortrackingandidentifyingrootcausesofthedeviations.TrendanalysisofcustomercomplaintsispresentedatOWS/TWSmeetingsandquarterlyatLTmeetings,anditisincorporatedintotheSPPforprocessimprovements.Thisallowstheorganizationtoavoidsimilarcomplaintsinthefuture.

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Figure 3.2-2: Customer Complaint Process

Receive Customer Complaint

Resolve and Provide Feedback to Customer

Track and Trend Complaints

Identify and Implement Improvement

Log Customer Complaint in CAPA System

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Figure 3.2-1: Customer Life Cycle (Phases)

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Figure 3.2-2: Customer Complaint Process

Receive Customer Complaint

Resolve and Provide Feedback to Customer

Track and Trend Complaints

Identify and Implement Improvement

Log Customer Complaint in CAPA System

Referral

Figure 3.2-1: Customer Life Cycle (Phases)

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3.2b Determination of Customer Satisfaction and Engagement3.2b(1) Localorgantransplantcenterandtissueprocessorsatisfactionisdeterminedthroughformalsurveyresults(Figures 7.2-1A–C; 7.2-2; and 7.2-2A–D)andpersonalcommunicationandinteractionwithmembersoftheLOTSworkforce(Figure 3.1-1).Themethodstodeterminecus-tomersatisfactionarethesameforallservicelines.Surveydataaresegmentedbymultipledimensions,includingbycustomergroupormarketsegment,thelevelofservicequalityreceived,andcustomerrequirements.CustomersatisfactiondataareanalyzedandsharedviatheCommunicationProcess(Figure 1.1-3)throughSDsatTWS/OWSmeetings,andthefindingsareincorporatedintotheSPP(Figure 2.1-1,Steps2and8).

LOTSusesmultiplemethods,includingsurveys,tocapturecustomerdissatisfactionasshownintheVOC(Figure 3.1-1).LocalorgantransplantcenterandtissueprocessorfeedbackissharedviatheCommunicationProcesswithLOTSstaffandotherstakeholdersandcustomers.ItisalsoreviewedaspartoftheSPP(Figure 2.1-1)andSDsoccurringatworksystemmeetingstoensureactionablefeedbackandprocessimprove-ments.ADeviationandComplaintProcessispartoftheCAPAsystem.DissatisfactiondataaretrendedthroughtheCAPAsystemusingcollecteddeviationand/orcomplaintreports.Thisresultsintheidentificationofrootcausesandactionableitems.TheimplementationoftheFeedbackProcesscreatestheframeworkforanalysisbasedontheservicesprovidedatcertainintervalsintheCustomerLifeCycle(Figure 3.2-1)asitrelatestocustomerrequirements.

LOTSmeasurescustomerengagementbasedonthetheorythatrelationshipstrengthiscorrelatedwithcustomerloyalty,andthatloyaltyisobtainedviathosecustomersthatarehighlysatisfied.Customersatisfaction—or“engagement”—atthehighestlevelisdeterminedvia“top-box”scores—orscoresof5onasurveymeasuringsatisfactiononascalefrom1to5.

ThePMS(Figure 4.1-1)isusedtodefineandcollectkeyper-formanceindicatorsfrombothworksystems.Thesedataare

transferredbackintotheseprocessesintheformofactionableinformationviatheCommunicationProcess,wherethedatacanbeusedtodeliverimprovementstomeetandexceedcus-tomers’expectations,therebysecuringcustomerengagementforthelongterm.Forexample,processorsatisfactionwiththeDonorScreeningProcesswasidentifiedasalow-scoringmetricona2016survey.DiscussionsintheOMPledtothedevelopmentandimplementationofAPsin2017and2018toaddressthegap,resultinginchangesinthewayinforma-tionwasprovidedatscreening.Scoresforprocessoroverallsatisfactionwithdonorscreening,andwiththeinformationprovidedatscreening,werehigherin2017and2018.

3.2b(2) DuetodesignationofitsserviceareabyCMS,LOTSdoesnothavecustomercompetitorsintheOWS.IntheTWS,LOTScollaboratestoobtainindustrybenchmarksoncustomersatisfactionfromotherOPOs(Figure 4.1-4).Processorsprovidemetricsusingindustrycomparisons,whichprovideinformationonkeytissuemetrics.

3.2c Use of Voice-of-the-Customer and Market DataLOTSselectsandcollectsVOCdatathroughmultiplelisten-ing,interaction,andobservationmethodsasindicatedinVOC(Figure 3.1-1).VOCdataareintegratedintothePMS,whichdrivesoperationalandstrategicdecisionmakingthroughtheOMPandSPP,ensuringthatacustomer-focusedcultureexistsintheorganization.Dataaresegmentedbymultipledimensions,includingcustomergroupormarketsegment,thelevelofservicequalityreceived,customerrequirements,andthephaseofthecustomerlifecycle.VOCdataareanalyzedandsharedviatheCommunicationProcess(Figure 1.1-3)throughSDsandatworksystemmeetings.APstobridgegapsinperformanceandminimizecomplaintsaredeployedtoappropriatemembersoftheworkforce(3.1b[1])asanoutputoftheCustomerSurveyProcess(AOS).LOTSusesdataandinformationgatheredthroughsocialmediatohelpenhancetheorganization’sbrandbyraisingawarenessofdonationandtransplantationand,ultimately,drivingitsvisionof organs and tissues are always available.

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Category 4: Measurement, Analysis, and Knowledge Management

4.1 Measurement, Analysis, and Improvement cascadingscorecardsystemandthePEP(Figure 5.1-2).APof Organizational Performance progressistrackedusingaweb-basedperformancemeasure-

mentsystem,andAPsarereviewedatLTmeetingsand4.1a Performance Measurement individuallyduringRFO.Scorecardsuseaseriesoftargets

4.1a(1) LOTSusesthePMS(Figure 4.1-1),whichhas (definedasgoals)tomeasureorganizationalperformanceundergoneacycleoflearning,tomonitorallkeybusiness andprojections,whicharedefinedasannualizedcalculationsanddailyoperationalprocesses.Keyperformancemeasures basedonyear-to-dateand/oractualperformanceinachievingareselected,collected,aligned,andintegratedintheSPP theSOs.Targetsfacilitatethedeterminationoftheappropriate(Figure 2.1-1).TheSPPisthemechanismthattheorganiza- color-codingforallmetrics,allowingreal-timeevaluationtionusestoselectitsSOsandtodevelopgoalssupportedby andtrackingofprogressoftheorganization’sperformance.alignedAPs.Toaccomplishitsmission,LOTSusesthedata TheCommunicationProcess(Figure 1.1-3)deploysandandinformationcollectedfromthePMSasinputsintothe integratesthisinformationacrosstheorganization.TheLTandkeydecision-makingprocesses,SPP,andOMP(Figure 6.1-1). workforceareabletonavigatethecolor-codedscorecardtoCentraltothePMSisanelectronicsystemofcascading enhancedecision-makingeffectivenessandsupportcontinuousscorecards(Figure 5.1-4)startingwiththeToplineScorecard improvement.OncePIstaffmemberspopulateandvalidate(Figure 4.1-2),whichhasthecapabilitytodrilldownthrough theorganization’sscorecards,theymaynotifytheappropriateworksystem-anddepartment-levelscorecards.Informationis managertosetupameetingtoanalyzethedataanddevelopreadilyavailabletoassistintrackingdailyoperationsthrough anAPormodifiedAPifmetricsfallingshortofthetargethavetheDataMall,acentralrepositoryforthePMSthatisavail- beenidentified.Thekeyorganizationalperformancemeasuresabletotheworkforce24/7throughtheLOTSintranet. aretrackedmonthlyandfoundintheToplineScorecardPerformancemeasuresareusedtosupportorganizationaldeci- (Figure 4.1-2).KeyFinancialMeasures(Figure 4.1-3)aresionmakingthroughtheiraggregationandintegrationintothe bothshort-andlong-term.

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Category 4: Measurement, Analysis, and Knowledge Management

4.1 Measurement, Analysis, and Improvement of Organizational Performance4.1a Performance Measurement 4.1a(1) LOTSusesthePMS(Figure 4.1-1),whichhasundergoneacycleoflearning,tomonitorallkeybusinessanddailyoperationalprocesses.Keyperformancemeasuresareselected,collected,aligned,andintegratedintheSPP(Figure 2.1-1).TheSPPisthemechanismthattheorganiza-tionusestoselectitsSOsandtodevelopgoalssupportedbyalignedAPs.Toaccomplishitsmission,LOTSusesthedataandinformationcollectedfromthePMSasinputsintothekeydecision-makingprocesses,SPP,andOMP(Figure 6.1-1). CentraltothePMSisanelectronicsystemofcascadingscorecards(Figure 5.1-4)startingwiththeToplineScorecard(Figure 4.1-2),whichhasthecapabilitytodrilldownthroughworksystem-anddepartment-levelscorecards.InformationisreadilyavailabletoassistintrackingdailyoperationsthroughtheDataMall,acentralrepositoryforthePMSthatisavail-abletotheworkforce24/7throughtheLOTSintranet.

Performancemeasuresareusedtosupportorganizationaldeci-sionmakingthroughtheiraggregationandintegrationintothe

cascadingscorecardsystemandthePEP(Figure 5.1-2).APprogressistrackedusingaweb-basedperformancemeasure-mentsystem,andAPsarereviewedatLTmeetingsandindividuallyduringRFO.Scorecardsuseaseriesoftargets(definedasgoals)tomeasureorganizationalperformanceandprojections,whicharedefinedasannualizedcalculationsbasedonyear-to-dateand/oractualperformanceinachievingtheSOs.Targetsfacilitatethedeterminationoftheappropriatecolor-codingforallmetrics,allowingreal-timeevaluationandtrackingofprogressoftheorganization’sperformance.TheCommunicationProcess(Figure 1.1-3)deploysandintegratesthisinformationacrosstheorganization.TheLTandworkforceareabletonavigatethecolor-codedscorecardtoenhancedecision-makingeffectivenessandsupportcontinuousimprovement.OncePIstaffmemberspopulateandvalidatetheorganization’sscorecards,theymaynotifytheappropriatemanagertosetupameetingtoanalyzethedataanddevelopanAPormodifiedAPifmetricsfallingshortofthetargethavebeenidentified.ThekeyorganizationalperformancemeasuresaretrackedmonthlyandfoundintheToplineScorecard(Figure 4.1-2).KeyFinancialMeasures(Figure 4.1-3)arebothshort-andlong-term.

Figure 4.1-2: Topline Scorecard

2019 Year to Date End-of-Year Projection Last Year

Topline Key Metrics Actual Target % Gap Annualized Year-End Target 2018

First-YearTurnoverRate 22.0% 31.5% 30% 22.0% 31.5% 38%

OrganConversion 58% 60% 23% 58% 60% 58%

OrganDonors 120 125 24% 160 110 150

OrgansTransplanted 335 330 2% 440 375 430

DonorServices AuthorizationRate

55% 55% 0% 55% 55% 53%

BoneDonors 500 520 23.8% 667 800 650

Figure 4.1-1: Performance Measurement System (PMS)

Collect • VOC (Figure 3.1-1) • Comparative DataProcess (Figure 4.1-4)

• Deviations

Transfer • Cascading Scorecards • AP Tracking • Financial Performance • Key Customer Reports

Utilize • LS (Figure 1.1-1) • SPP (Figure 2.1-1) • OMP (Figure 6.1-1) • PEP (Figure 5.1-2) • LDS (Figure 5.2-2)

Define Measures • SPP (Figure 2.1-1) • Comparative DataProcess (Figure 4.1-4)

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performanceregularlyonscorecards.ThesedatasupportoperationaldecisionmakingastheyallowLOTStoassessitssuccessinmeetingtissueprocessorrequirementsandpermittheidentificationofbestpractices.Forexample,whileLOTS’sprocurementeffortsmettheTissueTransformationsrequire-mentforaverageusableskinyieldperdonor,anoperationaldecisionwasmadetoexceedtheprocessorrequirementbyincreasingskinyieldresults.LOTScontactedtheTis-sueTransformationsliaison,discussedbestpractices,andimplementedanewprocessforrecoveringskinthathasledtosizeableimprovements(Figure 7.1-23).

4.1a(3) LOTSformallyreviewsthePMS(Figure 4.1-1)andmodifiesitasappropriateduringtheSPP,ensuringthattheorganizationiscurrentwithaccreditation,regulatory,opera-tional,andfinancialneedsandrequirements.TheorganizationaddressesrapidorunexpectedchangesandtheirimpactonthePMSduringODsandSDsandwithintheworksystemmeetings(Figure 6.1-1).TheformalPDSAimprovementmethodology,inconjunctionwiththeorganizationalstructure(Figure 1.2-2)andongoingSDs,ensuresthattheorganizationisagileandabletorespondquicklytoissuesthatarise.

4.1b Performance Analysis and ReviewTheLTreviewsthekeyorganizationalperformancemea-suresandcapabilitiesduringworksystemmeetingsaspartofODsandduringquarterlyC&Cmeetings.IndividualLTmembersarealsoresponsibleforconductingmonthlyreviewsofworksystemanddepartmentscorecardswithintheirscopeofresponsibilities,asappropriate,withintheOMP(Figure 6.1-1).ComparativeandcustomerdataareinputsintothePMSandareusedtoreviewperformancemetrics.Thesereviewsidentifygapstogoalsandcomparisonstoprovideamechanismtogeneratestepstobringperformancebackontrack,asneeded.PIstaffmembersareresponsiblefordatavalidationandanalysisusingavarietyofstatisticaltools,andtheyworkcollaborativelywithLTmemberstoensureLOTS’sabilitytomeetgoalsandobjectives.ScorecardsanddatareportsarestoredinaDataMallontheintranetthatisaccessible24/7.

LOTSreviewsprogressrelativetotheSOs,keyprocessoutcomemeasures,andAPsduringSDsandthroughtheOMPtoensurethattheorganizationisontargettomeetorexceedthedefinedgoalsandisprogressingtowardsbestinclassinallareas.Organizationalperformance,competitivestanding,financialhealth,andcompletionofSOsandAPsbeginwiththeToplineScorecardandcascadetodepartmentscorecards.ScorecardreviewsprovideamechanismtorapidlyrespondtochangesidentifiedthroughtheSPPorOMP,aswellastoensurechangestoAPsasappropriate,whichmightincludearesponsetoatransformationalchangeinstructureorworksystem.TheworkforceisprovidedwithupdatesonkeyorganizationalmetricsandAPsatvariousmeetings,andtheyhavetheopportunitytoasktheLTquestionsregardingorganizationalperformanceanddirection.

4.1a(2) LOTSusestheComparativeDataProcess(Figure 4.1-4) toselectandeffectivelyusekeycomparativedataandinfor-mationtosupportoperationaldecisionmaking.IntheOWS,nationalregulatoryagenciesselectkeyperformanceindicatorsandestablishperformancethresholdlevelsthatmustbemetbyallOPOsinordertomaintaindesignation.Publishedquarterly,thisinformationisusedtoidentifygapsinperfor-mancebetweenLOTSandhigh-performingpeers.TheOPOCalculatorisagageoforganizationalperformance.ProvidedbytheScientificRegistryofTransplantRecipients(SRTR),thistoolallowsforthemonitoringoflocalorgandonoryieldbycomparingobserved(actual)resultsversuswhatwouldbeexpectedbasedonthenationalexperience(Figure 7.1-19A).Thisinformationisusedinpost-casereviews,SDs,andODs,andgapsinperformanceareaddressedaccordingly.

Duetothelackofastandardnationalprocessoravailabilityofcomparativetissuedata,theselectionofkeyperformanceindicatorsandthedeterminationofperformancethresholdsareestablishedbytissueprocessors.ProcessorstrackOPO

Figure 4.1-4: Comparative Data Process

Evaluation Criteria

Monitor Performance

PMS (Figure 4.1-1)

Define Measures & Comparisons

SPP (Figure 2.1-1)PMS (Figure 4.1-1)

Benchmark Scorecard • AOPO • OPTN/SRTR

• AOPO • Tissue Processors

• AOPO • Board info • DHSS • US DoL

Key Support Processes

TWS

OWS

Figure 4.1-3: Key Financial MeasuresKey Financial Measures

Shor

t Te

rmConsolidatedResultsofOperations 7.5-1

DaysCashonHand 7.5-9

DaysinAccountsReceivable 7.5-5

Lon

g Te

rm OperatingReserves 7.5-8

Total Assets 7.5-10

AverageOACComparison 7.5-12





4.1b Performance Analysis and ReviewTheLTreviewsthekeyorganizationalperformancemea-suresandcapabilitiesduringworksystemmeetingsaspartofODsandduringquarterlyC&Cmeetings.IndividualLTmembersarealsoresponsibleforconductingmonthlyreviewsofworksystemanddepartmentscorecardswithintheirscopeofresponsibilities,asappropriate,withintheOMP(Figure 6.1-1).ComparativeandcustomerdataareinputsintothePMSandareusedtoreviewperformancemetrics.Thesereviewsidentifygapstogoalsandcomparisonstoprovidea

mechanismtogeneratestepstobringperformancebackontrack,asneeded.PIstaffmembersareresponsiblefordatavalidationandanalysisusingavarietyofstatisticaltools,andtheyworkcollaborativelywithLTmemberstoensureLOTS’sabilitytomeetgoalsandobjectives.ScorecardsanddatareportsarestoredinaDataMallontheintranetthatisaccessible24/7.

LOTSreviewsprogressrelativetotheSOs,keyprocessoutcomemeasures,andAPsduringSDsandthroughtheOMPtoensurethattheorganizationisontargettomeetorexceedthedefinedgoalsandisprogressingtowardsbestinclassinallareas.Organizationalperformance,competitivestanding,financialhealth,andcompletionofSOsandAPsbeginwiththeToplineScorecardandcascadetodepart-mentscorecards.ScorecardreviewsprovideamechanismtorapidlyrespondtochangesidentifiedthroughtheSPPorOMP,aswellastoensurechangestoAPsasappropri-ate,whichmightincludearesponsetoatransformationalchangeinstructureorworksystem.TheworkforceisprovidedwithupdatesonkeyorganizationalmetricsandAPsatvariousmeetings,andtheyhavetheopportunitytoasktheLTquestionsregardingorganizationalperformanceanddirection.

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4.1b Performance Analysis and ReviewTheLTreviewsthekeyorganizationalperformancemea-suresandcapabilitiesduringworksystemmeetingsaspartofODsandduringquarterlyC&Cmeetings.IndividualLTmembersarealsoresponsibleforconductingmonthlyreviewsofworksystemanddepartmentscorecardswithintheirscopeofresponsibilities,asappropriate,withintheOMP(Figure 6.1-1).ComparativeandcustomerdataareinputsintothePMSandareusedtoreviewperformancemetrics.Thesereviewsidentifygapstogoalsandcomparisonstoprovideamechanismtogeneratestepstobringperformancebackontrack,asneeded.PIstaffmembersareresponsiblefordatavalidationandanalysisusingavarietyofstatisticaltools,andtheyworkcollaborativelywithLTmemberstoensureLOTS’sabilitytomeetgoalsandobjectives.ScorecardsanddatareportsarestoredinaDataMallontheintranetthatisaccessible24/7.

LOTSreviewsprogressrelativetotheSOs,keyprocessoutcomemeasures,andAPsduringSDsandthroughtheOMPtoensurethattheorganizationisontargettomeetorexceedthedefinedgoalsandisprogressingtowardsbestinclassinallareas.Organizationalperformance,competitivestanding,financialhealth,andcompletionofSOsandAPsbeginwiththeToplineScorecardandcascadetodepartmentscorecards.ScorecardreviewsprovideamechanismtorapidlyrespondtochangesidentifiedthroughtheSPPorOMP,aswellastoensurechangestoAPsasappropriate,whichmightincludearesponsetoatransformationalchangeinstructureorworksystem.TheworkforceisprovidedwithupdatesonkeyorganizationalmetricsandAPsatvariousmeetings,andtheyhavetheopportunitytoasktheLTquestionsregardingorganizationalperformanceanddirection.



Figure 4.1-4: Comparative Data Process

Evaluation Criteria

Monitor Performance

PMS (Figure 4.1-1)

Define Measures & Comparisons

SPP (Figure 2.1-1)PMS (Figure 4.1-1)

Benchmark Scorecard • AOPO • OPTN/SRTR

• AOPO • Tissue Processors

• AOPO • Board info • DHSS • US DoL

Key Support Processes

TWS

OWS

Figure 4.1-3: Key Financial MeasuresKey Financial Measures

Shor

t Te

rmConsolidatedResultsofOperations 7.5-1

DaysCashonHand 7.5-9

DaysinAccountsReceivable 7.5-5

Lon

g Te

rm OperatingReserves 7.5-8

Total Assets 7.5-10

AverageOACComparison 7.5-12

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TheBODreviewstheorganization’sperformancebyreview-ingtheToplineScorecardandmonthlyfinancialstatements.TheCEOreportsongapsinperformance;progressisalsoreportedonachievingstrategicSOsandAPs.

4.1c Performance Improvement4.1c(1) Theorganization’sfutureperformanceisprojectedthroughtheanalysisofthree-year,historical,organizationaltrenddataandindustrytrendstoidentifygapsandareasofopportunity.Thisanalysiscreatesshort-andlong-termprojectionsthatareutilizedinthePMS(Figure 4.1-1)andPEP(Figure 5.1-2).Identifyingtop-decileperformancefromcomparativeorganizationsforkeymeasurescreatesabenchmarkandacourseofactionforimprovementefforts,asapplicable.Ifindicated,APsarecreatedtoreplicatethetop-decileperformanceofcomparativeorganizations.Thecollegialnatureoftheindustrycreatesanenvironmentforopendialogueforsharingthenecessarystepstoreplicatebenchmarkresultsdemonstratedbyotherorganizations.

Reconciliationofdifferencesbetweenprojectionsoffutureperformance(4.1[b])andperformanceprojections(2.2[b])occursthroughthePMS.

4.1c(2) LOTSutilizesthesystematicreviewofperformancedataintheOMP(Figure 6.1-1)toidentifyopportunitiesforimprovementandinnovationinthein-processandoutcomemeasures.Thesefindingsformthefoundationfortheorganiza-tion’scontinuousimprovementapproach.DiscussionintheOMPalsoprovidesopportunitiesforidentifyingpossibleimprovementsorinnovations.Ifindicated,ateammaybeiden-tifiedtolookatpossibleopportunities.TheteamdevelopsideasthatarevettedthroughtheLTforprioritizationanddisposition.ApprovedplansaredeployedviatheCommunicationProcess.Directorsandmanagersdeploytheprioritiesandopportunitiestomembersoftheirrespectivedepartmentsandworkgroups.Incorporationofaprojectreportatstaffmeetings,usingtheCommunicationProcess,reinforcesthedepartmentalandworkgroupdiscussions.Whenappropriate,prioritiesandopportuni-tiesareidentified,andorganizationalAPsaredeployedtoLOTS’ssuppliersandpartnersthroughtheOMP.

4.2 Information and Knowledge Management4.2a Data and Information4.2a(1) LOTS’spoliciesandproceduresaddressaccuracyfromtheinitialreferral,throughtheorganization’sworksystems,totheallocationoforgansandtissues.Clinicalinfor-mationisenteredintoTransplantTechnology,anelectronicsoftwaresystemthatnowhasseveralbuilt-inaccuracyanderror-proofingcheckpoints.Forkeynonelectronicdata,LOTSensuresaccuracyandintegritythroughmanualvalidationofreportsandauditsofcriticalinformation.Forexample,uponcasecompletion,bothelectronicandnonelectronicdataarevalidatedthroughchartreviewbytheQualitySystems(QS)departmenttoensureaccuracy.QSstaffmembersconductmonthlyaudits,ensuringasystematicapproachforexisting

processevaluationandfeedback.Validity,integrity,reliability,currency,andconfidentiality(Figure 1.1-2)ofelectronicdataandinformationareensuredthroughthemethodslistedin6.2b.

4.2a(2) Dataandinformationavailabilityiscriticaltotheabilityoftheworkforcetocarryoutthemissiontosavelives.Becausemanyemployeesworkoff-site,electronicsystemsareusedtoensurethatstaffmembershaveaccesstocriticaldataandinformation.Toensureuser-friendlyaccesswhilekeepingallconfidentialdatasecure,thecorporateintranetmayonlybeaccessedremotelyviaadirectaccesssoftware.Becausethestaffaccessandinputdatafromaremotelocation,theEMRisaccessiblewhereverwebaccessisavailable.Laptopsareissuedwithpassword-protected,encrypted,diskpartitionstoprotectdatafromcompromiseintheeventoftheftand/orloss.Thetimelinessofdataiscrucialtotheprocessesfordonationandtransplantation.TheTransplantTechnologysystemcreatesreal-timeaccesstodonationactivityfortheworkforceandpartners.Togainneededaccess,datanotstoredinTransplantTechnologycanbeobtainedthroughmultiplemethodsinclud-ingtelephone,fax,email,andtheDataMall.

LOTSprovidesinformationtotheworkforce,partners,sup-pliers,customers,andcollaboratorsusingtheCommunicationProcess(Figure 1.1-3).Inaddition,LOTSprovidesinforma-tiontocustomersthroughreal-timeaccesstotheTransplantTechnologysystemforread-onlyinformation.TransplantTechnologyclinicaldataareuploadedintoanationaldatabase,DonorNet.Thesedataareusedbyregulatorybodiesandorganizationswithintheindustryforcollaboration.Accesstosuchcriticaldatahasimprovedturn-aroundanddecision-makingtimeforLOTS’spartners.TissueprocessorscanaccesscriticaldatathroughadedicatedSharePointportalandcanreceivereal-timedataviaXMLtransferfromTransplantTechnology.TherequirementsforkeysuppliersarecapturedannuallythroughtheSPPandongoingSDs.Currently,therearenooperationalrequirementsforsupplierstobelinkedwithLOTS’sdatainformationsystems(IS).Informationanddataaremadeavailabletosuppliersviaelectronicmeans,conferencecalls,andin-personmeetings,asappropriate.Throughcyclesoflearningandstrategicimprovement,beforeimplementationofnewsoftwareand/orhardware,ausercom-mitteeisformedtoensurethatthesoftwareand/orhardwareisuser-friendly,accessible,andfunctional.

4.2b Organizational KnowledgeLOTSreliesonelectronicmeans,aswellaspersonalcom-munication,tomanageinformationandorganizationalknowledge.TheorganizationisabletocapitalizeontheaccessibleOrganizationalStructure(Figure 1.2-2)throughtheSPP(Figure 2.1-1)andtheOMP(Figure 6.1-1).Thesesystemsworktogethertosynthesizeinformationandturnitintoknowledgethatcanbeusedtoinnovateandmanageworksystemsandprocesses.

4.2b(1) LOTScollectsinformationfrompeople,processes,andtheenvironmentthroughelectronicandnonelectronic

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methodsviathePMS(Figure 4.1-1),whichfeedsintotheOMPwhereSDsorODsoccurandinformationisanalyzedandtranslatedintoactions.TheLDS(Figure 5.2-2)andtheCommunicationProcess(Figure 1.1-3)demonstratehowjob-relatedknowledgeisdisseminated.Transferofworkforceknowledgereadilyoccursduetothealignmentofthework-forceintoworksystems.Multidisciplinarymeetingswithintheworksystemsensurethatconsistentmessagesandinformationareshared.One-on-oneRFOconversationsamongstaffmem-bersandtheirdirectmanagersensurethattheorganizationbenefitsfromtheknowledgeassetsoftheworkforce.Ideas

andinformationgatheredthroughthesystematicdeploymentofRFOaresharedwiththeworkforceatstaffmeetingsviaaStoplightReport.Theintranetservesasa24/7vehicletodisseminateinformationtoadecentralizedworkforce.LOTSreportsorganizationalinformationthroughthePMSandanalyzesittocreateknowledgeusingtheSPP,SDs,andtheOMP(Figure 6.1-1).

AsevidencedinthesecondstepofthePMS,avarietyofdatatypesarecollectedfromcustomersviatheVOC(Figure 3.1-1)andremainingstakeholdergroups(Figure 4.2-1),inadditiontoclinicalinformationcapturedthroughtheorganization’s

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methodsviathePMS(Figure 4.1-1),whichfeedsintotheOMPwhereSDsorODsoccurandinformationisanalyzedandtranslatedintoactions.TheLDS(Figure 5.2-2)andtheCommunicationProcess(Figure 1.1-3)demonstratehowjob-relatedknowledgeisdisseminated.Transferofworkforceknowledgereadilyoccursduetothealignmentofthework-forceintoworksystems.Multidisciplinarymeetingswithintheworksystemsensurethatconsistentmessagesandinformationareshared.One-on-oneRFOconversationsamongstaffmem-bersandtheirdirectmanagersensurethattheorganizationbenefitsfromtheknowledgeassetsoftheworkforce.Ideas

andinformationgatheredthroughthesystematicdeploymentofRFOaresharedwiththeworkforceatstaffmeetingsviaaStoplightReport.Theintranetservesasa24/7vehicletodisseminateinformationtoadecentralizedworkforce.LOTSreportsorganizationalinformationthroughthePMSandanalyzesittocreateknowledgeusingtheSPP,SDs,andtheOMP (Figure 6.1-1).

AsevidencedinthesecondstepofthePMS,avarietyofdatatypesarecollectedfromcustomersviatheVOC(Figure 3.1-1)andremainingstakeholdergroups(Figure 4.2-1),inadditiontoclinicalinformationcapturedthroughtheorganization’s

Figure 4.2-1: Voice of the Stakeholder (VOS)

Method

Frequency Collaborators Partners Suppliers InternalA

A

nnua

l M

M

onth

ly

O

Ong

oing

Q

Q

uart

erly

W

W

eekl

y

Don

or F

amili

es

Fune

ral H

omes

Don

or H

ospi

tals

Non

-Hos

pita

l R

efer

ral S

ourc

es

Gua

rdia

n

Wri

ght B

roth

ers

TT

Tran

spla

nt T

ech.

Col

umbi

a C

rem

atio

n

Boa

rd o

f Dir

ecto

rs

Wor

kfor

ce

Col

lect

(F

igur

e 4.

1-1)

OperationalDiscussions O • • • • • • • • •

SupplierMeetings Q,W • • • • • •

StrategicDiscussions O • • • • • • • •

ParticipationinSPP (Figure 2.1-1) O • • • • • • • •

Rounding/PEP (Figure 5.1-2) / LDS (Figure 5.2-2)

O •

Surveys O • • • • • • •

Audits,Internal/External O • • • • • • • • •

SocialandElectronicMedia O • • • • • • •

CorporateComplianceProcess (Figure 1.1-2)

O • • • • • • • • •

Contracts O • • • • • • • • •

CAPA/Deviations O • • • • • • • • •

Tran

sfer

(F

igur

e 1.

1-3)

BestPracticeSharing O • • • • • •

Scorecards/StatusReports/ MetricsOn-Demand

O • • • • • • • • •

SurveyFeedbackReports A,O • • • • • • • •

SOPs/SharePoint/Intranet/Email O • • •

Util

ize

StrategicPlanningProcess (Figure 2.1-1)

O • • • • • • • • • • •

SurveyFeedback/ BaldrigeFeedback/AnnualReport

A • • • • • • • • • •

CAPA/Deviations/CorporateComplianceProcess (Figure 1.1-2)

O • • • • • • • • • • •

BestPracticeSharing O • • • • • • • • • •

OMP (Figure 6.1-1) O • • • • • • • • • • •

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EMR(TransplantTechnology).Forexample,combiningtheSRTRdatawiththeTransplantTechnologydatatoanalyze2018organyielddataprovidedinformationaboutthequalityof2018donorsthatwasusedtovalidatefutureperformanceprojections.AvarietyofmechanismsfoundintheOMPareusedtotransferrelevantknowledgetocustomers,suppliers,partners,andcollaborators.ThePMSservesasthebasisfortheknowledgeassemblytointegrateintotheOMPandSPP.TheseprocessesinvolvedetaileddataanalysisdevelopedincollaborationwiththePIstaff.ImprovementinitiativesarepresentedatLTmeetingstoensuretransferofknowledgeandhelpdriveimprovementandinnovationthroughouttheorganization.Step3ofthePMSensuresthetransferoforganizationalawarenessandknowledge.

4.2b(2) ThescorecardsandComparativeDataProcesswithinthePMS(Figure 4.1-1)providetheorganization’sworkforcewithtoolstomonitororganizationalperformance,includingidentificationofbestpractices.Performancereviewdata,whichincludeevidenceofhighperformancewithinorganizationalunitsandbestpractices,aresharedacrosstheorganizationinSDsviatheSPP,OMP,andCommunicationProcess.Implementationofbestpracticesisaccomplished

throughthedevelopmentofAPsandongoingmonitoringofthePMSforsuccess.Forexample,theCommunicationCenterdepartment’sorganauthorizationratefor2018(Figure 7.1-17)exceededallpreviousrecords.Best-practiceidentificationincludedmonitoringmonthlygapsinperformanceattheindividuallevelandtheuseofadepartmentmanagertosup-portandretrainstrugglingindividuals,aswellasidentificationofbestpractices.InformationonthebestpracticeswassharedattheOWS/TWSmeetings,whichcontributedtothehiringofacombinedTWS/OWStrainer.

4.2b(3) LOTShasanumberofprocessesinplacetoensurethatlearningisembeddedintheorganization.TheprimarymechanismforthisistheLDS(Figure 5.2-2),whichisalignedandintegratedwithmultipleorganizationalprocesses.Specificprocessesincluderegulartrainingofferingsinresponsetostafffeedbackandorganizationalgaps,andper-sonallearninggoalsforstaffmembers.Knowledgesharingisastandingagendaiteminworksystemmeetings.Forexample,animprovementteamwasusedtoincreasesatisfactionwithstaffmeetings,whichresultedintheadditionofmanagerreport-outsandaQ/AsessionwiththeCEOateachmeeting.

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Category 5: Workforce

5.1 Workforce Environment5.1a Workforce Capability and Capacity5.1a(1) WorkforceC&CisassessedthroughtheWorkforcePlanningProcess(Figure 5.1-1).Theorganizationhasidenti-fiedtheskillsandcompetenciesthatareneededtoperformeachrolewithintheorganizationsuccessfully.Tobetterdefinecapability,LOTSidentifiesnecessaryskillsinjobdescrip-tions,andjobcompetenciesaremonitoredthroughthePEP(Figure 5.1-2).LOTScontinuallyevaluatestheneedfornewcompetenciesthroughmultipleinputmechanisms,includingtheSPP(Figure 2.1-1),RFO,LDS(Figure 5.2-2),andC&Cmeetings.Inaddition,theneedforvariouscertificationsisdiscussedduringtheHiringProcess(Figure 5.1-3)asacondi-tionofemployment,ifapplicable,andisincludedinthejobdescriptionfortherole.Afterhiring,thecertificationrequire-ments,ifapplicable,arediscussedthroughthecommunicationcycleanddocumentedintheemployee’strainingfile.

LOTSsystematicallyassessesstaffinglevelsbysolicitingfeedbackthroughRFO,ongoingSDsatworksystemmeetings,LTmeetings,ELTmeetings,andC&Cdiscussions.UsingthePMS,LOTSforecastsstaffingneedsintheSPP(Figure 2.1-1).TheSPPassistswithprojectingpotentialstaffingneedsoneyearout,ensur-ingaright-sizedworkforcefortheorganization.Asanexample,intheCommunicationCenterdepartment,thecapabilitytoprovideongoingsupportandtrainingforstaffmembersapproachingfamilieswasidentifiedasadepartmentneed.OngoingSDsandC&Cmeetingsledtotheadditionofatrainertothedepartmentin2016.SubsequentC&CmeetingsandSDsledtothetransitionofthetrainertoamanager/trainerinearly2018.TheresultingorganauthorizationratefortheCommunicationCenterfor2018wasthehighestinorganizationalhistory(Figure 7.1-17).

5.1a(2) LOTSusestheHiringProcess(Figure 5.1-3)torecruit,hire,place,andretainnewworkforcemembers.Validatedintheworkforcesurvey(AOS),LOTS’smissionisthehighestscoringkeyfactorforstaffengagementandsatisfaction(Figures 7.3-12 and 7.3-12A).Therefore,hiringright-fittalentbeginspriortoemploymentbyensuringthattheorganizationalcultureiscleartoallapplicants(Figure 5.1-3,Phase1).Toensurethattheworkforcerepresentsthediverseculturesofthecommunity,LOTSusesdiverserecruitingmethods,includinglocalcommunitycollegesanduniversities,aswellassocialmediasites.Donorfamiliesandrecipientsarealsoconsideredforappropriatepositionswithintheorganization.Theseindividualsreflectthethinkingofthe

organization’skeycommunitiesbyalreadypossessingastrongconnectiontothemission.Thefitoforganizationalculturewithnewstaffisensuredthroughseveralhiringandonboard-ingprocessesincludingshadowingandbehavioral-basedinterviewingpractices.

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Figure 5.1-1: Workforce Planning Process

SPP (Figure 2.1-1) │ RFO │ C&C │ LDS (Figure 5.2-2)

Data analysis

Determine appropriate action

Right-size workforce Hire/Reduce/Realign or train

Prioritize & select needs to address

Communicate the action (Figure 1.1-3)

PMS

│ SD

s


Figure 5.1-2: Performance Evaluation Process (PEP)

VMV

(1)Goal Setting During SPP Figure 2.1-1

(2)Goal &

AP Updates

(3)Annual

Evaluations with LT & Staff

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Figure 5.1-1: Workforce Planning Process

SPP (Figure 2.1-1) │ RFO │ C&C │ LDS (Figure 5.2-2)

Data analysis

Determine appropriate action

Right-size workforce Hire/Reduce/Realign or train

Prioritize & select needs to address

Communicate the action (Figure 1.1-3)

PMS

│ SD

s


Figure 5.1-2: Performance Evaluation Process (PEP)

VMV

(1)Goal Setting During SPP Figure 2.1-1

(2)Goal &

AP Updates

(3)Annual

Evaluations with LT & Staff

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5.1a(3) LOTSpreparestheworkforceforchangesinC&CneedsthroughtheWorkforcePlanningProcess(Figure 5.1-1).InformationaboutchangingC&Crequirementsandneeds,includingworkforcegrowth,isgatheredthroughseveralmethodsincludingC&CmeetingsandRFO.ThroughtheWorkforcePlanningProcess,LOTSmanagestheneedsoftheworkforceandtheorganization,ensurescontinuity,preventsworkforcereductions,andconsidersperiodsofgrowth(2.2a[4]).Additionally,theHiringProcess(Figure 5.1-3)supportscontinuitybyencouragingpromotionfromwithin,aswellascross-trainingforapplicableroles,wheneverpossible.Shouldaworkforcereduction,periodofgrowth,orchangeinorganizationalstructureorworksystemberequired,qualita-tiveorquantitativeinformationfromthePMS(Figure 4.1-1)wouldbeusedtoconductaseriesofSDstodetermineappropriateaction.Suchactionmightincluderecruitment,contingencyplanningforremainingstaff,orpotentialreas-signmentorexitstrategyforaffectedstaff.

5.1a(4) LOTSorganizesandmanagesitsworkforceattheindividual,keyprocess,andworksystemlevelsthroughsystematiccascadingofgoals/scorecards(Figure 5.1-4).

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TheLTprovidesworksystemoversightandstrategicdirectionthroughtheLS(Figure 1.1-1),whichservesasthefoundationforkeydecisionmaking.

Systematiccascadingofgoals/scorecardsreinforcesacustomerandbusinessfocus.ThereinforcementofcustomerandbusinessneedsisapriorityandismanagedbytheLS,whichincorporatesapproachesforcreatingtheenvironment,operationalizingthestrategy,andmonitoringtheorganiza-tion’sperformance.ThisapproachbeginswiththeHiringProcess(Figure 5.1-3),whichensuresthatthebestcandidatesarehiredandfitwiththeLOTScultureofamission-drivenworkforce(CC).TheintegrationoftheLDS(Figure 5.2-2)withtheLSreinforcestheV/M/Vandprovidestrainingforperformingdailytasksandmeetingcustomerneeds.Workforcemembersareempoweredtomakedecisionsforthepromptresolutionofcustomerconcerns.Theseeffortsleadtocompetenceinthedeliveryofservice,whichallowstheorganizationtomeetandexceedcustomersatisfactionandtostrengthenloyalty(Figure 7.2-4).

TheSPP(Figure 2.1-1)createsfocus,establishespriori-ties,andsetsexpectationsfortheworkoftheorganization,whileongoingperformanceismonitoredthroughthePMS( Figure 4.1-1)andPEP(Figure 5.1-2).Performanceexpecta-tionsarereinforcedthroughSDs,RFO,andPEP.Organiza-tionalgoalrangesareestablishedtodefinehowemployeescanexceedexpectations.Ongoingdiscussionsaresupportedthroughaweb-basedPEPsystemthatusestargetsforAPstocreateanawarenessofhoweachmemberoftheworkforcecanmeetandexceedexpectationsandsubsequentlyberewardedthroughmultiplemechanisms.Organizationaltransparencyandaccountabilityareensuredthroughtheweb-basedsystem,allowingeachmemberoftheworkforcetomonitorallstaffprogresstowardsgoals.



Figure 5.1-3: Hiring Process

Workforce Needs IdentifiedCapability and capacity meetings

Position/Opportunity Posted

Phase 1Initial interview with HR

Phase 2Interview with hiring manager/point person

Applicants Identified

Selection • Manager & HR decide best-fit candidate

• Reference check completed

• Conditional offer made

Phase 3Peer interview

Candidate Not Selected

• External: Notify • Internal: Provide developmental feedback

Employee Hired

Figure 5.1-4: Examples of Cascading Goals

Goal: Increase Local Organs Transplanted

Front-line Workforce Level • Educate partners

Director Level • Build relationships w/transplant partners • Review cases

SO: Maximize Donation

OPC/Front-line Workforce Level • Donor management protocols • Follow allocation processes

SPP SPP



TheSPP(Figure 2.1-1)createsfocus,establishespriori-ties,andsetsexpectationsfortheworkoftheorganization,whileongoingperformanceismonitoredthroughthePMS(Figure 4.1-1)andPEP(Figure 5.1-2).Performanceexpecta-tionsarereinforcedthroughSDs,RFO,andPEP.Organiza-tionalgoalrangesareestablishedtodefinehowemployeescanexceedexpectations.Ongoingdiscussionsaresupportedthroughaweb-basedPEPsystemthatusestargetsforAPstocreateanawarenessofhoweachmemberoftheworkforcecanmeetandexceedexpectationsandsubsequentlyberewardedthroughmultiplemechanisms.Organizationaltransparencyandaccountabilityareensuredthroughtheweb-basedsystem,allowingeachmemberoftheworkforcetomonitorallstaffprogresstowardsgoals.

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TheSPP(Figure 2.1-1)createsfocus,establishespriori-ties,andsetsexpectationsfortheworkoftheorganization,whileongoingperformanceismonitoredthroughthePMS( Figure 4.1-1)andPEP(Figure 5.1-2).Performanceexpecta-tionsarereinforcedthroughSDs,RFO,andPEP.Organiza-tionalgoalrangesareestablishedtodefinehowemployeescanexceedexpectations.Ongoingdiscussionsaresupportedthroughaweb-basedPEPsystemthatusestargetsforAPstocreateanawarenessofhoweachmemberoftheworkforcecanmeetandexceedexpectationsandsubsequentlyberewardedthroughmultiplemechanisms.Organizationaltransparencyandaccountabilityareensuredthroughtheweb-basedsystem,allowingeachmemberoftheworkforcetomonitorallstaffprogresstowardsgoals.



Figure 5.1-3: Hiring Process

Workforce Needs IdentifiedCapability and capacity meetings

Position/Opportunity Posted

Phase 1Initial interview with HR

Phase 2Interview with hiring manager/point person

Applicants Identified

Selection • Manager & HR decide best-fit candidate

• Reference check completed

• Conditional offer made

Phase 3Peer interview

Candidate Not Selected

• External: Notify • Internal: Provide developmental feedback

Employee Hired

Figure 5.1-4: Examples of Cascading Goals

Goal: Increase Local Organs Transplanted

Front-line Workforce Level • Educate partners

Director Level • Build relationships w/transplant partners • Review cases

SO: Maximize Donation

OPC/Front-line Workforce Level • Donor management protocols • Follow allocation processes

SPP SPP

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5.1b Workforce Climate5.1b(1) LOTSsystematicallyassessesworkplaceenviron-mentalfactorstoensureandimproveworkforcehealthbyusingacomprehensivewellnessprogram.Componentsofthiscomprehensivewellnessprogramincludeexceptionalhealthinsurancepackages,$20/monthreimbursementtowardswellness-relatedexpenses,no-costwellnessscreenings(Figure 7.3-5)andflushots,24/7accesstoanemployeeassistanceprogram,andotherhealthopportunities.Workplaceenvironmentaldifferencesarenotpertinentforthesebenefits;theseprogramsencourageemployeestobecomemoreproac-tiveinimprovingtheiroverallhealth.

Toensureandimproveworkforcesecurity(Figure 7.3-9),LOTSmaintainsasafefacilitycompletewithautomaticlockingdoorsand24/7videosurveillance.Badgesarerequiredforentryintoalltheworkareasofthefacility,withlevelsofrestrictionbasedonjobfunction.Toensureasecureworkplaceenvironment,policyrequiresallvisitorstosigninandbeescortedbyanemployeethroughthebuilding.Toensureworkplacesecurityforemployeeswhoworkindifferentworkplaceenvironments,includingatareahospitals,employeesarerequiredtoadheretothatsite’suniquesecuritymeasures.LOTShastakenadditionalmeasurestoensurethesecurityoftheworkforcebyofferingpersonalalarmstoallstaffmembers.TraininginCPR,workplaceviolenceresponse,anddefensivedrivingclassesarealsoprovided.

LOTSensuresworkplaceaccessibilitybymaintaininganAmericanswithDisabilitiesAct(ADA)-compliantfacilitywithhandicapentranceoptions.Moreover,LOTSisanequalopportunityemployerandmaintainsrealisticandflexibleexpectationsregardingtheimportanceofreasonableaccom-modations.Toguaranteetechnologicalworkplaceaccessibil-ity,LOTSprovidesallemployeeswithITtrainingtoensuretheirunderstandingoftheITsystems.

Asamplelistingofperformancemeasuresforworkforcehealth,security,andworkplaceaccessibilitycanbefoundinWorkplaceEnvironment(Figure 5.1-5)andWorkforcePreparedness(Figure 7.3-6).Theseperformancemeasuresaredesignedtoprovideaworkenvironmentconducivetosupport-ingtheLOTSworkforcetoaccomplishthemission.

5.1b(2) FocusingontheCCofamission-drivenworkforce,LOTSmaintainsaworkforcephilosophyof“We take care of ‘Our People’ so they can take care of others.”Tomeettheneedsofadiverseworkforce,multiplebenefitsplanoptionsareavailablewithdistinctionswithintheservices,benefits,andpoliciesdependentonworkforcedemographics,includingtenureandperformance.

Thesupportiveworkenvironmentincludesmultifacetedhealth,financial,andschedulingoptionsandbenefits.Theworkforceservices,benefits,andpoliciesareassessedintheworkforcesurvey.LOTShasmanyservicesasapartofitswellnessinitiativethatareavailabletoallemployees,includ-inghealthscreenings,flushots,ahealthcoach,voluntary

smokingcessationprograms,optionalflexiblescheduling,andanemployeeassistanceprogram,whichisavailabletostaffmembersaswellastheirfamilymembers.

LOTSsupportsitsworkforcebyprovidingacomprehensiveinsurancebenefitpackagetoallfull-timeemployees;thepackageincludesthreemedicalplanoptions,aswellasdentalandvisionplans,onatiered-costplatform.Employeescanselectthebestplantomeettheirmedical,financial,andfamilyneeds.Theorganizationalpoliciesthatsupporttheworkforceincludeagenerouspaidtime-off(PTO)plan,ExtendedMedi-calBank(EMB)plan,paidholidays,andtuitionassistance.Benefitswithfinancialimpactsmayvarybasedonstafftype,lengthofservice,andperformance.Agenerous401kplan,whichincludesadiscretionarycontribution,isprovidedtoalleligiblestaffmembers.EmployeeswhochoosetheEmployeeKeyRequirement(EKR)ofbenefitsinthe2017staffsurveyscoredtheirsatisfactionat85%,meetingtheindustrycompar-ative(Figure 7.3-15).TheseworkforcebenefitsandpoliciesenableLOTStostrengthenitsCCoffullyengagedworkforcememberswhoaremotivatedtofulfillitsmissiontosaveandimprovemorelives.

5.2 Workforce Engagement5.2a Assessment of Workforce Engagement 5.2a(1) ThekeydriversofworkforceengagementaredeterminedthroughcustomizedworkforcesurveysdevelopedbySurveySystemSuccess.From2008through2014,theengagementelementsincludedintheworkforcesurveyweredeterminedbyastafffocusgroup.Thesurveyincludedopen-endedquestionstoassesseachemployee’sdriversofwork-forceengagementandsatisfaction.AllworkforcesegmentsindicatedthattheoverarchingreasonsforworkingatLOTSwerethemission,relationshipswithcoworkers,andbenefits.Surveyresultsduringthistimeperiodwereexceptional,withtheorganizationscoringinthe90thpercentileinthevendor’sdatabaseforthe2014survey.Adifferentvendorwaschosenforthe2017workforcesurvey.Thegoalforchanging

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5.1b Workforce Climate5.1b(1) LOTSsystematicallyassessesworkplaceenviron-mentalfactorstoensureandimproveworkforcehealthbyusingacomprehensivewellnessprogram.Componentsofthiscomprehensivewellnessprogramincludeexceptionalhealthinsurancepackages,$20/monthreimbursementtowardswellness-relatedexpenses,no-costwellnessscreenings(Figure 7.3-5)andflushots,24/7accesstoanemployeeassistanceprogram,andotherhealthopportunities.Workplaceenvironmentaldifferencesarenotpertinentforthesebenefits;theseprogramsencourageemployeestobecomemoreproac-tiveinimprovingtheiroverallhealth.

Toensureandimproveworkforcesecurity(Figure 7.3-9),LOTSmaintainsasafefacilitycompletewithautomaticlockingdoorsand24/7videosurveillance.Badgesarerequiredforentryintoalltheworkareasofthefacility,withlevelsofrestrictionbasedonjobfunction.Toensureasecureworkplaceenvironment,policyrequiresallvisitorstosigninandbeescortedbyanemployeethroughthebuilding.Toensureworkplacesecurityforemployeeswhoworkindifferentworkplaceenvironments,includingatareahospitals,employeesarerequiredtoadheretothatsite’suniquesecuritymeasures.LOTShastakenadditionalmeasurestoensurethesecurityoftheworkforcebyofferingpersonalalarmstoallstaffmembers.TraininginCPR,workplaceviolenceresponse,anddefensivedrivingclassesarealsoprovided.

LOTSensuresworkplaceaccessibilitybymaintaininganAmericanswithDisabilitiesAct(ADA)-compliantfacilitywithhandicapentranceoptions.Moreover,LOTSisanequalopportunityemployerandmaintainsrealisticandflexibleexpectationsregardingtheimportanceofreasonableaccom-modations.Toguaranteetechnologicalworkplaceaccessibil-ity,LOTSprovidesallemployeeswithITtrainingtoensuretheirunderstandingoftheITsystems.

Asamplelistingofperformancemeasuresforworkforcehealth,security,andworkplaceaccessibilitycanbefoundinWorkplaceEnvironment(Figure 5.1-5)andWorkforcePreparedness(Figure 7.3-6).Theseperformancemeasuresaredesignedtoprovideaworkenvironmentconducivetosupport-ingtheLOTSworkforcetoaccomplishthemission.

5.1b(2) FocusingontheCCofamission-drivenworkforce,LOTSmaintainsaworkforcephilosophyof“We take care of ‘Our People’ so they can take care of others.”Tomeettheneedsofadiverseworkforce,multiplebenefitsplanoptionsareavailablewithdistinctionswithintheservices,benefits,andpoliciesdependentonworkforcedemographics,includingtenureandperformance.

Thesupportiveworkenvironmentincludesmultifacetedhealth,financial,andschedulingoptionsandbenefits.Theworkforceservices,benefits,andpoliciesareassessedintheworkforcesurvey.LOTShasmanyservicesasapartofitswellnessinitiativethatareavailabletoallemployees,includ-inghealthscreenings,flushots,ahealthcoach,voluntary

smokingcessationprograms,optionalflexiblescheduling,andanemployeeassistanceprogram,whichisavailabletostaffmembersaswellastheirfamilymembers.

LOTSsupportsitsworkforcebyprovidingacomprehensiveinsurancebenefitpackagetoallfull-timeemployees;thepackageincludesthreemedicalplanoptions,aswellasdentalandvisionplans,onatiered-costplatform.Employeescanselectthebestplantomeettheirmedical,financial,andfamilyneeds.Theorganizationalpoliciesthatsupporttheworkforceincludeagenerouspaidtime-off(PTO)plan,ExtendedMedi-calBank(EMB)plan,paidholidays,andtuitionassistance.Benefitswithfinancialimpactsmayvarybasedonstafftype,lengthofservice,andperformance.Agenerous401kplan,whichincludesadiscretionarycontribution,isprovidedtoalleligiblestaffmembers.EmployeeswhochoosetheEmployeeKeyRequirement(EKR)ofbenefitsinthe2017staffsurveyscoredtheirsatisfactionat85%,meetingthehealthcaretop-quartilebenchmark(Figure 7.3-15).TheseworkforcebenefitsandpoliciesenableLOTStostrengthenitsCCoffullyengagedworkforcememberswhoaremotivatedtofulfillitsmissiontosaveandimprovemorelives.

5.2 Workforce Engagement5.2a Assessment of Workforce Engagement 5.2a(1) ThekeydriversofworkforceengagementaredeterminedthroughcustomizedworkforcesurveysdevelopedbySurveySystemSuccess.From2008through2014,theengagementelementsincludedintheworkforcesurveyweredeterminedbyastafffocusgroup.Thesurveyincludedopen-endedquestionstoassesseachemployee’sdriversofwork-forceengagementandsatisfaction.AllworkforcesegmentsindicatedthattheoverarchingreasonsforworkingatLOTSwerethemission,relationshipswithcoworkers,andbenefits.Surveyresultsduringthistimeperiodwereexceptional,withtheorganizationscoringinthe90thpercentileinthevendor’sdatabaseforthe2014survey.Adifferentvendorwaschosenforthe2017workforcesurvey.Thegoalforchanging

Figure 5.1-5: Workplace Environment

Factors Measures Results

Health EAPOSHAComplianceWellnessProgramWellnessScreeningParticipation

AOS7.3-7AOS7.3-5

Security LimitedaccessbyjobfunctionERPTraining

AOSAOSAOS

Accessibility ADAcompliantEEOCcompliantITresources

AOSAOSAOS

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providerswastogainadeeperunderstandingofemployeeengagement,validationofthekeydriversofemployeesatis-factionandengagement,andactionablefeedback.Thevendorchosenforthe2017survey,ExcelEmployeeEngagement,allowedthestaffindividualselectionofsatisfierandengage-mentdrivers(EKRs).ExcelEmployeeEngagementalsoprovidesbenchmarkdatafromavarietyofsources,includingabenchmarkfromacohortof400healthcareorganizationsandanOPO/blooddonationfacilitybenchmark.Segmentedsurveyresults,includingseveralbenchmarks,areAOS.

5.2a(2) LOTSassessesworkforceengagementthroughtheWorkforceSurveyProcess(AOS).Throughlearningandstrategicimprovement,thesurveyhasgonefromaninternallytabulatedquestionnaireregardingcultureandbenefits,toanexternallydevelopedprocessthatincludesnationalbench-marksandprovidesinputintotheSPP(Figure 2.1-1).The2017workforcesurveyvalidatedLOTS’sCCofamission-drivenworkforce(Figures 7.3-11, 7.3-12, and 7.3-12A).TheWorkforceSurveyProcessallowsmeasurementofengage-mentacrossworkforcegroupsandsegments,includingworksystem,tenure,anddepartment(AOS).WorkforceretentionismeasuredontheToplineScorecardandhasremainedapriority(Figure 7.3-13).Departmentalretentionisassessed,andAPsmaybedevelopedforareasthatarefallingbelowtarget.Absenteeismisnotmonitoredasanorganizationalmetricbutismonitoredonacase-by-casebasis.ProductivityismonitoredthroughtheaccomplishmentofAPsthroughthePEPandPMSandismeasuredviagrossrevenueperfull-timeemployee(FTE;AOS).ProductivityoftheworkforceisacknowledgedthroughtheRewardsandRecognitionProgram(Figure 5.2-1).

5.2b Organizational CultureTheLS(Figure 1.1-1),PMS(Figure 4.1-1),SPP(Figure 2.1-1), andV/M/Vfosterandreinforceanorganizationalculturecharacterizedbyopencommunication,highperformance,andanengagedworkforcethatprovidesexcellentservicetoitscustomers.AsacomponentoftheCommunicationProcess(Figure 1.1-3),RFOfostersopencommunication.The2017workforcesurveynotedsatisfactionwithclear,effectivecommunicationat75%,exceedingthehealthcaremedianby15%(AOS).TheRFOquestionshavevariedbasedonSDsandstafffeedbackandcurrentlyincludequestionslike“Whatdoyouneedtoaccomplishyourgoals?”and“Isthereanyoneyouwouldliketorecognize?”AStoplightReport(AOS)wasdesignedtocommunicateprogresstotheorganizationaspartofastaffmeeting;thisservesasafeedbackloopandpossibleinputintoorganizationalimprovements.Anengagementtoolwasaddedin2018andofferedthestafftheoptiontoattendagrouplunchhostedbytheCEO.ThissettingallowsemployeestohaveaccessandconversationswiththeCEOinsmall-groupsettings.These“CafeCEO”luncheshaveprovidedanadditionalforumforopencommunication.

TheSPPandPMSprovidethefoundationforacultureofhighperformance.ThePMSengagesbothleadersandemployeesindefininghigh-performancework,whichisdocumentedthroughthePEP.EmployeeperformanceandsuccessareevaluatedbasedoncompletionofAPsandachievementofspecificgoalsthatalignwiththeSOs.TheLTregularlyacknowledgessuccesstodriveahigh-performanceworkforcethroughtheRewardsandRecognitionProgram(Figure 5.2-1).RFOalsoencourageshighperformanceandachievementofgoalsthroughregulargoalreview.

LOTSfostersanengagedworkforcethroughtheV/M/V(Figure P.1-1).ToreinforceLOTS’sculturalmessage,donorfamiliesandrecipientsperiodicallyattendstaffmeetingsandsharetheirheartfeltstories.ThesestoriesallowLOTStoputafacetothemission,whilemotivating,inspiring,andengag-ingthestaff.ThesetouchingtestimoniesarewhytheLOTSworkforceworkssohardtofulfillitsmission.In2017,staffmembersscoredtheirconnectiontothemissionat93.7%,thehighestofall22EKRs,exceedingthehealthcaremedianbenchmark(Figure 7.3-11).Inaddition,valuesarepartofthePEP(Figure 5.1-2)systemandarehighlightedatvariousstaffmeetingstodemonstratehowthatvaluemaybeapplicableinday-to-dayworkforstaff.Forexample,arecentstaffmeetingpresentationwasmadearoundthevalueofhonestyandtheapplicabilityofthatvaluewhendealingwithdonorfamilies.

TheCommunicationProcessengagestheLOTSworkforceinsharingideasandensuresthattheorganizationbenefitsfromthediverseideas,culture,andthinkingoftheworkforcetosupporttheorganizationalculture.Theworkforceisempow-eredtomakedecisionsandactstoachieveindividualandorganizationalsuccessthroughtransparentcommunication,andspecificallythroughthePMSandPEP.Leveragingitsmission-drivenworkforce(CC),LOTSensuresthattherightstaffmemberisplacedintherightjobwiththerighttraining,empoweringtheworkforcetoprovidesuperiorcustomerservice(includingresolutionofcomplaints),resultingincustomerloyaltyandengagement(Figure 7.2-4).

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providerswastogainadeeperunderstandingofemployeeengagement,validationofthekeydriversofemployeesatis-factionandengagement,andactionablefeedback.Thevendorchosenforthe2017survey,ExcelEmployeeEngagement,allowedthestaffindividualselectionofsatisfierandengage-mentdrivers(EKRs).ExcelEmployeeEngagementalsoprovidesbenchmarkdatafromavarietyofsources,includingabenchmarkfromacohortof400healthcareorganizationsandanOPO/blooddonationfacilitybenchmark.Segmentedsurveyresults,includingseveralbenchmarks,areAOS.

5.2a(2) LOTSassessesworkforceengagementthroughtheWorkforceSurveyProcess(AOS).Throughlearningandstrategicimprovement,thesurveyhasgonefromaninternallytabulatedquestionnaireregardingcultureandbenefits,toanexternallydevelopedprocessthatincludesnationalbench-marksandprovidesinputintotheSPP(Figure 2.1-1).The2017workforcesurveyvalidatedLOTS’sCCofamission-drivenworkforce(Figures 7.3-11, 7.3-12, and 7.3-12A).TheWorkforceSurveyProcessallowsmeasurementofengage-mentacrossworkforcegroupsandsegments,includingworksystem,tenure,anddepartment(AOS).WorkforceretentionismeasuredontheToplineScorecardandhasremainedapriority(Figure 7.3-13).Departmentalretentionisassessed,andAPsmaybedevelopedforareasthatarefallingbelowtarget.Absenteeismisnotmonitoredasanorganizationalmetricbutismonitoredonacase-by-casebasis.ProductivityismonitoredthroughtheaccomplishmentofAPsthroughthePEPandPMSandismeasuredviagrossrevenueperfull-timeemployee(FTE;AOS).ProductivityoftheworkforceisacknowledgedthroughtheRewardsandRecognitionProgram(Figure 5.2-1).

5.2b Organizational CultureTheLS(Figure 1.1-1),PMS(Figure 4.1-1),SPP(Figure 2.1-1), andV/M/Vfosterandreinforceanorganizationalculturecharacterizedbyopencommunication,highperformance,andanengagedworkforcethatprovidesexcellentservicetoitscustomers.AsacomponentoftheCommunicationProcess(Figure 1.1-3),RFOfostersopencommunication.The2017workforcesurveynotedsatisfactionwithclear,effectivecommunicationat75%,exceedingthehealthcaremedianby15%(AOS).TheRFOquestionshavevariedbasedonSDsandstafffeedbackandcurrentlyincludequestionslike“Whatdoyouneedtoaccomplishyourgoals?”and“Isthereanyoneyouwouldliketorecognize?”AStoplightReport(AOS)wasdesignedtocommunicateprogresstotheorganizationaspartofastaffmeeting;thisservesasafeedbackloopandpossibleinputintoorganizationalimprovements.Anengagementtoolwasaddedin2018andofferedthestafftheoptiontoattendagrouplunchhostedbytheCEO.ThissettingallowsemployeestohaveaccessandconversationswiththeCEOinsmall-groupsettings.These“CafeCEO”luncheshaveprovidedanadditionalforumforopencommunication.

TheSPPandPMSprovidethefoundationforacultureofhighperformance.ThePMSengagesbothleadersandemployeesindefininghigh-performancework,whichisdocumentedthroughthePEP.EmployeeperformanceandsuccessareevaluatedbasedoncompletionofAPsandachievementofspecificgoalsthatalignwiththeSOs.TheLTregularlyacknowledgessuccesstodriveahigh-performanceworkforcethroughtheRewardsandRecognitionProgram(Figure 5.2-1).RFOalsoencourageshighperformanceandachievementofgoalsthroughregulargoalreview.

LOTSfostersanengagedworkforcethroughtheV/M/V(Figure P.1-1).ToreinforceLOTS’sculturalmessage,donorfamiliesandrecipientsperiodicallyattendstaffmeetingsandsharetheirheartfeltstories.ThesestoriesallowLOTStoputafacetothemission,whilemotivating,inspiring,andengag-ingthestaff.ThesetouchingtestimoniesarewhytheLOTSworkforceworkssohardtofulfillitsmission.In2017,staffmembersscoredtheirconnectiontothemissionat93.7%,thehighestofall22EKRs,exceedingthehealthcaremedianbenchmark(Figure 7.3-11).Inaddition,valuesarepartofthePEP (Figure 5.1-2)systemandarehighlightedatvariousstaffmeetingstodemonstratehowthatvaluemaybeapplicableinday-to-dayworkforstaff.Forexample,arecentstaffmeetingpresentationwasmadearoundthevalueofhonestyandtheapplicabilityofthatvaluewhendealingwithdonorfamilies.

TheCommunicationProcessengagestheLOTSworkforceinsharingideasandensuresthattheorganizationbenefitsfromthediverseideas,culture,andthinkingoftheworkforcetosupporttheorganizationalculture.Theworkforceisempow-eredtomakedecisionsandactstoachieveindividualandorganizationalsuccessthroughtransparentcommunication,andspecificallythroughthePMSandPEP.Leveragingitsmission-drivenworkforce(CC),LOTSensuresthattherightstaffmemberisplacedintherightjobwiththerighttraining,empoweringtheworkforcetoprovidesuperiorcustomerservice(includingresolutionofcomplaints),resultingincustomerloyaltyandengagement(Figure 7.2-4).

Figure 5.2-1: Rewards and Recognition

Giv

en b

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Giv

en b

y St

aff

Reward/Recognition Org

aniz

atio

n-W

ide

Dep

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Indi

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Congratulatoryslideatstaffmeeting

Sharingofrecipientthank-youletters

Personalnotes/emails/cards

Peer-to-peerrecognition

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Thekeydriversofemployeeengagementandsatisfactionhave staffandLT,beginningwithnew-employeeorientation.New-beendeterminedusingtheworkforcesurveyandtheCommu- employeeorientationisnowofferedintwophases:Introduc-nicationProcess(Figure 1.1-3).Inthe2017workforcesurvey, tionandLOTSLearning.DuringtheIntroductionPhase,newtheoverallengagementscorewas75%,exceedingthehealth hiresareintroducedtothecultureandcompleteonboardingcaremedianaswellastheOPObenchmarkgroup.Workforce activitiesduringtheirfirstweekofemploymenttocreatesurveysegmentationbasedondemographics,includingwork anunderstandingoftheorganization’sneeds.TheLOTSsystem,tenure,andlengthofservice,isAOS. LearningPhaseisofferedasanextensionofnew-employee

orientation.Thiscomprehensive,eight-hourprogramhigh-5.2c Performance Management and Development lightskeyorganizationalelements.Staffmembersparticipate5.2c(1) TheWorkforcePerformanceMeasurementSystem inLOTSLearningaftertheyhavecompletedseveralweekssupportshighperformanceandengagementoftheworkforce ofemployment.TheutilizationofatraininganddevelopmentandLTthroughthefullydeployedPEP(Figure 5.1-2).The goalallowsstaffmembersandleaderstoidentifytrainingPEPconsistsofseverallayersthatarestructuredandsystem- anddevelopmentneedscollaboratively,basedonstrengthsatic.UtilizingtheSPPasthefoundation,APsarecreatedusing andopportunitiesfortheindividual.Thisalsoenhancesthestaffinputtosupporthighperformanceintheaccomplishment organization’scapabilityforgoalaccomplishment.oforganizationalgoals,whichultimatelydrivestheachieve- TheprioritiesoftheworkforceLDS(Figure 5.2-2)areevalu-mentofSOs.ThesegoalsarealignedwiththeV/M/Vofthe atedannuallyandalignedwiththeSOs,SCs,APs(short-andorganizationandarecascadedtotheworkforce.Partofthe long-term),andgoalstoensuresupportoforganizationalPEPalsoincludesindividualpersonaldevelopmentgoalsfor needs.Asanexample,anAPwasinitiatedtoimplementaeachstaffmemberthathelpensurepersonaldevelopment web-basedperformancemanagementsystem.Thecomplexityandgrowthand,ultimately,ensurethattheneedsofthe ofthesoftwarerequiredatwo-yearAP,includingimplementa-organizationaremet.Managersanalyzeperformancereview tionandincorporationoffuturemodelsofthesoftwareandscoresandtrackgoalsandAPprogressinreal-time.ThePEP atrainingcomponent.ThesuccessfulcompletionofthisAPisdesignedtoensuretransparencyacrosstheorganization;in resultedintheworkforcehaving24/7accesstomonitortheturn,eachevaluationtoolincludesresultsonorganizational statusoforganizationalandindividualgoals,whilepromotingandindividualgoals,demonstrationofcorevalues,and transparencyacrosstheorganization.personaldevelopmentplans.

Organizationalimprovement,performanceimprovement,Whilestaffmembersnamethemission,coworkers,and organizationalchange,andinnovationaredrivenfromthebenefitsasthehighest-scoringEKRs,LOTSrecognizesthe SPPthroughtheLS(Figure 1.1-1)andtheOrganizationalimportanceofcompensationandrewardsandrecognition Structure(Figure 1.2-2),totheemployeelevelwheretheyare(Figure 5.2-1).Theorganization’scompensationsystem reinforcedbythePMS(Figure 4.1-1).ForallLTmembers,establishescompetitivesalaryrangesandamerit-basedpay LOTSdeploysasystematicleadershipcurriculum,whichincreasesystemtorewardstaffmembersforachievement isreviewedannually.NewLTmembersareprovidedwithoftheirgoalsanddemonstrationofthecorevalues.LOTS internaltrainingtoassistwithculturalintegrationandtosharehasastrongcommitmenttomaintainingmarket-based organizationalknowledge.Additionally,newleaderscompletesalariesandworkstrienniallywithanexternalconsultantto aleadershiptrainingsessionthatincludescoaching,perfor-determinenecessarymarketadjustments.Theorganization’s mancemanagement,behavioralinterviewing,anddevelop-RewardsandRecognitionProgramincludesaprogramthat mentofdecision-makingskills.allowsemployeestorecognizeoneanother,accomplishmentoforganizationalgoals,andotherpersonalizedrecognition Tosupportethicsandethicalbusinesspractices,annualpolicyopportunities(Figure 5.2-1). trainingincludesreviewoftheConflictofInterestPolicy,

CodeofProfessionalConduct,CorporateComplianceTrain-ThePEP,viatheLDS(Figure 5.2-2),isusedtoevaluate ing,andongoingprocedurecompliance.TheLOTSworkforceeffectiveness,identifylearninganddevelopmentneeds, iseducatedontheorganization’slegalandregulatoryrequire-andserveasadirectinputtothePMS(Figure 4.1-1).The mentsthroughmandatorytraining.TheCCP(Figure 1.1-2)informationfromthePEPisusedthroughouttheyearin trainingisconductedduringnew-employeeorientation,andongoingSDs.LOTS’scustomerandbusinessfocus,aswellas theCCPpolicycompetencyisassessedannuallythereafter;theachievementofAPs,isguidedbythePMSandreinforced CCPtrainingencouragesthereportingofsuspectedbreachesbythePEP.Thisallowstheorganizationtoensurethatall ofpolicyviolationsorunethicalpractices.goalsandtargetsarecloselymonitored,andaccountabilityisachieved. Toperpetuateandimprovethecustomerfocusoftheorganiza-

tion,LOTStrainsallnewemployeesduringorientationon5.2c(2) LOTS’sLDS(Figure 5.2-2)beginswiththeorienta- theorganization’scustomercomplaintphilosophytoensuretionofmission-drivenworkforcemembers,alignmentwith superiorcustomerservice.Customerfocusisalsoachievedtheorganizationalculturetosupporttheorganization’sneeds, throughavarietyofAPstargetingcustomersatisfactionandanandthepersonaldevelopmentoftheworkforce.Toachieve extensiveCustomerSurveyProcessthatassessesperformance.theV/M/V,LOTSfocusesonthecontinualdevelopmentofits

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Thelearninganddevelopmentneedsofworkforcemembers arecapturedinRFOandarealsopartoftheLDS(Figure 5.2-2). AsacomponentoftheLDS,LOTSreinforcesnewknowledgeandon-the-jobskillsthroughongoingcompetencytesting,worksystemdialogue,bringinginsubject-matterexpertsfortraining,andtheCommunicationProcess(Figure 1.1-3).KnowledgesharingisalsoacomponentoftheLDS.

5.2c(3) Learninganddevelopmentarecriticalcomponentsofstaffsuccess,whichinturndrivesorganizationalsustainabilityandsupportstheCCofamission-drivenworkforce.TheLDSsystem(Figure 5.2-2)isvalidatedaspartoftheSPP;pastimprovementshaveincludedtheadditionofskillsdaysandaformalexitinterviewprocess(AOS).Inthe2017staffsurvey,theEKRofcontinuouslearning,training,anddevelopmentshowedan80.6%satisfactionlevel,exceedingthehealthcaremean(Figure 7.3-16).TheHumanResourcesstaffevaluatestheeffectivenessoftrainingbyconductingevaluationsofinternalandexternalopportunitiesattheorganization,worksystem,anddepartmentlevels,affordingemployeestheoppor-tunitytoprovidefeedbackaboutthetrainingtheyreceivedandalsotoidentifyanysubsequenttrainingneedsofinterestthatwillsupportthemission(Figure 5.2-2,Step4).Dependingonthenatureofthetraining,learningislinkedtoanoutcomemeasuredinthegoalplanforeachemployee.Staffmemberswhoattendtrainingoff-siteareaskedtosharetheinformationtheylearnedattheirdepartmentmeetings,worksystems,or

LTmeetingstohelpotherteammembersgaininsightfromthetraining.

5.2c(4) AtLOTS,mostjob-andcareer-relateddevelopmentinvolvesjobenhancementopportunitieswithintheorganiza-tion.Duetotheorganization’ssizeandstructure,careerdevelopmentisoftensupportedinhorizontaltransitionstodifferentroles.Overhalfoftheworkforceisinadifferentpositiontodaythanoriginallyhiredfor,andmanyofthosehavetransitionedmultipletimes.ThePEPhelpsidentifyhighperformerswhocanutilizetheirskills,knowledge,andabilitiesinvariousways.

TheLDSisusedtopreparetheworkforceforreplacementandsuccessionplanning.ThesuccessionplanisreviewedannuallythroughtheSPP(Figure 2.1-1,Step5)andmodifiedasneededbytheCHRO,CEO,COO,CMO,andeachLTmember;theplanprovidesstrategyforshort-andlong-termcoverageforeachLTposition.TheLTsuccessionplanfocusesonthedevelopmentofcurrentleaderspositionedtotakeonadditionalresponsibilitiesandemergingleaderswhocouldserveasthenextgenerationofleadership.Developmentneedsofidentifiedemergingleadersarenowincorporatedwithinthetraininganddevelopmentplanaspartoftheemployee’sPEP.Asanexample,targetedtrainingisbeingprovidedquarterlytoteamleadsacrosstheorganizationtoensurefoundationalunderstanding,includingteamdynamics,difficultconversa-tions,andteammotivation.

Figure 5.2-2: Learning and Development System (LDS)

Identification & Evaluation of Learning and Development Needs

1

Evaluate Effectiveness 4 Knowledge Sharing

3

• Orientation • On-the-Job Training • Policies & Procedures

• Intranet

• On-the-Job Training • Leadership Development

• Industry Networking • Leadership Development

• Industry Conferences

• Regulatory Information

Job/T

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Staff Knowledge

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Thelearninganddevelopmentneedsofworkforcemembers LTmeetingstohelpotherteammembersgaininsightfromthearecapturedinRFOandarealsopartoftheLDS(Figure 5.2-2). training.AsacomponentoftheLDS,LOTSreinforcesnewknowledge 5.2c(4) AtLOTS,mostjob-andcareer-relateddevelopmentandon-the-jobskillsthroughongoingcompetencytesting, involvesjobenhancementopportunitieswithintheorganiza-worksystemdialogue,bringinginsubject-matterexpertsfor tion.Duetotheorganization’ssizeandstructure,careertraining,andtheCommunicationProcess(Figure 1.1-3). developmentisoftensupportedinhorizontaltransitionstoKnowledgesharingisalsoacomponentoftheLDS. differentroles.Overhalfoftheworkforceisinadifferent5.2c(3) Learninganddevelopmentarecriticalcomponentsof positiontodaythanoriginallyhiredfor,andmanyofthosestaffsuccess,whichinturndrivesorganizationalsustainability havetransitionedmultipletimes.ThePEPhelpsidentifyandsupportstheCCofamission-drivenworkforce.TheLDS highperformerswhocanutilizetheirskills,knowledge,andsystem(Figure 5.2-2)isvalidatedaspartoftheSPP;past abilitiesinvariousways.improvementshaveincludedtheadditionofskillsdaysanda TheLDSisusedtopreparetheworkforceforreplacementformalexitinterviewprocess(AOS).Inthe2017staffsurvey, andsuccessionplanning.ThesuccessionplanisreviewedtheEKRofcontinuouslearning,training,anddevelopment annuallythroughtheSPP(Figure 2.1-1,Step5)andmodifiedshowedan80.6%satisfactionlevel,exceedingthehealthcare asneededbytheCHRO,CEO,COO,CMO,andeachLTmean(Figure 7.3-16).TheHumanResourcesstaffevaluates member;theplanprovidesstrategyforshort-andlong-termtheeffectivenessoftrainingbyconductingevaluationsof coverageforeachLTposition.TheLTsuccessionplanfocusesinternalandexternalopportunitiesattheorganization,work onthedevelopmentofcurrentleaderspositionedtotakeonsystem,anddepartmentlevels,affordingemployeestheoppor- additionalresponsibilitiesandemergingleaderswhocouldtunitytoprovidefeedbackaboutthetrainingtheyreceivedand serveasthenextgenerationofleadership.Developmentneedsalsotoidentifyanysubsequenttrainingneedsofinterestthat ofidentifiedemergingleadersarenowincorporatedwithinthewillsupportthemission(Figure 5.2-2,Step4).Depending traininganddevelopmentplanaspartoftheemployee’sPEP.onthenatureofthetraining,learningislinkedtoanoutcome Asanexample,targetedtrainingisbeingprovidedquarterlymeasuredinthegoalplanforeachemployee.Staffmembers toteamleadsacrosstheorganizationtoensurefoundationalwhoattendtrainingoff-siteareaskedtosharetheinformation understanding,includingteamdynamics,difficultconversa-theylearnedattheirdepartmentmeetings,worksystems,or tions,andteammotivation.

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Category 6: Operations

6.1 Work Processes 6.1a(3) TheOMP(Figure 6.1-1)demonstratesthemethodsusedtodesign,refine,andconstructkeyworkprocessesto6.1a Product and Process Designmeetrequirements.TheOMPensuresthatkeyrequirements

6.1a(1) Keyworkproductandprocessrequirementsare drivingworkprocessesareanalyzed,reviewed,andtranslateddeterminedthroughavarietyoflisteningandlearningmethods intoprioritiesduringtheSPPandcontinuedthroughouttheviatheVOC(Figure 3.1-1),includingformalandinformal yearduringongoingSDsandODs.surveys,feedbackreports,andinformalinteractions.The

Incorporationoforganizationalknowledge,newtechnology,productandprocessrequirementanalysisanddiscussionstartserviceexcellence,customervalue,risk,andagilityisalsointheSPP(Figure 2.1-1,Step8)andcontinueduringtheyearaccomplishedthroughtheOMPandstep4oftheLDS inongoingSDsandthroughouttheOMP(Figure 6.1-1).For(Figure 5.2-2).BoththeOMPandLDSareintegralinputsexample,itwasdeterminedthroughsurveydatafeedbackintotheSPP,whichdrivesODs,dataanalysis,real-timethatreferringphysiciansfromdonorhospitalpartnersdiddecisionmaking,andimprovementtoensurecustomervalue.notfeelpreparedfortheirinvolvementinDonationafterLOTS’sstaffmembersdriveorganizationalimprovementsCardiacDeath(DCD)organdonorcases.ThisrequirementforusingtheSPP,OMP,andthePMS(Figures 2.1-1, 6.1-1, and informationwastakentotheCriticalCareTaskforce,anda4.1-1)toassessperformance,lookforimprovements,andtoolwasdevelopedusingitsinput.Aninformationcardisnowdeployappropriatesolutionstomeetcustomerneeds.distributedtophysiciansandnursescaringforpotentialorgan

donorstohelppreparethemforinvolvement.In2018,there 6.1b Process Management and ImprovementwerearecordnumberofDCDdonors(AOS),andthehospital 6.1b(1) TheOMPdrivesworkprocessesthroughmultiplepartnersatisfactionexceededprioryears(Figure 7.1-1A) .

inputs,includingtheSPP,PMS,staffknowledge,and6.1a(2) LOTS’skeyserviceisthefacilitationoforganand stakeholderandenvironmentalinformationtoensurethattissuedonation(Figure 2.1-2),aserviceprovidedtocustom- theymeetkeyprocessrequirements.WithintheOMP,theersincollaborationwithkeypartners(Figure P.1-6).Key PMS(Figure 4.1-1)ensuresthatkeymetricrequirementsworkprocessesofreferralmanagement,authorization,and aremeasured,analyzed,andbenchmarked.ODsalsoincludeprocurementaredesignedtodriveorganizationalsustainability analysisofmetrics,evaluationofcurrentAPsandprocessbyfulfillingtheneedsandrequirementsofkeycustomers steps,andvalidationthatcurrentperformanceismeetingor(Figure P.1-6).Throughthesekeyprocesses,theworkforce trendingtomeettargets.Asanexample,duringOrganOpera-advancestheorganization’sSOsandultimatelyprovides tionsmeetings,asystematicreviewofselectedorgancasesorgansandtissuesfortransplant. isperformed.Duringthesemultidisciplinaryreviews,staff

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Figure 6.1-1: Operational Management Process (OMP)

Operational Discussions

• Operations Mtgs • Department Mtgs

PMS(Figure 4.1-1)

Staff Knowledge (RFO)

VOC(Figure 3.1-1)

VOS(Figure 4.2-1)

Environmental Information

Knowledge Feedback Loop/Analyze

SPP(Figure 2.1-1) ANALYSIS

DECISION

MAK

ING

ALIGNMENT WITH V/M/V

6.1 Work Processes6.1a Product and Process Design6.1a(1) KeyworkproductandprocessrequirementsaredeterminedthroughavarietyoflisteningandlearningmethodsviatheVOC(Figure 3.1-1),includingformalandinformalsurveys,feedbackreports,andinformalinteractions.TheproductandprocessrequirementanalysisanddiscussionstartintheSPP(Figure 2.1-1,Step8)andcontinueduringtheyearinongoingSDsandthroughouttheOMP(Figure 6.1-1).Forexample,itwasdeterminedthroughsurveydatafeedbackthatreferringphysiciansfromdonorhospitalpartnersdidnotfeelpreparedfortheirinvolvementinDonationafterCardiacDeath(DCD)organdonorcases.ThisrequirementforinformationwastakentotheCriticalCareTaskforce,andatoolwasdevelopedusingitsinput.Aninformationcardisnowdistributedtophysiciansandnursescaringforpotentialorgandonorstohelppreparethemforinvolvement.In2018,therewerearecordnumberofDCDdonors(AOS),andthehospitalpartnersatisfactionexceededprioryears(Figure 7.1-1A) .

6.1a(2) LOTS’skeyserviceisthefacilitationoforganandtissuedonation(Figure 2.1-2),aserviceprovidedtocustom-ersincollaborationwithkeypartners(Figure P.1-6).Keyworkprocessesofreferralmanagement,authorization,andprocurementaredesignedtodriveorganizationalsustainabilitybyfulfillingtheneedsandrequirementsofkeycustomers(Figure P.1-6).Throughthesekeyprocesses,theworkforceadvancestheorganization’sSOsandultimatelyprovidesorgansandtissuesfortransplant.

6.1a(3) TheOMP(Figure 6.1-1)demonstratesthemethodsusedtodesign,refine,andconstructkeyworkprocessestomeetrequirements.TheOMPensuresthatkeyrequirementsdrivingworkprocessesareanalyzed,reviewed,andtranslatedintoprioritiesduringtheSPPandcontinuedthroughouttheyearduringongoingSDsandODs.

Incorporationoforganizationalknowledge,newtechnology,serviceexcellence,customervalue,risk,andagilityisalsoaccomplishedthroughtheOMPandstep4oftheLDS (Figure 5.2-2).BoththeOMPandLDSareintegralinputsintotheSPP,whichdrivesODs,dataanalysis,real-timedecisionmaking,andimprovementtoensurecustomervalue.LOTS’sstaffmembersdriveorganizationalimprovementsusingtheSPP,OMP,andthePMS(Figures 2.1-1, 6.1-1, and 4.1-1)toassessperformance,lookforimprovements,anddeployappropriatesolutionstomeetcustomerneeds.

6.1b Process Management and Improvement6.1b(1) TheOMPdrivesworkprocessesthroughmultipleinputs,includingtheSPP,PMS,staffknowledge,andstakeholderandenvironmentalinformationtoensurethattheymeetkeyprocessrequirements.WithintheOMP,thePMS(Figure 4.1-1)ensuresthatkeymetricrequirementsaremeasured,analyzed,andbenchmarked.ODsalsoincludeanalysisofmetrics,evaluationofcurrentAPsandprocesssteps,andvalidationthatcurrentperformanceismeetingortrendingtomeettargets.Asanexample,duringOrganOpera-tionsmeetings,asystematicreviewofselectedorgancasesisperformed.Duringthesemultidisciplinaryreviews,staff

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membersassessachievementoftheHospitalReferralProcess,AuthorizationProcess,andtheClinicalProcurementProcesssteps,alongwithstakeholderfeedback.ThissystematicreviewhelpsdetermineifprocesschangesareindicatedandprovidesanopportunitytosharelearningacrosstheworksystemtoimproveOWSprocesses.

Keyperformanceandin-processmeasuresusedforthecontrolandimprovementofworkprocessesareoutlinedinFigure 6.1-2.Thesein-processmeasuresdriveincreasedperformanceandstrictadherencetoprocessestoensuremaxi-mizedoutcomesandservice.Anextensivesetofpoliciesandprocedures,incorporatingkeystakeholderinput,definestheworkrequiredtoaccomplishthekeyworkprocesses.Devia-tionstotheseprocessesarecapturedintheCAPAdeviationsystem,analyzedfortrendidentification,andresolved.APsaredeployedandworkprocessesaremodified,asindicated.CapitalizingonLOTS’sCCiscriticaltotheaccomplishmentofthekeyworkprocesses.OngoingevaluationofthesekeyworkprocessmeasuresoccursthroughthePMS;alignmentandintegrationofperformancemeasuresbeginintheSPPandcontinuethroughtheOMPtoensurethatalldataandinformationneedsaremettoeffectivelymanageperformance

outcomes.Keyin-processandoutcomemeasureselectionisusedtodriveandassessservicequalityandperformance.

6.1b(2) TheOMP(Figure 6.1-1)demonstratestheprocessusedtodeterminethekeyworksystemrequirementstoconstructthekeysupportprocesses:LaboratoryTesting,DonorChartReviewandReleaseProcess,SupplyandEquip-mentManagement,FinancialManagement,HRManagement,ITManagement,PI,andQualityComplianceManagement.Day-to-dayoperationofthesupportprocesses’abilitytomeetkeybusinesssupportrequirementsisensuredbytheOMP.WithintheOMP,thePMS(Figure 4.1-1)isusedtoensurethatkeysupportmetricrequirementsaremeasured,analyzed,andbenchmarkedtodriveassociatedAPs.ODsalsoincludeanaly-sisofmetricsandevaluationofcurrentAPsandprocesssteps.Keysupportmetricsarereviewedatthedepartmentleveltoassessperformanceformeetingkeybusinessrequirementsonanongoingbasis.Forexample,thelaboratoryrequisitionerrorratewastrackedasakeylaboratorymetricandwasoneofthehighestsourcesoferrors.Requisitionerrorswerethesourceofreworkandhadthepotentialtoslowthetestingand/orreleaseofcriticallaboratoryinfectiousdiseasetesting.PI,laboratory,organ,andtissueprocurementdepartmentsmetanddeveloped

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outcomes.Keyin-processandoutcomemeasureselectionisusedtodriveandassessservicequalityandperformance.

6.1b(2) TheOMP(Figure 6.1-1)demonstratestheprocessusedtodeterminethekeyworksystemrequirementstoconstructthekeysupportprocesses:LaboratoryTesting,DonorChartReviewandReleaseProcess,SupplyandEquip-mentManagement,FinancialManagement,HRManagement,ITManagement,PI,andQualityComplianceManagement.Day-to-dayoperationofthesupportprocesses’abilitytomeetkeybusinesssupportrequirementsisensuredbytheOMP.WithintheOMP,thePMS(Figure 4.1-1)isusedtoensurethatkeysupportmetricrequirementsaremeasured,analyzed,andbenchmarkedtodriveassociatedAPs.ODsalsoincludeanaly-sisofmetricsandevaluationofcurrentAPsandprocesssteps.Keysupportmetricsarereviewedatthedepartmentleveltoassessperformanceformeetingkeybusinessrequirementsonanongoingbasis.Forexample,thelaboratoryrequisitionerrorratewastrackedasakeylaboratorymetricandwasoneofthehighestsourcesoferrors.Requisitionerrorswerethesourceofreworkandhadthepotentialtoslowthetestingand/orreleaseofcriticallaboratoryinfectiousdiseasetesting.PI,laboratory,organ,andtissueprocurementdepartmentsmetanddeveloped

membersassessachievementoftheHospitalReferralProcess,AuthorizationProcess,andtheClinicalProcurementProcesssteps,alongwithstakeholderfeedback.ThissystematicreviewhelpsdetermineifprocesschangesareindicatedandprovidesanopportunitytosharelearningacrosstheworksystemtoimproveOWSprocesses.

Keyperformanceandin-processmeasuresusedforthecontrolandimprovementofworkprocessesareoutlinedinFigure 6.1-2.Thesein-processmeasuresdriveincreasedperformanceandstrictadherencetoprocessestoensuremaxi-mizedoutcomesandservice.Anextensivesetofpoliciesandprocedures,incorporatingkeystakeholderinput,definestheworkrequiredtoaccomplishthekeyworkprocesses.Devia-tionstotheseprocessesarecapturedintheCAPAdeviationsystem,analyzedfortrendidentification,andresolved.APsaredeployedandworkprocessesaremodified,asindicated.CapitalizingonLOTS’sCCiscriticaltotheaccomplishmentofthekeyworkprocesses.OngoingevaluationofthesekeyworkprocessmeasuresoccursthroughthePMS;alignmentandintegrationofperformancemeasuresbeginintheSPPandcontinuethroughtheOMPtoensurethatalldataandinformationneedsaremettoeffectivelymanageperformance

Figure 6.1-2: Key Work Processes

PHASE PRE-DONATION DONATION

Key Work Process Referral Management Authorization Procurement/Allocation

Work System Alignment

OWS TWS OWS TWS OWS TWS

Key Requirement Results

HospitalPartner

Satisfaction:OWS

(7.1-1A)

HospitalPartner

Satisfaction:TWS

(7.1-2A)

Referrals (7.1-1)

Referrals (7.1-2)

OrganDonors (7.1-3)

TissueDonors (7.1-4)

In-ProcessMeasures

MissedOrganReferrals(7.1-15)

LOTSTissueApproachRate

(7.1-16)

OrganAuthorization

(7.1-17)

CollaborativeApproach

TissueAuthorization

(7.1-18)

Re-approach Rate

DonorManagementProtocol

Compliance(7.1-20)

OrganDonorCasesIn-house

(7.1-21)

BoneNo GrowthRates

(7.1-22)

SkinYield (7.1-23)

Outcome Measures OrganReferrals(7.1-1)

TissueReferrals(7.1-2)

LocalOrganDonors(7.1-3)

OrganConversion

(7.1-19)

TotalTissueDonors(7.1-4)

LocalOrgansTransplanted

(7.1-5)

SkinDonors Released(7.1-7)

How Determined• Regulatory

CMS CMS UNOS/OPTN

UAGAAOPO

UAGAAATB VOC(3.1-1) UNOS/OPTN

AOPO

VOC(3.1-1) AATB

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anonlinelaboratoryrequisitionmodulethatreducedthenumberoferrorsdramatically(AOS).

6.1b(3) Improvementofworkprocesses,products(services),theCC,andperformanceisinitiatedthroughtheOMP(Figure 6.1-1)byusingthePMS(Figure 4.1-1)andSPP(Figure 2.1-1)toidentifyimprovementopportunities.TheoverarchingapproachtosupportworkprocessandproductimprovementsisthePDSA.Asanexample,theTWSstaffdevelopedaPDSAtotestamodifieddonorprepproceduretominimizethebonecontaminationrate,acriticalmetrictoensuremaximizingdonationandcustomersatisfaction(Figures 7.2-1 through 7.2-2, 7.2-2C, and 7.2-2D).Initialresultsshowedimprovedoutcomes,andtherigorouspreppracticewasincorporatedintoLOTS’spoliciesandproce-dures.LOTShashadthelowestcontaminationrateofallTissueTransformationspartners,andtheprepprocedurewasidentifiedasabestpractice.LOTShastrainedotherOPOsontheprocedure.Improvementsinworkprocessestoenhancethemission-drivenstaff(CC)arealsopartoftheOMP,ensuringamultifacetedandsystematicanalysisanddiscussionofproductandprocessimprovements.

6.1c Supply-Network Management Inanontraditionalsense,supply-networkmanagementincludesthereceiptofthedonorreferralfromLOTS’shospitalpartnersandisthemostcriticalsupply-networkeventfortheorganization(Figure 2.1-2).Theselectionofthesenontradi-tionalsuppliersispredeterminedbytheDSA.The“donor”supply-networkmanagemententailscreatingandcommunicat-ingperformancestandardsandexpectationsduringregularlyscheduledmeetings.Inaddition,thereisaStandardizedIdentificationandReferralProcessatpartnerhospitalsofallpotentialdonors,ensuringthatoperationalneedsaremet(Figures 7.1-1 and 7.1-2).Aftertheinitiationofthereferralprocess,potentialdonorsuitabilityisestablished,andthepotentialdonor’sfamilyisapproachedfordonation.Thedonorreferralsystemisdevelopedcollaborativelywithhospitalandnonhospitalpartners,andtheProcurementProcessbeginswiththedonorenteringtheOWSorTWS.Hospitalpartnersinitiatethereferral;theirsupplierperformanceisregularlytrackedviametricsnotedontheQuarterlyDashboardreportandintheHospitalServicesscorecard.Poorlyperforminghospitalsareidentifiedviathesemetrics,andsubsequentAPsareestab-lishedwithstaffbuy-intoensureimprovementinoutcomes.Forexample,onepartnerhospitalreferralcompliancefor2017was68%.TheHospitalServicesstaffpersonworkedwiththehospitaltoPDSAseveralimprovements,includingtraining,additionalapproachestocommunication(includingdailyemails),newstafforientation,andfollow-upwithhospitaladministration.AsaresultofthisfocusedPDSA,thehospi-tal’s2018complianceimprovedto85%(AOS).

LOTSrecognizesthatcollaborativerelationshipswithmoretraditionalsuppliersplayanimportantroleinenhancingorga-nizationalperformanceandcustomersatisfaction.LOTSman-agesitstraditionalsupply-networkwithanonlineinventory

managementsystem.Thissystemenablestheorganizationtomanageordering,purchaseorders,purchasinghistory,andsupplyexpirationmonitoring,whichallowsLOTStoestablishminimuminventorylevelsthattakeintoaccountleadtimesandexpirationdates.Additionally,aQuarantineandReleaseProcessforcriticalsuppliesensuresthatsterilitycertificatesandinventoryqualificationsmeetorexceedindustryrequire-ments.Suppliers’performanceismeasuredandevaluatedonavarietyoflevels,includingmetricsondamagedandreturnedsuppliesanddeliverytimes.Poorlyperformingsuppliersarecontactedtoresolverecurringissues,andifissuespersist,theyarereplacedbyanotheravailablesupplier/supply.

Keysupplierperformance(GuardianAmbulance,ColumbiaCremation,TransplantTechnologies,andWrightBrothersCharters)ismonitored,tracked,andtrendedandisincludedinregularfeedbackwiththekeysuppliers(Figures 7.1-30, 7.1-31, 7.1-32, 7.1-33, and 7.1-34).ThesekeysuppliersarealsovettedbasedontheirabilitiestoalignandcollaboratewithLOTS.Forinstance,WrightBrothersChartersrecentlyexpandeditsabilitytotransportdonorsbyaddingplanesandpilotstoadditionalsitesintheDSAtoensurethatitcouldmeettimerequirements.

Organizationalalignmentandcollaborationwithsuppliersincludeensuringthattwo-waycommunicationisutilized.

6.1d Innovation Management InnovationandimprovementareembeddedintheculturefromthegovernancelevelwiththeBOD,downthroughthemission-drivenworkforce.ImprovementorinnovationisinitiatedandmanagedthroughtheOMP(Figure 6.1-1),LDS,andSPP.ImprovementdiscussionscanoriginateintheSPP,OMP,and/orLDS,andanimprovementteammaybeformed.Animprovementteamcomprisesstaffmembersfromdepart-mentsacrosstheorganizationandisledbythePIstaff.Duringimprovementteammeetings,theteamusesvariousPItoolsanddataanalysisfromthePMStodevelopnewprocessestotestandimplementnewideasorprocesses.

TheSAoffinancialstabilitypositionstheorganizationtoactivelypursueinnovativeideasandimprovements.Ideaassessmentincludesthescopeofapotentialproject,schedule,andneededresources,includingfinancialresources.ThesearereviewedattheLTmeetings.Financialandotherresourcesaremadeavailablethrougharobustbudgetingprocessandmul-tiplefinancialanalysistools,includingfinancialprojections.

Decisionstodiscontinuepursuingopportunitiesattheappropri-atetimeareevaluatedthroughtheOMP.TheOMPallowsforasystematicreviewofpotentialandcurrentprojects,anditensurestheagilitytoenhancesupportforhigher-priorityoppor-tunities.Asanexample,organbiopsieshadbeenperformedin-houseformanyyears.AdiscussionduringaC&Cmeeting,alongwithcontinueddiscussionintheOWSmeeting,resultedintheevaluationofwhetherbiopsiesshouldbeperformedin-houseoroutsourced.Robustdiscussionsandanalysisaddressedfinancial,capability,andcustomersatisfaction.Ultimately,the

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OrganBiopsyProcesswasoutsourced,resultingindecreasedcostandhighercustomersatisfaction(AOS).

6.2 Operational Effectiveness 6.2a Process Efficiency and Effectiveness Overallcostsoftheoperations,cycletime,productivity,efficiency,andeffectivenessfactorsareassessedthroughtheOMP,whichincludesinputsfromthePMS.LOTScontrolstheoverallcostofoperationsthroughefficiencyandimprovementgainedbyquarterlyC&Cmeetings,grouppurchasingorgani-zations,inventorycontrol,andLeantools,includingprocessmapping.Thesestrategiesincludefinancialanalysis,suchasanevaluationofbudget,costmodeling,andROI,alongwithongoingSDs(Figure 2.1-1,Step8).Efficiencyandeffective-nessfactorsarepartofthein-processmetricsincludedinFigure 6.1-2.AnexampleofcostcontrolisthedevelopmentofLOTS’sin-houseOR,whichincorporatedcustomerfeedbackandhasresultedinprocessefficienciesandsub-stantialcostssavings.Thesecostsavingshaveimpactedthechargestructure,allowingLOTS’sorganacquisitioncharges(OACs)tobebelowthemedianforallOPOs(Figure 7.5-12).TWSefficiencieshaveallowedincreasesindonorvolumethathavenotrequiredadditionalstaffing(Figure 7.3-3).AnotherexamplethatillustratesthereductionandcostofreworkistheutilizationoftheCMOinreal-timetissuedonorsuitabilityassessments,whichhaveledtoreductionsinon-sitedeferrals,whichhaveimpactedoveralltissuedonornumbers(AOS).

OriginatingfromtheannualSPPsession,awell-definedauditcalendarisestablishedeachyear.Auditsareconductedsystematically,andoutcomesdrivefrequencyandsamplesize,ensuringmaximumeffectivenesswithminimalauditcosts.LOTSusesaninternalqualityreporttocommunicateauditfindingsattheLTmeetings.LOTSexceedsindustrystandardsbyproactivelyseekingallvoluntaryaccreditations(Figure P.1-5)andparticipatinginaccreditationcouncils.Accreditationinspectionsassisttheorganizationwithidentify-ingpossiblegapsinpracticesthatresultinminimizingserviceerrors,rework,anddefects.Participationonthecouncilsallowsforsharingofinformationandbestpracticestoproac-tivelyevaluateandimproveoperations.Inputfrommission-drivenworkforcemembers(CC)duringauditpreparationmeetingsensuresthattheorganization’sworkforcecontributestoprocessimprovementopportunitieswhilemeetingregula-toryandcompliancerequirements.Tofurthermaximizeefficiencyandcostcontrol,LOTSusespreventativemeasurestominimizemaintenancecosts,andcontractsareestablishedtoensurethatcapitalequipmentisproperlymaintainedtopre-ventunplanned,costlyrepairs.Grouppurchasingagreementsareutilizedtoleverageeconomiesofscaleinordertonegoti-atereasonablepricesforsuppliesandmaintenancecontracts.Newsupplyrequestsareevaluatedandapproved/deniedatthedirectorlevelviatheSupplyRequisitionProcess.LOTSemployscomprehensivemeasurestomaximizeefficiencyandensurecostcontrol,whicharebalancedwithcustomerneeds.TheworkwithintheOMPdrivestheorganizationtoperform

asefficientlyaspossible.Costsavingsallowforcontinuedandincreasedfundingofprojectstoensurehighlevelsofcustomersatisfaction.

6.2b Security and CybersecurityTheISusedincludessoftware,data,networkinfrastructure,computerhardware,andkeyassets.AnoverviewofISisacomponentoftheannualSPP.LOTSusescloudsoftwareforserverhardwareanddata;thesoftwareprovidesredundancy,reliability,andmonitoringtoolstoensurespeed,security,uptime,andoverallreliability.In-houseserverscontainredundantcomponents,includingdualpowersupplies,net-workinterfacecards,anddisks.Allhardwareisundervendorsupportandmonitored24/7usingvarioustools.Vendorcontractsincluderequirementsforresponsibilitiesandrolesregardingcybersecurity.Inaddition,vendorcontractsincluderequirementstoovernighthardwarecomponentsthatmayfail;thisensuresthatfullinternalredundancyremainsintact,anduptimeandreliabilitymeetorganizationalrequirements(Figure 7.1-30).

LOTSutilizesSoftwareasaService(SaaS)asapplicable.SaaSdecreasesriskandincreasesoverallreliabilitybyusingvariousvendorsthathostfromdifferentserversanddatacenters.LOTSalsousestheLinkingSmartticketingsystemtotrackITneeds,problems,and/orissues.LinkingSmartallowstrendanalysisanddetectionofapplicationsandcomponents’reliability;unreliablecomponentscanthenberepairedorreplacedbeforereliabilitybecomesanissue.Communica-tionCenterdatareliabilityisensuredthroughaprocessthatincludesnightlybackups,withonecopysenttoasecureoff-sitelocationinColumbia,NT,andtheothercopysenttoWashington,DC(ensuringprotectionfromlocal/regionaldisasters;4.2a[1]).

LOTShasestablishedmultiplepoliciesandprocedurestoensurethesecurityandcybersecurityofsensitiveorprivilegeddataandinformation.Thesepoliciesandproceduresoutlinethephysicalandtechnicalsafeguardsforallcomputersthataccesselectronic,protected,healthinformationtorestrictaccesstoauthorizedusers.Theorganization’spasswordpolicyoutlinestheappropriateparametersforselectingandsecuringsystem-anduser-levelpasswords.StaffmemberswithEMRaccessarerequiredtosignconfidentialityagreements,andITauditsperformedbyQSverifyappropriateaccessandcurrentusers.

TTisLOTS’sprimaryinfrastructurecontractor.TTmonitorssecurity,includingreal-timealertsfromthreat-detectionsystems.TTpreparesalldesktopandlaptopcomputerspriortousetoensurethattheyincludethelatestsecuritypatches,antivirusengines,andhard-driveencryption.Allusersaretrained,andpoliciesrequirestaffmemberstolocktheircomputerswhentheyareaway.LOTSusesfullyredundantfirewallstoensurenetworkandInternetsecurity.Thefirewallincludesintrusiondetectionandpreventionfeatures.Securitypatchesareappliedmonthlyforallphysicalservers,virtualmachines,desktops,andlaptops.LOTShasamailencryption

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policy,whichrequiresencryptionofallemailsthatcontain anddriversafety,andmaliciousintrudertraining.Theinjurypersonallyidentifiedinformation(PII)orpersonalhealth reportingprocessensuresthatallinjuriesareinvestigated,rootinformation(PHI). causeisdetermined,andachangein-processorenvironment

istakenifindicatedtoensurerecovery.Forexample,in2018,Cybersecuritythreatandemergingsecurityissueawarenesstherewasa25%decreaseintissueneedlesticks/injuriesinaremaintainedthroughanumberofapproaches.LOTSthetissueprocurementdepartment,whichwasaresultofreceivessecuritybulletinsdirectlyfromathird-partyvendorimprovedtraininginorientationandtherequiringofprotectiveandcanrespondtoeminent,day-zerothreats.Antivirusgloves.SafetyknowledgeissharedviatheCommunicationenginesarerequiredtobecurrent,andtheycontinuouslyscanProcess;regularsafetyupdatesarecommunicatedtothetheLOTSenvironment.workforceatdepartmentandstaffmeetings.Fireandtornado

Identificationandprioritizationoftechnologysystemprotec- drills,alongwithothersafetydrills,areregularlyconducted.tionfromcybersecurityattacksareprovidedthroughthe PersonalsafetyclassesnowincludeprovidingpersonalsafetyutilizationofSaaS,whichprovideshostingofsolutionsfrom alarmstostaffmembers.Badgesarerequiredforentryintocompleteseparateserversanddatacenters.LOTS’spayroll, workareas,withlevelsofrestrictionbasedonnecessityasaccounting,EMR,andBusinessIntelligencesystems,for determinedbyjobdescription.Moreover,alocalsecurityexample,areallhostedbydifferentvendorsatdifferentdata companyisusedtoprovidecontinuousperimeterandcampuscenters.Inaddition,necessaryintegrationoccursbehind securityduringnonbusinesshours,includingweekendsandLOTS’sfirewalls. holidays.SecuritycamerasaremanagedintheCommunica-Detectionofcybersecuritybreachesisprovidedbymonitoring tionCenterareaandallowfor24/7monitoringofperimetertoolsthatareinplacetocontinuouslyscantheenvironmentfor doorandaccesspoints,alongwithafencedparkingareaforsuspiciousactivity.Acybersecuritybreachhasnotoccurredat staffmembers.LOTS.Theresponseandrecoveryfromapotentialcybersecu- 6.2c(2) LOTShasawell-documented,executabledisasterritybreachwouldincludedetectionoftheattack,andcompro- preparednessplanthatallowstheworksystemstocontinuemisedserverswouldberecovered.Recoverywouldtypically toachieveahighlevelofcustomersatisfaction.Emergencyincluderunningantivirussoftwareandothersecuritytoolsto preparednessisensuredthroughregulartestingandanalysisremoveandcleananyviruses,Trojans,ormonitoringagents. oftheEmergencyResponsePlan(ERP;AOS).TheplanisAnycompromiseddatawouldbedeletedandrecoveredfrom aguidelinethatpreparesthestafftorespondtosafetyandbackups. operationaldisruptionsintheeventofanemergency.Multiple

measuresarealsoinplacetoensurecontinuityofoperations.6.2c Safety and Emergency PreparednessThedesignofLOTS’sfacilityensuresthatallcriticalservices,

6.2c(1) LOTShasestablishedaSafetyProgram,managed includingtheCommunicationCenter,ISnetwork,andclinicalbytheSafetyOfficer,thatutilizessystematicprocesses, operations,arecontinuouslyonlineandsupportedbyanemer-includingtheLDS,forensuringasafeoperatingenvironment. gencygenerator.RoutinetestingandpreventativemaintenanceIdentificationofworkforcesafetyconcernsandaTimely ofallcriticalequipmentoptimizetheorganization’sabilitytoInjuryReportingProcessallowforasystematicreviewto respondtoanyevent.Additionally,remoteaccesscapabilitiesidentifyareasforpreventionandimprovement.Injuriesare allowworktocontinueuninterruptedincaseofadisaster,reported,andthesedataaremonitoredtoidentifypotential emergency,orweatherinterruption.Remoteaccesstophonetrendsandopportunitiesfortrainingonaccidentprevention systemsensures24/7remoteaccessforexternalservices.In(Figure 7.3-7).Inaddition,a2018staffsafetysurveynoted theeventofadisaster,anextremevolumeofcases,orcriticaloverallsatisfactionwithsafetyat85%,anincreaseof2%over staffingshortages,LOTShasagreementswithmultipleotherthepriorsurvey(AOS).Accidentprevention,embeddedinthe OPOstoreciprocateemergencystaffingandfacilitiesonacultureoftheorganization,startswithnewhiresinorientation short-termbasis.Intheeventofalong-term,off-siteoption,andcontinueswithannualtraining.Preventionexamples LOTSispreparedtocompleteorganandtissueclinicalincludeOSHAtraining,blood-bornepathogenstraining,the processesatlocalhospitals,andtheCommunicationCenterprovisionofpersonalprotectionequipment,andstaffmembers wouldbeoperationalviaremoteaccess.RecoveryfollowingbeingprovidedthehepatitisBvaccine.Inaddition,workforce aneventwouldbedependentontheincidentorevent,butsafetyconcernsareidentifiedinODs,departmentmeetings, LOTS’sfacilitywouldbere-establishedatanotherlocationifRFO,staffsurveys,regularqualityaudits,andinvestigationof necessary.Theorganizationmaintainsbusinessinterruptioninjuries.TheSafetyProgram,utilizingtheSafetyCommittee, insurancetoensureadequatefinancialresourcestosupportrecommendsneededtrainingsessions,policychangerecom- continuedoperations.IntheeventthatLOTS’scontinuitycon-mendations,and/orotherneededsafetyenhancements.These tingencyplans,includingsuppliersandpartners,aredeemedlearningsmayresultintrainingsessionsforstaffmembersor ineffectiveornotavailableduetocatastrophiccircumstances,changestopolicy,ifrequired. thehighest-rankingleadershipmemberavailablemaymakeTheSafetyCalendar(AOS)includesmonthlysafetyprograms thedecisiontoceaseoperationsuntilalternativeoptionsareencompassingpersonalsafety,CPR,automatedexternaldefi- identifiedbytheELT.brillators(AED),fireextinguishertraining,defensivedriving

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Category 7: Results

7.1 Product and Process Results7.1a Customer-Focused Product and Service Results AtLOTS,mostjob-andcareer-relatedprogressioninvolvesjobenhancementopportunitieswithintheorganization.Duetotheorganization’ssizeandstructure,careerenhancementisoftensupportedinhorizontaltransitionstodifferentroles.Overhalfoftheworkforceisinadifferentpositiontodaythanorigi-nallyhiredfor,andmanyofthosehavetransitionedmultipletimes.ThePEPhelpsidentifyhighperformerswhocanutilizetheirskills,knowledge,andabilitiesinvariousways.

TheLDSisusedtopreparetheworkforceforreplacementandsuccessionplanning.ThesuccessionplanisreviewedannuallythroughtheSPP(Figure 2.1-1,Step5)andmodifiedasneededbytheCHRO,CEO,COO,CMO,andeachLTmember;theplanprovidesstrategyforshort-andlong-termcoverageforeachLTposition.TheLTsuccessionplanfocusesonthedevelopmentofcurrentleaderspositionedtotakeonadditionalresponsibilitiesandemergingleaderswhocouldserveasthenextgenerationofleadership.Developmentneedsofidentifiedemergingleadersarenowincorporatedwithinthetraininganddevelopmentplanaspartoftheemployee’sPEP.Asanexample,targetedtrainingisbeingprovidedquarterlytoteamleadsacrosstheorganizationtoensurefoundationalunderstanding,includingteamdynamics,difficultconversa-tions,andteammotivation.

LOTShasthreekeyworkprocesseswithintheworksystems:ReferralManagement,Authorization,andProcurement/Allocation(Figure 6.1-2).ReferralManagement,thefirstkeyprocessinbothworksystems,ismeasuredbyorganandtissuereferrals.Referralisthestartofcollaboration;hospitalsatisfactionwiththedonationisreflectedinFigures 7.1-1A and 7.1-2A.Organreferrals(Figure 7.1-1)haveexperiencedorganizationalbestlevelsin2018.Tissuereferralshaveincreased,allowingLOTStoachieve“tenthinthenation”statusin2018(Figure 7.1-2).(GPRisanationalorganizationprovidingcomparativesatisfactionandengagementdata.)

0

1,200

2,400

2016 2017 2018 2019 ytd

Refer

rals

Figure 7.1-1: Organ Referrals

LOTS Internal Target

INTERNAL METRIC

Organ Referrals Remain Consistent Goo

d

0

2,500

5,000

2016 2017 2018 2019 ytd

Refer

rals

/ M P

opFigure 7.1-2: Tissue Referrals

LOTS AOPO Top Quartile

Tenth in the Nation in 2018 Goo

d

INTERNAL METRIC

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ThekeyoutcomemeasurementforauthorizationintheOWSisorgandonors(Figure 7.1-3)andorganauthorization(Figure 7.1-17),andtheauthorizationoutcomemeasureintheTWSistissuedonors(Figure 7.1-4).Organdonornumbersremainhigh.Tissuedonornumbershaveremainedsteadyoverthelastthreeyears,meetingtheindustrycomparative.

Thelastkeyprocessofbothworksystemsisprocurement,whichismeasuredbylocalorganstransplantedintheOWS(Figure 7.1-5).IntheTWS,themeasuresareAge-TargetedBoneDonorsReleased(Figure 7.1-6)andSkinDonorsReleased(Figure 7.1-7).Localorganstransplantedareatopline

0

25

50

2016 2017 2018 2019 ytd

Dono

rs / M

Pop

Figure 7.1-3: Local Organ Donors by Population

LOTS OPTN Top Quartile

Goo

d

Increasing Lives Saved

0

250

500

2016 2017 2018 2019 ytdTissu

e Don

ors /

M P

op

Figure 7.1-4: Total Tissue Donors by Population


Goo

d

Tissue Donors Remain Steady

0

75

150

2016 2017 2018 2019 ytd

Orga

ns T

XP/M

Pop

Figure 7.1-5: Local Organs Transplanted by Population


Goo

d

Near Top Quartile in 2018

0

450

900

2016 2017 2018 2019 ytdBone

Don

ors R

eleas

ed

Figure 7.1-6: Age-Targeted Bone Donors Released

LOTS Allograft Resources Best in Class

Goo

d

Increasing Bone Donors Released

0

450

900

2016 2017 2018 2019 ytd

Skin

Dono

rs Re

lease

d

Figure 7.1-7: Skin Donors Released


Goo

d

Meeting Internal Release Quotas

measuredirectlyresponsibleforincreasinglivessaved.LocalorganstransplantedpositionsLOTSatthenationaltopquartile.Age-targetedbonedonorsreleasedshowafavorabletrend;skindonorsreleased,amorerecentlyaddedmetric,exceedstheinternaltargetfor2018andshowsabeneficialtrend.

Thetwoworksystemsincludetwoservicelinesthataresegmentedintotwocustomergroups:localorgantransplantcentersandtissueprocessors(Figure P.1-6).Theorganstransplantedcanbesegmentedbyorgantype:heart,lung,liver,kidney,andpancreas,andresultsareshownbyorganstransplantedpermillion(Figures 7.1-8, 7.1-9, 7.1-10, 7.1-11,

0

10

20

2016 2017 2018 2019 ytd

Hear

ts TX

P/M

Pop

Figure 7.1-8: Local Hearts Transplanted


Goo

d

Near Top-Quartile Performance

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0

25

50

2016 2017 2018 2019 ytd

Lung

s TXP

/M P

opFigure 7.1-9: Local Lungs Transplanted


Goo

d

Strong Performance Continues

0

25

50

2016 2017 2018 2019 ytd

Liver

s TXP

/M P

op

Figure 7.1-10: Local Livers Transplanted


Goo

d


0

45

90

2016 2017 2018 2019 ytd

Kidn

eys T

XP/M

Pop

Figure 7.1-11: Local Kidneys Transplanted


Goo

d

Steady Achievement

and 7.1-12).In2018,therewasanincreaseinHepatitisC+donorsandPublicHealthServices(PHS)-increasedriskdonors,whichlimitedgrowthinresults.Tohelpincreasethenumberofheartstransplanted,LOTSisinvolvedinaheartresearchprojecttoimproveheartfunction.Locallungstrans-plantedpermillionplacesLOTSinthetopquartilein2018.Liverstransplantedpermillionremainssteady,nearingthetopquartile.Kidneystransplantedpermillionremainssteady,

0

7

14

2016 2017 2018 2019 ytd

Panc

reata

TXP

/M P

op

Figure 7.1-12: Local Pancreata Transplanted


Goo

d


withsteadyimprovementsince2017.Pancreatatransplantedpermillionremainsneartop-quartileperformance.Tissuedonorscanbesegmentedbybonedonors(Figure 7.1-13)andskindonors(Figure 7.1-14).Boneandskindonornumbershavebeenimpactedbytheopioidepidemic,resultingindecreasedsuitability,andprocessorlimitshavealsoresultedindecreases.

0

800

1,600

2016 2017 2018 2019 ytd

Dono

rs

Figure 7.1-13: Total Bone Donors


Good

Suitability Impacts Performance

0

750

1,500

2016 2017 2018 2019 ytd

Dono

rs

Figure 7.1-14: Total Skin Donors


Goo

d

Meeting Processor Needs

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7.1b Work Process Effectiveness Results7.1b(1) LOTS’skeyprocesseffectivenessandefficiencyresultsarenotedinFigure 6.1-2as“in-processmeasures.”TherelationshipmanagementefficiencyandeffectivenessresultsforOWSaremissedorganreferrals(Figure 7.1-15).Missedreferralshaveremainedatorunder2%since2016.ForTWS,therelationshipmanagementin-processmeasureisthepercentageofapproachesbyLOTS(Figure 7.1-16).HospitalServicesstaffhaveworkedcloselywithhospitalpartnerstotransitiontheTissueAuthorizationProcesstotheLOTSCommunicationCenterdepartment.In2018,LOTSperformedtheapproachfortissueauthorizationat99%ofthehospitals,anincreaseofnearly8%inthelastthreeyears.

Theauthorizationin-processmeasureforOWSistheorganauthorizationrate(Figure 7.1-17),whichshowssteadyperformance.TheTWSin-processauthorizationmeasureisthetissueauthorizationrate(Figure 7.1-18).Breakthroughprocesschangesimplemented,combinedwithnewjobrequirements,hiringpractices,andworkforcedevelopmentandtraining,haveresultedintissueauthorizationoutcomesexceedingtheindustrytopquartile.

0%

2%

4%

2016 2017 2018 2019 ytd

Miss

ed R

eferra

ls

Figure 7.1-15: Missed Organ Referrals

LOTS Hospital PartnersAllograft Resources Best in Class

Good

Relationship Management Results

0%

50%

100%

2016 2017 2018 2019 ytd

Figure 7.1-17: Organ Authorization


Goo

d

Top-Quartile Performance

0%

50%

100%

2016 2017 2018 2019 ytd

Figure 7.1-18: Tissue Authorization


Goo

d

Top-Quartile Performance

Thein-processmeasuresforprocurementarelistedinFigure 6.1-2.Optimizingthegift(yield;Figure 7.1-19)isdemonstratedintheOWSbytheabilityoftheclinicalstafftomanagethedonor’sclinicalstatustoensurethehighestnumberoftransplantableorgans.Yieldwasimpactedin2018byanorganizationalrecordofDCDdonorsandanincreaseinHepatitisC+donorsandPHS-increasedriskdonors.Despitethosechallenges,LOTS’sobservedperformanceexceedsexpectedresultswithlungs(Figure 7.1-19A).DonorManage-mentProtocolCompliance(Figure 7.1-20)continuestoshow100%complianceandrepresentstheabilityoftheclinicalorganstafftomanagedonorseffectively.OrganDonorCases

0.00

2.00

4.00

2016 2017 2018 2019 ytd

Orga

ns T

XP/D

onor

Figure 7.1-19: Organ Donor Yield


Goo

d

APs in Place to Drive Yield

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0.00

1.00

2.00

2016 2017 2018 2019 ytd

Obse

rved :

Exp

ected

Figure 7.1-19A: Observed vs Expected by Organ

Kidneys Heart LiverLungs Pancreas Expected

APs in Place to Drive Yield Goo

d

0%

50%

100%

2016 2017 2018 2019 ytd

Rate

Figure 7.1-20: Donor Management Protocol Compliance


INTERNAL METRIC

Process Compliance Ensures High ResultsG

ood

In-House(Figure 7.1-21)isthepracticeresponsibleforcreat-ingsignificantcostsavingsandcustomersatisfaction.Thisisapartner/customersatisfierforthedonorhospitalsandthetransplantcenters.LOTSoutperformstheexternalbenchmarkcomparisonswithorganizationalhighoutcomesfor2019.TheTWSprocurementin-processmeasuresincludeboneno-growthandskinyield.LOTSmettheAllograftResourcespartnerbenchmarkforBoneNo-GrowthRates(Figure 7.1-22). SkinYield(Figure 7.1-23)showsfavorabletrends;APsweredevelopedtoaddressbenchmarkperformancegaps.

0%

50%

100%

2016 2017 2018 2019 ytd% E

ligibl

e Cas

es In

-Hou

se

Figure 7.1-21: Organ Donor Cases In-House


Goo

d

Growing In-House Cases

0%

50%

100%

2016 2017 2018 2019

Bone

w/N

o Gro

wth

Figure 7.1-22: Bone No-Growth Rates


Goo

d

Meeting Customer Requirements

0

3,000

6,000

2016 2017 2018 2019 ytd

Avg.

Skin

Yield

(cm2 )

Figure 7.1-23: Skin Yield


Goo

d

APs in Place to Drive Results

ThekeyorganizationalperformanceindicatorsforkeysupportprocessesareshowninFigure 7.1-27 through Figure 7.1-33 . Laboratorytestingturnaroundtime(Figure 7.1-24)hasseensteadyperformance,withLOTSmeetingitsinternalbench-mark.ChartReleaseCycleTime—Organ(Figure 7.1-25)hasseensteadyperformanceinthenumberofdaysneededfororganchartstobereviewedanduploadedtomeetregulatoryrequirements.ChartReleaseCycleTime—Tissue(Figure 7.1-26) reflectsacriticalstepintheTWSProcessduringwhichchartsarecompleted,qualitychecked,andreleasedtotheprocessors,

0:00

4:48

9:36

14:24

19:12

2018 2019 ytd

Time (

hh:m

m)

Figure 7.1-24: Laboratory Turnaround Time by Work System

LOTs Organ LOTs TissueInternal Benchmark Organ Internal Benchmark Tissue

Turnaround time Ensuring Safe Organs and Tissues

Good

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0%

50%

100%

2016 2017 2018 2019 ytd

% C

omple

ted on

Tim

eFigure 7.1-25: Chart Release Cycle Time—

Organ

LOTS UNOS/OPTN

Steady Performance

Goo

d

0

25

50

2016 2017 2018 2019 ytd

Days

to C

lear

Figure 7.1-26: Chart Release Cycle Time—Tissue

LOTS Allograft Resources Requirement

Releasing More Charts in Less Time

Good

fulfillingatissueprocessorrequirementandtriggeringreimbursementtoLOTS.Thetissuechartcycletimeismeet-ingorexceedingtheAllograftResourcespartnerrequirement.SterilizerAccuracy(Figure 7.1-27)showsthedocumentationcompliancethatimpactsclinicalequipmentavailability.ITmanagement(Figure 7.1-28)continuouslyshowstheabilityoftheITdepartmenttohaveserveravailability24/7inordertosupportbusinessoperations.AsseeninFigure 7.1-29,processimprovementisanindicatorofPIutilizationacrossthecompanyandshowsconsistentuseoverthelastthreeyears.QualityComplianceManagement(Figure P.1-5)highlightsLOTS’saccreditationresultsinvoluntaryandrequiredcertifications,meetingorexceedingFDA,UNOS,AOPO,andAATBrequirements.

7.1b(2) EmergencypreparednessactionstakentominimizeinterruptionsinthedeliveryofLOTS’sservicesareAOS.

0%

50%

100%

2016 2017 2018 2019 ytd

Accu

racy

Figure 7.1-27: Sterilizer Accuracy


Goo

d

Consistently High Accuracy

0%

50%

100%

2016 2017 2018 2019 ytd

Uptim

e

Figure 7.1-28: Server Uptime


Goo

d

Continuous Availability

0

200

2017 2018 2019 ytd

Ticke

t Req

uests

Figure 7.1-29: PI Help Desk Tickets

Scorecard / Report Data Mining

Procedure or Process Enhancement Survey

Committed to Improvement

7.1c Supply-Network Management ResultsSupplyOptimization(Figure 7.1-30)viaanelectronicinven-torysystemhasresultedin97%availabilityforsuppliesforallin-housecases.WrightBrothersCharters,akeysupplier,providesairservicelogisticsfordonationactivityoutsideoftheColumbia,NT,metropolitanarea.WrightBrothersprovides24/7accesstoaircraftwitha90-minutelaunchrequirement,andasdemonstratedinFigure 7.1-31,delaysduetoproviderissuesoccurredinlessthan5%ofthe260-plus

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0%

50%

100%

2016 2017 2018 2019 ytd

Avail

abilit

yFigure 7.1-30: Supply Optimization


Strong Compliance Goo

d

0%

50%

100%

2013 2016 2017 2018

% of

Tota

l Leg

s Dela

yed

Figure 7.1-31: Wright Brothers Delays

LOTS Wright Brothers

Good

Few Delays Attributed to Vendor

launchesannually.GuardianAmbulanceexceedsrequirements100%ofthetime(Figure 7.1-32).ColumbiaCremation,anotherkeysupplier,hasseenimprovementssince2016,exceedingdeliverytimerequirementsin2018(Figure 7.1-33).TransplantTechnologies,akeysupplier,hasseenincreasing

0:00

1:00

2:00

2016 2017 2018 2019 ytd

Time (

h:mm)

Figure 7.1-32: Guardian Cycle Time

LOTS Requirement Guardian

Good

Meeting Our Requirements

0.00

1.50

3.00

2016 2017 2018 2019 ytd

Time (

Hour

s)

Figure 7.1-33: Columbia Cremation Cycle Time

LOTS Requirement Columbia Cremation

Good

Improvement Efforts Drive Compliance

numbersofmajorreleaseswithcomplexfeaturesin2018thatexposesmoreopportunitiesfordefects.TransplantTechnolo-giescontinuestoworkwithLOTStoresolveopportunitiesinatimelymanner(Figure 7.1-34).TitanTechnologies,arecentlyaddedkeysupplier,hasmanagedtoreducethenumberofopenITHelpDeskTicketsinQueue(Figure 7.1-35).

0%

20%

40%

0

40

80

2016 2017 2018 2019 ytd

Defec

ts

Featu

res P

ublis

hed

Figure 7.1-34: Transplant Technologies Change Requests

Features Published Defects

Major EMR Enhancements Released in 2018

Good

0

50

100

2017 2018 2019 YTD

Avg #

Tick

ets

Figure 7.1-35: IT Help Desk Tickets in Queue

IT Helpdesk Queue

Good

Significant Reduction in Helpdesk Tickets

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7.2 Customer Results7.2a Customer-Focused Results7.2a(1) AsthefederallydesignatedOPOwithinitsservicearea,LOTSdoesnothaveorganprocurementcompetitors.Regardless,maximizingcustomersatisfactionandengage-mentisanorganizationalgoal,andLOTSworkscloselywithitscustomergroupstomeetandexceedtheirrequirements.CustomersatisfactiondataaregatheredthroughtheVOCmethodsaslistedinFigure 3.1-1,includingtheCustomerSurveyProcess(AOS),whichhasundergonemultiplecyclesoflearningandstrategicimprovement.(Keymeasuresincludeoverallsatisfaction,andsegmentationbycustomergroupandservicelineareAOS.)

OverallsatisfactionlevelswithLOTS’sorgantransplantcen-ters(Figure 7.2-1)demonstrateperformancethatisequaltoorexceedsthebenchmarkforthelastthreeyears.Localorgantransplantcentersatisfaction,segmentedbykeyrequirement,showsstrongperformancein“competence”(Figure 7.2-1A)and“information”(Figure 7.2-1B).Customersatisfactioninmeetingthethirdrequirement,“maximizedonation,”isnotmeasuredthroughsurveys.Instead,operationalresultsareutilizedtogaugeeffectivenessinachievingthiskeycustomerrequirementandSO(Figure 7.1-5).Organtransplantcentersatisfactioncanbesegmentedbyposition,whichincludesTransplantPhysician,Coordinator,andAdministrator (Figure 7.2-1C),andshowsstrongresultsfor2018inall threesegments.

0.0

2.5

5.0

2017 2018 2019 ytd

Satis

factio

n

Figure 7.2-1C: Transplant Center Satisfaction—Organ

Administrator Coordinator Physician

Goo

dOverall Satisfaction

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SatisfactionlevelsamongLOTS’stissueprocessors(Figure 7.2-2)arecriticaltoensuringorganizationalsuccess.Overallsatisfactiondemonstratesnearhighperformance.Cus-tomersatisfactionmeetingthefirstkeyrequirement“account-ability,”definedaserrorrateminimization,ismeasuredutilizingoperationalmetricsreportedviatissueprocessorscorecards(Figures 7.2-2A and 7.2-2B).Whensegmentedbythekeycustomerrequirementof“information”(Figure 7.2-2C),resultsareconsistentlyhigh.Thethirdprocessorrequirementis“maximizedonation,”whichistiedtoLOTS’stissuedona-tionrates(Figure 7.1-4).Tissueprocessorsatisfactioncanbesegmentedbyindividualprocessor(Figure 7.2-2D).Satisfac-tionbyprocessorhasremainedstrong;2019year-to-dateresultsshowbeneficialtrendsforallprocessors.APsareinplacefor2019thattargetspecificareasforfocustocontinueexceptionalresults.FullsegmentedresultsbycustomerandservicelineareAOS.

0%

50%

100%

0.0

2.5

5.0

2016 2017 2018 2019

Enga

geme

nt

Over

all S

atisfa

ction

(All T

Ps)

Figure 7.2-2: Tissue Processor Satisfaction

Overall Satisfaction (All TPs)Allograft Resources Partner (Satisfaction)%Top Box (Engagement)

Goo

d

High Levels of Overall Satisfaction

0%

50%

100%

2016 2017 2018 2019 ytd

Accu

racy

Figure 7.2-2A: Vein Accuracy Rates

Saphenous VeinFemoral VeinCardioSolutions Saphenous VeinCardioSolutions Femoral Vein

Goo

d

Key Requirement: Accountability

0%

50%

100%

2016 2017 2018 2019 ytd

Accu

racy

Figure 7.2-2B: Heart Valve Accuracy Rates

LOTS CardioSolutions Top Quartile

Goo

d

Key Requirement: Accountability

0%

50%

100%

0.0

2.5

5.0

2016 2017 2018

Enga

geme

nt

Satis

factio

n

Figure 7.2-2C: Tissue Processor Satisfaction

Satisfaction %Top Box (Engagement)

Goo

d

Key Requirement: Information

0.0

2.5

5.0

2016 2017

Satis

factio

n

Figure 7.2-2D: Tissue Processor Satisfaction

Allograft Resources CardioSolutions Regeneration Associates

Goo

d

Increasing Overall Satisfaction

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Todeterminedissatisfactionlevelswithlocalorgantransplantcentersandtissueprocessors,LOTSanalyzesdataobtainedthroughtheCustomerComplaintProcess(Figure 3.2-2).Despiteanincreaseinthenumberoforganandtissuedonors,thepercentageofcustomercomplaintsforthetwocustomergroupshasdemonstratedfavorabletrends(Figure 7.2-3).TheimplementationofaformalizedCAPAsystemprovidesstan-dardizationandallowsforsystematicevaluationofcomplaintsregardlessofwheretheyoccurwithinthecustomerlifecycle.

Inadditiontocomplaints,LOTSutilizescustomersurveydatatomeasuredissatisfactionbydeterminingthepercentageofpoorandverypoorresponses(scoresof1or2)oncustomersurveys.Resultsfororganandtissueareatornear0%,withbothmaintaininglowtrendssince2016(Figures 7.2-3A and 7.2-3B).

0%

5%

10%

2016 2017 2018 2019 ytd

Comp

laints

/ Cas

es

Figure 7.2-3: Customer Complaints

Organ Tissue

Systematic Process Drives improvements

Good

0%

5%

10%

2016 2017 2018 2019

Diss

atisfa

ction

Figure 7.2-3A: Customer Dissatisfaction—Organ

Dissatisfaction

Good

Scored as "Poor" or "Very Poor"

0%

5%

10%

2016 2017 2018 2019 ytd

Diss

atisfa

ction

Figure 7.2-3B: Customer Dissatisfaction—Tissue

Dissatisfaction

Good

Scored as "Poor" or "Very Poor"

7.2a(2) Toidentifylevelsandtrendsincustomerengage-ment,LOTScalculatesthepercentageofverysatisfiedortop-boxscores(perfect5outof5)onitscustomersatisfactionscores.Thismethodologyisbasedupon The Loyalty Effect (FredReichheld),whichtheorizesthatrelationshipstrengthisdirectlyrelatedtocustomerloyaltyandengagement(3.2).LOTShasmaintainedconsistentlevelsofengagementwithitslocalorgantransplantcenters(Figure 7.2-1).Tissueprocessorengagementresultshavedemonstratedfavorabletrendssince2016(Figures 7.2-2).

Toassessitsperformanceinbuildingcustomerrelationships,LOTSanalyzesitsnumberofactivecustomers(Figure 7.2-4).Theorganservicelineoperatesinanoncompetitiveserviceareadesignatedbythefederalgovernment,sothenumberoflocalorgantransplantcentershasnotchangedin15years.Inthetissueserviceline,LOTSmaintainscontractualagreementswithitstissuecustomersandexpandeditscustomerbaseattheendof2017andinto2018.

0

10

20

2016 2017 2018 2019

Activ

e Cus

tomer

s

Figure 7.2-4: Customer Loyalty

Organ Tissue

Sustaining Customer Relationships Goo

d

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7.3 Workforce Results7.3a Workforce-Focused Results7.3a(1) WorkforceC&CkeymeasuresandresultsareshowninFigures 7.3-1 through 7.3-4.ThePEPratings(Figures 5.1-2 and 7.3-1)illustratetheaverageperformanceevalua-tionscorefortheLOTSworkforce,whichismeasuredonafour-pointscale.Throughtheimplementationofanoutcome-basedperformanceevaluationtool,PEPratingresultsindicatethatthemajorityoftheworkforce“achieveexpectations,”thereforemeetingtheorganization’scapabilityneeds.LOTSmaintainsadequatecapacityfortheOWSthroughevaluationoforgandonorspertheOPC(Figure 7.3-2).WithintheTWS,evaluationofworkforcecapacityisassessedatquarterlyC&CmeetingsbyongoingcomparisonofthenumberoftissuedonorstothenumberofTOPCstaffmembers(Figure 7.3-3).

WorkforceGrowth(Figure 7.3-4)demonstratescontinuedstaffinglevelsandstableNewHireDiversity(Figure 7.3-4A)overthepastthreeyearsasserviceshaveexpanded.NIST Training Draft

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7.3a(2) Workforceclimatemeasuresarekeytoretainingamission-drivenworkforce(CC)anddonotdifferbydiversityoftheworkforceorworkgroup.Workforcehealth,safety,andsecurity,aswellasemployer-providedservicesandbenefits,aremonitoredcontinuouslytoensureeffectiveness.

Inanefforttoexhibitconcernandcarefortheemployeesaswellasengageemployeesinthetopicofpersonalhealth,awellnessprogramwasinitiatedin2009.Thewellnessprogramparticipationremainsstrong(Figure 7.3-5).LOTStakesgreatcareinensuringthatallemployeesaretraineduponhireandannuallythereafteronproperproceduresandsafetyprotocolsineachpositionanddepartment.WorkplacePreparedness(Figure 7.3-6)demonstratesmultipleeffortsdeployedtoensurethesafetyoftheworkforce.Asaresultoftheorganiza-tion’sdedicationtoadherencetosafetyproceduresandproto-cols,LOTSmonitorsitsDARTrate(DaysAway/Restricted/TransferredRate)duetoworkplaceinjuries(Figure 7.3-7).

RadiationExposure(Figure 7.3-8)ratesareusedtoassesstheamountofradiationorganclinicalstaffmembersareexposedtowhenutilizingimagingequipment.LOTSpoliciesandproceduresensurethatemployeesaresafefromradiationexposure.

Multiplesecuritymeasuresareinplacetocreatethemostsecureenvironmentfortheworkforce(Figure 7.3-9).

Theorganizationhasconsistentlyshowncommitmenttothehealthandsatisfactionofitsemployeesbycontinuingtoofferrichbenefitsplansinmedical,dental,vision,andlifecoverage,aswellasadditionalbenefitsasshowninBenefitsExpenditures(Figure 7.3-10).

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Figure 7.3-6: Workplace Preparedness

Preparations Goal 2016 2017 2018 2019 YTD

SafetyTraining AllEmployees 100% 100% 100% 100%

FireAlarmTesting Quarterly 4 4 4 3

AeroCharterSafetyTraining AllAplicableEmployees 100% 100% 100% 100%

GeneratorsandSystemAvailabilityTesting Weekly 100% 100% 100% 100%

InjuryInvestigation AllInjuries 100% 100% 100% 100%

Data/VOIP(Communication)Testing RealTime 100% 100% 100% 100%

7.3a(2) Workforceclimatemeasuresarekeytoretainingamission-drivenworkforce(CC)anddonotdifferbydiversityoftheworkforceorworkgroup.Workforcehealth,safety,andsecurity,aswellasemployer-providedservicesandbenefits,aremonitoredcontinuouslytoensureeffectiveness.

Inanefforttoexhibitconcernandcarefortheemployeesaswellasengageemployeesinthetopicofpersonalhealth,awellnessprogramwasinitiatedin2009.Thewellnessprogramparticipationremainsstrong(Figure 7.3-5).LOTStakesgreatcareinensuringthatallemployeesaretraineduponhireandannuallythereafteronproperproceduresandsafetyprotocolsineachpositionanddepartment.WorkplacePreparedness(Figure 7.3-6)demonstratesmultipleeffortsdeployedtoensurethesafetyoftheworkforce.Asaresultoftheorganiza-tion’sdedicationtoadherencetosafetyproceduresandproto-cols,LOTSmonitorsitsDARTrate(DaysAway/Restricted/TransferredRate)duetoworkplaceinjuries(Figure 7.3-7).

RadiationExposure(Figure 7.3-8)ratesareusedtoassesstheamountofradiationorganclinicalstaffmembersareexposedtowhenutilizingimagingequipment.LOTSpoliciesandproceduresensurethatemployeesaresafefromradiationexposure.

Multiplesecuritymeasuresareinplacetocreatethemostsecureenvironmentfortheworkforce(Figure 7.3-9).

Theorganizationhasconsistentlyshowncommitmenttothehealthandsatisfactionofitsemployeesbycontinuingtoofferrichbenefitsplansinmedical,dental,vision,andlifecoverage,aswellasadditionalbenefitsasshowninBenefitsExpenditures(Figure 7.3-10).

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7.3a(3) Essentialtotheworkforceclimate,andakeycontributortoemployeeengagement,istheconnectiontotheorganization’smission.Onworkforcesurveys,staffmembersrepeatedlyindicateanexceptionallevelofunderstandingofhowtheirindividualpositionscontributetothemission,exceedingtop-quartileperformance(Figure 7.3-11).ResultsintheExcelEmployeeEngagementsurveyassessingtheorganization’soverallengagementexceedthehealthtop-quartilebenchmark.Inaddition,segmentationbyworksystemdemonstratesstrongengagementscoresinboththetissueandorganworksystems(Figure 7.3-12A).

LOTScontinuestohaveconsistentorganizationalretention;departmentalAPsareinplacefor2018toaddressopportuni-ties(Figure 7.3-13).Overthelastseveralyears,LOTShasfocusedonensuringworkforcesatisfaction.Overallworkforcesatisfactionsurveyresultsshowasustainedtrendandfavor-ablecomparisontotheexternalbenchmark(Figure 7.3-14).Overallbenefitssatisfaction(Figure 7.3-15)showsstrongresults,equaltothehealthcareindustrytopquartile.

Figure 7.3-9: Security Measures

Preparations Goal 2016 2017 2018 2019

SecurityAlarmSurveillance 24/7 24/7 24/7 24/7 24/7

Motion-SensoredLighting 24/7 24/7 24/7 24/7 24/7

DVR-MonitoredSecurityCameras 24/7 24/7 24/7 24/7 24/7

MonitoredPanicButtons(Vendor) 24/7 24/7 24/7 24/7 24/7

BadgeAccessRequired

SecureParking 24/7 NA 24/7 24/7 24/7

In Compliance

7.3a(3) Essentialtotheworkforceclimate,andakeycontributortoemployeeengagement,istheconnectiontotheorganization’smission.Onworkforcesurveys,staffmembersrepeatedlyindicateanexceptionallevelofunderstandingofhowtheirindividualpositionscontributetothemission,exceedinghealthcaremedianperformance(Figure 7.3-11).ResultsintheExcelEmployeeEngagementsurveyassessingtheorganization’soverallengagementexceedthehealthtop-quartilebenchmark.Inaddition,segmentationbyworksystemdemonstratesstrongengagementscoresinboththetissueandorganworksystems(Figure 7.3-12A).

LOTScontinuestohaveconsistentorganizationalretention;departmentalAPsareinplacefor2018toaddressopportuni-ties(Figure 7.3-13).Overthelastseveralyears,LOTShasfocusedonensuringworkforcesatisfaction.Overallworkforcesatisfactionsurveyresultsshowasustainedtrendandfavor-ablecomparisontotheexternalbenchmark(Figure 7.3-14).Overallbenefitssatisfaction(Figure 7.3-15)showsstrongresults,equaltothehealthcareindustrytopquartile.

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7.3a(4) LOTSsupportsthetraininganddevelopmentoftheentireworkforce,asseeninOverallTrainingandDevelop-mentSatisfaction(Figure 7.3-16)andLOTS’sfinancialinvestmentintrainingexpendituresperfull-timeequivalent(FTE;Figure 7.3-17).LOTSalsomeasureslevelsandtrendsinleaderdevelopmentthroughtheannualworkforcesurvey.Figure 7.3-18showsleaderresultsindicatingsatisfactionwithemployer-sponsoredtraininganddevelopmentmeetingtheindustrytopquartile.

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7.4 Leadership and Governance Results7.4a Leadership, Governance, and Societal Contribution Results7.4a(1) LeaderCommunication(Figure 7.4-1)reflectsseniorleadercommunicationwiththeworkforce.Communicationhasremainedsteady,andtherearemultipleAPsinplacein2019tocontinuetodriveperformancetoexceedtop-quartilebenchmarks.

7.4a(2) LOTSBoardSelf-Assessment(Figure 7.4-2)comparesfavorablytothebenchmark.FullsurveydataandresultantactionsareAOS.

LOTSengagesinmultipleactivitiestoensurefiscalaccount-ability,aslistedinsection1.2a(1).Asanonprofitorganization,anAuditCommitteeisnotarequirement,butonewasvolun-tarilyestablishedasabestpracticeingovernancetoexpandfiscalaccountability.Externalfinancialauditssanctionedbythiscommitteehavealwaysachievedthehighestratingof“unqualified”opinion(Figure 7.4-4).

7.4a(3) LOTSviewsaccreditationandregulatorycomplianceasabaselineexpectationforperformance.Theorganizationhasreceivedfullaccreditationfromallvoluntaryaccreditingbodieswithinitsindustryandhasmaintainedthistrendforseveralyears.Additionally,LOTSmaintainsfullcompliancewithregulatoryandlegalmandatesthathavebeensustainedsincetheorganization’sinception(Figure 7.4-3).

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Figure 7.4-3: Regulatory & Legal Compliance Key Measures

Measures & Indicators Results

AATBAccreditation(3years) FullAccreditation

AOPOAccreditation(3years) FullAccreditation

CMSCertification(4years) FullCertification

DHSS(3years) FullCompliance

DOR NoAdverseFindings

EEOC 0Issues

FDAApproval NoAdverseFindings

FLSA 0Issues

IRSCompliance 0Issues

OSHA FullCompliance

UNOS/OPTN(3years) MemberinGoodStanding

UnblemishedPerformance

Figure 7.4-4: External Financial Audit

Year External Auditor Determination

2013 Brother,Sister,&Auditor UnqualifiedOpinion





ExcellentFiscalAccountability





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Figure 7.4-3: Regulatory & Legal Compliance Key Measures

Measures & Indicators Results

AATBAccreditation(3years) FullAccreditation

AOPOAccreditation(3years) FullAccreditation

CMSCertification(4years) FullCertification

DHSS(3years) FullCompliance

DOR NoAdverseFindings

EEOC 0Issues

FDAApproval NoAdverseFindings

FLSA 0Issues

IRSCompliance 0Issues

OSHA FullCompliance

UNOS/OPTN(3years) MemberinGoodStanding

UnblemishedPerformance

Figure 7.4-4: External Financial Audit

Year External Auditor Determination






ExcellentFiscalAccountability





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7.4a(4) ThenatureofLOTS’sbusinessrequiresthattheorganizationlivesitscorevalueofhonestyanddemonstratessocialresponsibilityasindicatedbykeymetricsrelatedtoethicalbehavior.Inaddition,100%oftheBOD,LT,andworkforcecompleteannualconflict-of-interestdocumentation.EthicalbehaviorisensuredbyprovidingannualCCPtrainingtoallemployees.Currently,100%oftheworkforceandboardisCCP-trained.LimitedcorporatecomplianceissuesarenotedinReportofCorporateComplianceHotlineIssues(Figure 7.4-6), whichillustratesprogrameffectiveness.

Stakeholder(BOD)requirementsshowahighlevelofsatisfac-tion(Figure 7.4-5)basedontheBODevaluationoftheCEO’sperformance.Similarly,trustinleadership(CEO)bytheBODconsistentlymeetsorexceedstheorganizationalgoalof2.5ona3-pointscale(Figure 7.4-7).

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7.4a(4) ThenatureofLOTS’sbusinessrequiresthattheorganizationlivesitscorevalueofhonestyanddemonstratessocialresponsibilityasindicatedbykeymetricsrelatedtoethicalbehavior.Inaddition,100%oftheBOD,LT,andworkforcecompleteannualconflict-of-interestdocumentation.EthicalbehaviorisensuredbyprovidingannualCCPtrainingtoallemployees.Currently,100%oftheworkforceandboardisCCP-trained.LimitedcorporatecomplianceissuesarenotedinReportofCorporateComplianceHotlineIssues(Figure 7.4-6), whichillustratesprogrameffectiveness.

Stakeholder(BOD)requirementsshowahighlevelofsatisfac-tion(Figure 7.4-5)basedontheBODevaluationoftheCEO’sperformance.Similarly,trustinleadership(CEO)bytheBODconsistentlymeetsorexceedstheorganizationalgoalof2.5ona3-pointscale(Figure 7.4-7).

Figure 7.4-6: Reported Corporate Compliance Hotline Issues

Year Results

2014 0ComplaintsReported

2015 0ComplaintsReported

2016 1ComplaintReported



2019YTD 4ComplaintsReported

CommitmenttoIntegrity

Good

7.4a(5) AtruemeasureofsocietalbenefitisthereductionofdeathsonthelocalwaitinglistasLOTSincreasestransplantedorgans;thisdynamictrendhasimpactedthecommunitylivingwithintheDSA(Figure 7.4-8).

7.4a(5) AtruemeasureofsocietalbenefitisthereductionofdeathsonthelocalwaitinglistasLOTSincreasestransplantedorgans;thisdynamictrendhasimpactedthecommunitylivingwithintheDSA(Figure 7.4-8).NIST Training Draft

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7.5 Financial, Market, and Strategy Results7.5a Financial and Market Results7.5a(1) LOTS’sfinancialperformanceisbenchmarkedbyevaluatingkeymeasureswithinOPOfinancialsurveysconductedbyAOPO.LOTSutilizesthesurveystoexamineitsoverallfinancialcondition.TheorganizationalgoalistoassesswhetherLOTS’sfinancialandoperatingstatusareimprovingovertimeandagainstbenchmarks.LOTSalsousesbudgetstooptimizeoutcomesandcontinuebeingaleaderintheindustry.

ConsolidatedResultsofOperations(Figure 7.5-1)demon-stratesthatLOTSisinastrongpositionwithgoodperfor-mancelevelscomparedtobudget,with2018organizationalresultsof$3.36million.LOTSdemonstratesfavorablefinan-ciallevelsinseveralfinancialmeasuresutilizingtheAOPOtop-quartilebenchmarkincludinggrossrevenue(Figures 7.5-2, 7.5-2A, and 7.5-2B),OperatingMargin(Figure 7.5-3),

NetMargin(Figure 7.5-4),DaysinAccountsReceivable(Figure 7.5-5),DaysinAccountsPayable(Figure 7.5-6),CurrentRatioofAssetsversusLiabilities(Figure 7.5-7),andDaysCashonHand(Figure 7.5-9).TheseresultsreflectLOTS’sidentifiedstrategicadvantageofpossessingastrongfinancialpositionandsupportorganizationalsustainability.

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OperatingReserves(Figure 7.5-8)includescash,investments,andaccountsreceivable.TheamountofoperatingreservesissetbyBODpolicyandallowsLOTStoensuremissionattain-mentandorganizationalsustainability.LOTSsetsthestandardasTissueTransformationsbest-in-classperformer.

TotalAssets(Figure 7.5-10)indicatesLOTS’ssustainabilityandstrongfinancialposition.Performanceshowsbest-in- classresults.LOTS’sstrongfinancialandoperatingreturnsdemonstrateviabilityandcontinuetoimproveovertime.Overallfinancialperformancemeasurementsaresimilar,exceedingindustrycomparisons,andperformwellagainstthebudgetaryplan.

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7.5a(2) AsanonprofitorganizationwithaDSAthatisdesignatedbyCMS,LOTSdoesnotlooktoincreasemarket“share”inthetypicalwaythatothercompaniesdo,butitlookstoimproveitsownperformancewithinitsDSAandtotrackitsprogressviathemeasuresrepresentedinitem7.1.

OrganDonorCostComparison(Figure 7.5-11)demonstratesthedifferenceindonorcostswhendonorsarerecoveredinthetraditionalhospitalsettingversuswhentransferredtotheLOTSfacilityfordonorcareandsurgicalrecovery.EffortstocontaincostsaremeasuredbybudgetspendingtrendsandOACs.OACfeesthathavebeenchargedtothetransplantcenterpartnershavehistoricallybeen(andcontinuetobe)inthelowerquartileofsimilarOPOsatthestrategicdirectionoftheLOTSBOD(Figure 7.5-12).ThecomparisondataforthesechargesarecompiledfromOPOs,typicallywithgeographicproximity,thataremostfrequentlyinvolvedwithorgan-sharingactivitiesimpactingthelocaltransplantcenters.CostcontainmentisanessentialareaforLOTS’stransplantpartnerstoremaincompetitiveinthehealthcarepayermarket.

LimitedbyitsDSA,LOTSknowsthatincreasesintissuedonationsarestillpossiblewithidentificationofneworexpandedreferralsources.Tissueactivitylevelsremainstrong.MarketShareGrowth(Figure 7.5-13)showsLOTS’scontri-butiontothetotalTissueTransformationstissuevolume.

7.5b Strategy Implementation ResultsResultsforaccomplishingtheorganizationalAPsarefoundinFigure 7.4-9.APsareputinplaceeachyearatLOTS,andsuccessinaccomplishingthoseAPsismission-criticalinachievingtheSOs.

ThekeymetricsforstrategyachievementofthemissionincludeDeathsonLocalWaitingList(Figure 7.4-8)andorganandtissuedonorsbypopulation(Figures 7.1-3 and 7.1-4).ResultsforbuildingandstrengtheningtheCCofmission-drivenworkforcearegiveninOverallWorkforceEngagement(Figures 7.3-12 and 7.3-12A).

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LEADERSHIP

STRATEGY

CUSTOMERS

MEASUREMENT, ANALYSIS, AND KNOWLEDGE MANAGEMENT

WORKFORCE

OPERATIONS

RESULTS20192020 www.nist.gov/baldrige

business nonprofitgovernment

BALDRIGE EXCELLENCE FRAMEWORKProven leadership and management practices for high performance

2019–2020 Bald

rige Excellence Framew

ork

The ratio of the Baldrige Program’s benefits

for the U.S. economy to its costs is estimated

at 820 to 1.

110 Baldrige Award winners serve as national

role models.

2010 –2018 award applicants represent

641,693 jobs,

3,072 work sites, over $166 billion in

revenue/budgets, and about 451 million

customers served.

352 Baldrige examiners volunteered

roughly $7.9 million in

services in 2018.

State Baldrige-based examiners

volunteered around $29 million in

services in 2017.

What People Are Saying

I have always envisioned Stellar to be a company that is built to last. . . . And if you ask how we can ensure that we are built to last, I would say the answer is Baldrige.

Celeste Ford CEO and FounderStellar Solutions Palo Alto, CA Baldrige Award recipient

We believe that government can be great. We believe that local government can be great. And we believe that the Baldrige framework is ideally suited to help local government go from here to here[low to high].

Darin AtteberryCity ManagerCity of Fort Collins Fort Collins, CO Baldrige Award recipient

CONNECT WITH BALDRIGE@BaldrigeProgram #Baldrige

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820 to 1 Celeste Ford LifeBridge NIST Organ and Tissue ... · The LifeBridge Organ and Tissue Sharing Case Study is a fictitious Baldrige Award application prepared for use in the

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