DonateLife Network ROLE AND RESPONSIBILITIES GUIDELINES Roles and... · ROLE AND RESPONSIBILITIES GUIDELINES Version 3 – February 2016. ... eye and tissue bank(s), transplantation

DonateLife NetworkROLE AND RESPONSIBILITIES GUIDELINESVersion 3 – February 2016

The 2016-4-18 State and Territory Funding Agreements (the Funding Agreements) reference the DonateLife Network Roles and Responsibilities Guidelines.

According to the Funding Agreements, all Jurisdictions are required to maintain an agreed organ and tissue donation service delivery model for the implementation of the national reform program to deliver a world’s best practice approach to organ and tissue donation for transplantation.

The document serves as a general guide to the roles and responsibilities of positions within the DonateLife Network. It articulates the functions and deliverables of the DonateLife Network in each Jurisdiction within a consistent national approach. It is provided to guide development of position descriptions that are appropriate to each Jurisdiction’s operating environments.

As a generic document, it is unable to reflect every variance within these operating environments. It is accepted that there are differing staff profiles across Jurisdictions, including some variation in the allocation of responsibilities between roles that reflect the different operating systems within each Jurisdiction.

PREFACE

1

DonateLife Network Roles and Responsibilities Guidelines

State/Territory Medical Director of Organ and Tissue Donation 2

Donation Specialist Medical 5

Donation Specialist Nursing 8

Organ and Tissue Donation Operations Manager 12

Organ and Tissue Donation Clinical Manager 15

Organ and Tissue Donation Agency Manager 18

Donation Specialist Coordinator 20

Donation Specialist Nursing Coordinator 24

Donor Family Support Coordinator 29

Education Coordinator 31

National Training Coordinator 33

Communications Coordinator 35

Data and Audit Officer 37

Electronic Donor Record (EDR) Trainer 40

Electronic Donor Record (EDR) System Administrator 42

Administrative Officer 44

Appendix A: CPIP Phase 2 Key Performance Indicators (KPIS) 46

TABLE OF CONTENTS

2

Version 3 – February 2016

STATE/TERRITORY MEDICAL DIRECTOR OF ORGAN AND TISSUE DONATION

This document functions as a general guide to the role and responsibilities of the position and is provided to inform the development of position descriptions. Additionally, the key performance outcomes and measures articulate the expected areas of focus and outcomes for the position. It is the role of the Jurisdiction to develop and manage the position description and incumbent according to the key performance measures.

Accountability

A State/Territory Medical Director of Organ and Tissue Donation (State/Territory Medical Director) is employed in all Jurisdictions.

The State/Territory Medical Director is an employee of the State/Territory health department or health service/agency as applicable and is accountable to an executive member of the State/Territory health department or health service as applicable and may not necessarily be based in a hospital.

Recruitment

The National Medical Director of the Organ and Tissue Authority (OTA) is involved in the selection of the State/Territory Medical Director.

Responsibilities

The State/Territory Medical Director oversees organ and tissue donation processes and ensures consistency of practice within the Jurisdiction. The position liaises with, and reports to the Chief Executive Officer and the National Medical Director of the OTA on jurisdictional performance.

Specifically within the context of the Clinical Practice Improvement Program (CPIP) Phase 2 and the DonateLife Collaborative (DLC), the position is responsible and accountable for:

• Managing and monitoring implementation of the national reform program, including the agreed strategic plan and annual priorities, by the jurisdictional DonateLife Network

• Leading the jurisdictional DonateLife Network, including maintaining ultimate responsibility for operational and financial management

• Providing expert advice regarding organ and tissue donation processes and practice within the Jurisdiction

• Ensuring there are systems and processes in place to support hospital staff in the implementation, measuring and reporting of the CPIP, including the development of Hospital Activity Plans (HAP) and the DLC

• Facilitating the jurisdictional information and communication technology platform which supports the delivery and ongoing engagement in the use of the Electronic Donor Record (EDR), the DonateLife Audit and the DonateLife Extranet (Connect)

• Implementing, monitoring and evaluating the DonateLife Audit and the EDR in the Jurisdiction, including standardised adoption of endorsed clinical and administrative policies and protocols, and relevant education and professional programs

• Leading the implementation of the Australian best-practice request and consent model for organ and tissue donation for transplantation (best-practice consent model)

• Attending the core and practical Family Donation Conversation (FDC) workshops and ensuring all donation specialist staff attend the FDC workshops and meet repeat attendance requirements (according to Appendix A)

• Jurisdictional reporting against mutually agreed performance targets and goals using standardised reporting processes (according to Appendix A)

• Liaising with jurisdictional and interstate stakeholders in eye and tissue bank(s), transplantation teams, retrieval teams and other sectors as necessary to achieve common goals

• Leading engagement with all hospital executive and other key stakeholders in the Jurisdiction (see Appendix A).

Essential qualifications/experience

Current registration with the Australian Health Practitioner Regulation Agency (AHPRA) as a medical practitioner.

Experience undertaking a leadership position with delivered outcomes.

Desirable qualifications/experience

Experience and/or specialist qualifications in the organ and tissue donation sector.

3


State/Territory Medical Director Key performance outcomes and measures

KEY PERFORMANCE OUTCOMES PERFORMANCE MEASURES

Provide leadership to the Jurisdiction’s DonateLife Network including ultimate responsibility for operational and financial management

Participation in the negotiation of the funding agreements with the OTA

Regular and timely reporting to the OTA on jurisdictional issues relevant to the services funded by the OTA, including organ and tissue donation and transplantation activities, and performance and outcomes; and against the elements described in the funding agreements

Ensure there are systems in place for the implementation, measuring and reporting of the HAP, CPIP and DLC (see Appendix A)

Progress reports and progress meetings with the OTA demonstrate that there are systems in place for the implementation, measuring and reporting of the HAP, CPIP and DLC (see Appendix A)

Be the main point of contact regarding organ and tissue donation processes and practice within the Jurisdiction

Regular meetings with policy officers and senior medical personnel from the jurisdictional health or human services department

Participate in the preparation of briefs for senior health officials and ministers as required

Communicate with the public and private sector on behalf of the DonateLife Network and the OTA

Available for media requests and community consultation/engagement on organ and tissue donation issues

Implement, monitor and evaluate the DonateLife Audit and EDR (including any EDR system changes to accommodate the eye and tissue EDR modules) in the Jurisdiction (see Appendix A)

The DonateLife Audit and EDR are implemented and maintained in relevant DonateLife Network hospitals in the Jurisdiction in accordance with agreed national policies and protocols (see Appendix A)

Training programs are in place to support consistent use of the DonateLife Audit and the EDR

Implement, monitor and evaluate the best-practice consent model

Attend the core and practical FDC workshops and repeat attendance at the practical FDC every two years

Ensure all donation specialist staff attend – at a minimum – the core FDC training (as soon as possible after recruitment) and the practical FDC every two years

All family donation conversations are managed in accordance with the best-practice consent model

Documented evidence of attendance at the core and practical FDC workshops

100% of donation specialist staff attend FDC training and meet repeat attendance requirements

The following table details the specific key performance outcomes and measures as they relate to the roles and responsibilities described above.

4



Liaise with relevant staff, validate nationally agreed data related to the organ donation process and identify factors that limit donor retrieval or organ quality

Accurate completion of all data collection and validation of data e.g. DonateLife Audit with submission to the OTA within 1 month of peer review meeting

Completion of EDR donor cases and upload of data to the ANZOD within agreed timeframes

Development of mitigating strategies to address identified risks

Oversee organ and tissue donation referral, coordination and retrieval processes

Oversight and performance assessment of the entire donation process with collection and reporting of specific outcome measures related to donor management, logistical coordination, retrieval and referral of organs, relevant procurement, surgical audit and process metrics required by transplantation programs to reflect recipient outcomes

Participate in a national network of State/Territory Medical Directors under the leadership of the OTA

At least 75% attendance at jurisdictional Advisory Group and Clinical Governance Committee meetings in person or via teleconference

Work with the OTA and the Jurisdiction to integrate eye and tissue banks into the DonateLife Network

Regular liaison with managers and staff of eye and tissue banks to develop strategies and processes to increase eye and tissue donation that align with national strategies

State/Territory Medical Director | Key performance outcomes and measures (continued)

5


DONATION SPECIALIST MEDICAL


Accountability

The Donation Specialist Medical is an employee of State/Territory health department or health service as applicable and is accountable to:

• a senior administrator (e.g. hospital CEO, Medical Director) on a daily operational basis

• the State/Territory Medical Director (SMD) in an organ and tissue donation program capacity, including performance and compliance with the national framework

Recruitment

The SMD is involved in the recruitment process.

Responsibilities

The Donation Specialist Medical is responsible and accountable for the end-to-end process to optimise organ and tissue donation for transplantation in their hospital.

The Donation Specialist Medical position is responsible for systems that ensure:

• 100% of potential deceased donors are properly recognised and evaluated, and the opportunity for donation is offered;

• Integrated management of the hospital donation process to ensure quality and national consistency of all procedures from donor identification to organ retrieval;

• Organ and tissue donation is discussed with families in accordance with the best-practice consent model.

Specifically, within the context of the Clinical Practice Improvement Program (CPIP) and the DonateLife

Collaborative (DLC), the Donation Specialist Medical is responsible for:

• Championing the use of nationally consistent clinical triggers to improve the identification of potential organ and tissue donors

• Supporting implementation of the best-practice consent model and championing the model through active team planning, team debriefing and auditing

• Attending the core and practical Family Donation Conversation (FDC) workshops and meeting repeat attendance requirements (according to Appendix A)

• Facilitating organ and tissue donation by working with hospital teams to ensure that 100% of potential donors are identified and to optimise actual donations

• Implementing, monitoring and evaluating the CPIP/DLC in their hospital

• Educating medical, nursing and allied health staff in intensive care units (ICUs), emergency departments (EDs), operating theatres (OTs), the health service and the local community as a whole in accordance with programs as agreed by the DonateLife Network

• Liaising between ICUs, EDs, DonateLife Agency staff, eye and tissue banks, transplant and retrieval teams and private hospitals, to manage barriers to organ and tissue donation

• Reporting against the performance targets and goals as agreed by the DonateLife Network using standardised reporting processes (according to Appendix A)

• Leading evidence-based clinical practice improvements related to organ and tissue donation

• Supporting and monitoring data collection and validation in their hospital.


Current registration with AHPRA as a medical practitioner.

A specialist medical qualification in a relevant specialty e.g. ICU, ED, anaesthesia, surgery.


Experience in a leadership role with demonstrated outcomes.

6


Donation Specialist Medical Key performance outcomes and measures


Ensure there are systems and processes in place for the implementation, measuring and reporting of the Hospital Activity Plan (HAP), CPIP and DLC at the hospital level (see Appendix A)

CPIP surveys and progress reports/meetings with the DonateLife Network leadership demonstrate that there are systems in place for the implementation, measuring and reporting of the HAP, CPIP and DLC at the hospital level (see Appendix A)

Six monthly CPIP surveys are completed and submitted within agreed timeframes

Work with core hospital team of Donation Specialist Medical, Donation Specialist Nursing, Donation Specialist Coordinator, and Donation Specialist Nursing Coordinator (where applicable) to develop and implement HAPs

Communicate and meet regularly with the core hospital team at the direction of the SMD

Outcomes of meetings reported at scheduled DonateLife Network meetings

Participate in relevant meetings, seminars, conferences and working groups

Documented evidence of attendance and continuing professional development related to organ and tissue donation

Support the implementation of the best-practice consent model and actively encourage adoption of the model at the hospital site

Attend – at a minimum – the core FDC training (as soon as possible after recruitment) and the practical FDC every two years

All FDCs are managed in accordance with the best-practice consent model

Documented evidence of attendance at the core and practical FDC workshops

Provide education and support for hospital units and staff* on organ and tissue donation

Present at hospital-wide forums

Target >80% of staff involved in organ and tissue donation are provided with education

Report of education through established reporting system to the SMD including the number of sessions and participants

Sessions evaluated and reported to the SMD

Report participation to hospital executive

Participate in jurisdictional and national education and training activities and professional development modules

Involvement in all relevant national education and training activities

>80% of jurisdictional DonateLife Network meetings attended (over a 12 month period)

* All hospital staff may include: Donation Specialist Medical, Donation Specialist Nursing, Donation Specialist Coordinator, Donation Specialist Nursing Coordinator and relevant staff from other areas for example: ICU, ED, OT, neurosurgery, neurology, executive, clinical governance unit, palliative care, eye and tissue, transplant units, social work, aboriginal liaison, pastoral care and volunteers


7



Participate in peer meetings, seminars, conferences across the DonateLife Network

Documented evidence of ongoing professional development related to organ and tissue donation

Support the collection and validation of DonateLife Audit and EDR data according to the national processes

All DonateLife Audit and EDR processes completed accurately within agreed timeframes

Participate in case review meetings scheduled regularly at the direction of the SMD

>80% of inter-hospital case review meetings attended by Donation Specialist Medical (over a 12 month period)

Reconcile and submit case data reviewed at case review meeting within 1 month

Provide medical support for Donation Specialist Coordinators and DonateLife Agency

Where requested by the SMD, participate in on-call roster to provide advice to Donation Specialist Coordinators and DonateLife Agency about medical suitability and support to resolve logistical barriers

Ensure implementation of protocols for the identification, routine request and referral of eye and tissue donors in hospitals as appropriate to the relevant agency

Number of referrals and donors recorded through established reporting system to the SMD

8


DONATION SPECIALIST NURSING

This document functions as a general guide to the role and responsibilities of the position and is provided to inform the development of position descriptions within relevant Jurisdictions. Additionally, the key performance outcomes and measures articulate the expected areas of focus and outcomes for the position. It is the role of the Jurisdiction to develop and manage the position description and incumbent according to the key performance measures.

Accountability

The Donation Specialist Nursing is an employee of the State/Territory health department or health service as applicable and is accountable to:

• a senior administrator (e.g. hospital Director of Nursing or senior nurse in a relevant unit) on a daily operational basis;

• the Operations/Clinical/Agency Manager in an organ and tissue donation program capacity, including performance and compliance with the national framework and professional matters; and

• ultimately to the State/Territory Medical Director (SMD).

Recruitment

The Clinical Manager or delegate must participate in recruitment.

Responsibilities

The Donation Specialist Nursing is responsible for raising awareness of, and providing educational services on organ and tissue donation for all medical, nursing and allied health staff that come into contact with the donation process. The position also works with hospital teams and DonateLife Network staff to identify and convert potential organ donors to actual donors.

Specifically, within the context of the Clinical Practice Improvement Program (CPIP) and the DonateLife Collaborative (DLC), the Donation Specialist Nursing is responsible for:

• Championing the use of nationally consistent clinical triggers to improve the identification of potential organ and tissue donors in their hospital

• Facilitating organ and tissue donation by working with hospital teams to ensure that 100% of potential donors are identified and to optimise actual donors

• Implementing, monitoring and evaluating the CPIP/DLC in their hospital

• Supporting the implementation of the best-practice consent model and actively encouraging adoption of the model at the hospital level


• Ensuring that all families of potential and actual organ and/or tissue donors receive the support they need consistent with the National DonateLife Family Support Service (NDFSS) Guidelines

• Educating medical, nursing and allied health staff in intensive care units (ICUs), emergency departments (EDs), operating theatres (OTs), the health service and the local community in accordance with programs as agreed by the DonateLife Network

• Providing education and support to community-based activities

9


• Liaising between ICUs, EDs, OTs, DonateLife Agency staff, eye and tissue banks, transplant and retrieval teams and private hospitals, implementing strategies to improve systems to support increasing donation rates and to manage barriers to organ and tissue donation

• Where applicable, demonstrating/maintaining competency in the use of the Electronic Donor Record (EDR) including an understanding of the Acceptable Use Policy and breach notification processes

• Collecting data and reporting against the performance targets and goals set by the Organ and Tissue Authority (OTA) using standardised reporting processes (according to Appendix A)

• Implementing evidence-based clinical practice improvements related to organ and tissue donation

• Collecting and reporting data on hospital deaths for input to the DonateLife Audit.


Current registration with AHPRA as a Division 1 Registered Nurse with at least five years post registration experience and ideally at least three years of experience in the relevant specialty fields e.g. ICU, ED, OT and/or transplant units


Post registration qualifications in a specialty field relevant to organ and tissue donation

10


Donation Specialist Nursing Key performance outcomes and measures


Ensure there are systems and processes in place for the implementation, measuring and reporting of the Hospital Activity Plan (HAP), CPIP and DLC at the hospital level (see Appendix A)

CPIP surveys and progress reports/meetings with the DonateLife Network leadership demonstrate that there are systems and processes in place for the implementation, measuring and reporting of the HAP, CPIP and DLC at the hospital level (see Appendix A)

The HAP is developed and used to guide clinical practice improvement.

Six monthly reports/CPIP surveys are completed and submitted within agreed timeframes

Support and focus the DonateLife Network and clinical staff to meet national targets for request, consent and organ donation rates as identified in the DonateLife Audit Standard Operating Procedure and User Guide and the CPIP HAP

DonateLife Network and clinical staff are supported and focussed on meeting the targets as identified in the DonateLife Audit Standard Operating Procedure and User Guide and the CPIP HAP

Support the implementation of the FDC best-practice model and contribute to the promotion, adoption and evaluation of the model

Attend – at a minimum – the core FDC training (as soon as possible after recruitment) and the practical FDC every two years

All FDCs are managed in accordance with the best-practice consent model

Documented evidence of attendance at core and practical FDC workshops

Work with core hospital team of Donation Specialist Medical, Donation Specialist Nursing, Donation Specialist Coordinator, and Donation Specialist Nursing Coordinator (where applicable) to develop and implement HAPs

Communicate and meet regularly with the core hospital team at the direction of the SMD

Documentation of meetings and meetings reported at scheduled SMD/Donation Specialist Medical meetings


Documented evidence of attendance and ongoing professional development related to organ and tissue donation

Educate hospital staff* involved in organ and tissue donation for transplantation.



Report of education through established reporting system to the SMD including the number of sessions and participants

Sessions evaluated and reported to the SMD

Report participation to hospital executive


* Hospital staff may include: Donation Specialist Medical, Donation Specialist Nursing, Donation Specialist Coordinator, Donation Specialist Nursing Coordinator and relevant staff from other areas for example: ICU, ED, OT, neurosurgery, neurology, executive, clinical governance unit, palliative care, eye and tissue, transplant units, social work, aboriginal liaison, pastoral care and volunteers

11



Provide hospital and community education sessions about organ and tissue donation for transplantation, including clinical triggers, DCD and other donation-related matters

Number of sessions and participants recorded

Sessions evaluated and reported according to agreed jurisdictional processes

Participate in jurisdictional and national education and training activities and professional development sessions


>80% of DonateLife Network meetings attended (over a 12 month period)


Documented evidence of ongoing professional development related to organ and tissue donation

Support the collection and validation of DonateLife Audit and EDR data according to the national processes

All DonateLife Audit and EDR processes are completed in a timely and accurate manner

Attend case review meetings scheduled regularly at the direction of the SMD

>80% of inter-hospital case review meetings attended (over a 12 month period)

Reconcile and submit case data reviewed at case reviews meeting within 1 month

Implement protocols for the identification, routine request and referral of eye and tissue donors in hospitals as appropriate to the relevant agency


Provide donor family support according to the National DonateLife Family Support Service (NDFSS) Framework

NDFSS Framework provided and utilised

Where applicable, demonstrate/maintain competency in the use of the EDR including an understanding of the Acceptable Use Policy and breach notification processes

Where applicable:

Undertake the required training needed to demonstrate competency in the use of the EDR

Maintain competency in the use of the EDR through utilisation of the EDR training instance

Adhere to the Acceptable Use Policy and breach notification processes

12


ORGAN AND TISSUE DONATION OPERATIONS MANAGER

This document functions as a general guide to the role and responsibilities of the position and is provided to inform the development of position descriptions within relevant Jurisdictions. Additionally, the key performance outcomes and measures articulate the expected areas of focus and outcomes for the positions. It is the role of the Jurisdiction to develop and manage the position description and incumbent according to the key performance measures.

Accountability

The Organ and Tissue Donation Operations Manager (Operations Manager) is an employee of State/Territory health department or health service/agency as applicable and works to ensure the efficient management of DonateLife Network operations through delegations from the State/Territory Medical Director (SMD).

Recruitment

A Senior Executive of the Organ and Tissue Authority (OTA) is involved in the selection of the Operations Manager.

Responsibilities

Specifically, within the context of the Clinical Practice Improvement Program (CPIP) and the DonateLife Collaborative (DLC), the position is responsible and accountable for:

• Developing and managing the business, financial and operational functions of the DonateLife Network to ensure delivery of an integrated and effective service

• Providing key support to the SMD in providing leadership, and strategic and operational management of the service

• Coordinating the provision of timely reporting according to the requirements of the State and Territory funding agreements

• Supporting the development and implementation of strategic and business plans and operational policies and procedures within the context of the national strategic plan

• Working with the SMD to manage risks, resolve complex problems and improve the quality and performance of the organisation and its services

• Managing staff, the day to day running of the various administrative duties including the management of budgets, financial and performance reporting, human relations and any other infrastructure support services required to ensure the efficient delivery and operations of

the service

• Assuming responsibility for the environmental and occupational health and safety management of the DonateLife Agency

• Managing maintenance of the jurisdictional information and communication technology platform to support the delivery and ongoing engagement in the use of the Electronic Donor Record, the DonateLife Audit and the DonateLife Extranet (Connect)

• Supporting the SMD in ensuring there are systems and processes in place to support hospital staff in the implementation, measuring and reporting of the CPIP/Hospital Activity Plan (HAP)

• Implementing, monitoring and evaluating the DonateLife Audit and the Electronic Donor Record (EDR) in the Jurisdiction, including standardised adoption of endorsed clinical and administrative policies and protocols, and relevant education and professional programs


• Supporting the SMD to ensure all donation specialist staff attend the core and practical FDC workshops and meet repeat attendance requirements

• Ensuring compliance with all relevant Commonwealth and State legislation, standards and guidelines as appropriate

• Jurisdictional reporting against mutually agreed performance targets and goals using standardised reporting process (according to Appendix A)

• Developing and maintaining productive relationships with the OTA, the national DonateLife Network and other groups, including relevant industry, professional and government entities

• Leading cultural change to ensure development of systems to support the increase in donation and implementation of the national reform program

• With the SMD, engaging with hospital executive and other key stakeholders in the Jurisdiction (see Appendix A).


Business and managerial qualifications and experience with demonstrated outcomes in a complex setting.

Health-related qualification and experience in a complex health setting.

13


Organ and Tissue Donation Operations Manager Key performance outcomes and measures


Provide leadership to the Jurisdiction’s DonateLife Network including ultimate responsibility for operational and financial management

Manage the operations and business practices of the DonateLife Network including providing leadership, strategic direction, support and advice


Work with the SMD to mitigate any risks to the services provided by the DonateLife Network

Risk mitigation processes are in place, able to be followed and are measured

Communicate with the public and private sector on behalf of the DonateLife Network as required

Available for media requests and community consultation and participation in relevant DonateLife activities

Provide reporting as required by the State and Territory funding agreements and as requested

Timely and informative reports provided as required by the State and Territory funding agreements and as requested

Ensure there are systems and processes in place for the implementation, measuring and reporting of the HAP, CPIP and DLC (see Appendix A)

Management of operations and business functions of the DonateLife Network according to terms of the state and territory funding agreement

Attend the core FDC training (as soon as possible after recruitment) and the practical FDC every two years



Manage maintenance of the jurisdictional information and communication technology platform

Jurisdictional ICT reliably supports the delivery and ongoing engagement in the use of the EDR, the DonateLife Audit and the DonateLife Extranet (Connect)

Implement, monitor and evaluate the DonateLife Audit and EDR (including any EDR system changes to accommodate the eye and tissue EDR modules) in the Jurisdiction (see Appendix A)


Liaise with relevant staff to validate nationally agreed data related to the organ donation process to identify factors that limit donor retrieval or organ quality

Accurate completion of all data collect and validation of data e.g. DonateLife Audit with submission to the OTA within one month of peer review meeting




14



Support peer review meetings/DonateLife Network meetings to review cases, monitor adverse events and educate colleagues

Support the facilitation of DonateLife Network meetings at least bi-monthly, attending >80% each year

Support the oversight of organ and tissue donation referral, coordination and retrieval processes

Support the oversight and performance assessment of the entire donation process with the collection and reporting of specific outcome measures related to donor management, logistical coordination, retrieval and referral of organs, supporting procurement, surgical audit and process metrics required by transplantation programs to reflect recipient outcomes

Work with the SMD, the OTA and the Jurisdiction to integrate the eye and tissue banks into the DonateLife Network

Support the regular liaison with managers and staff of eye and tissue banks to develop strategies and processes to increase eye and tissue donation that align with national strategies

Provide advice to the OTA on matters of clinical relevance to the DonateLife Network

Regular attendance at Clinical Governance Committee meetings

Organ and Tissue Donation Operations Manager | Key performance outcomes and measures (continued)

15


ORGAN AND TISSUE DONATION CLINICAL MANAGER

This document functions as a general guide to the role and responsibilities of the position and is provided to inform the development of jurisdictional position descriptions within relevant Jurisdictions. Additionally, the key performance outcomes and measures articulate the expected areas of focus and outcomes for the position. It is the role of the Jurisdiction to develop and manage the position description and incumbent according to the key performance measures.

Accountability

The Clinical Manager is an employee of State/Territory health department or health service as applicable and is accountable to the State/Territory Medical Director (SMD) and Operations Manager (according to the jurisdictional structure) for the provision of hospital-based services across the DonateLife Network.

Recruitment

A Senior Executive of the Organ and Tissue Authority (OTA) is involved in the selection of the Clinical Manager.

Responsibilities

Specifically, within the context of the Clinical practice Improvement Program (CPIP) and the DonateLife Collaborative (DLC), the position is responsible and accountable for:

• Managing the clinical and/or hospital-based services of the DonateLife Network to effect clinical practice improvements

• Providing expert advice, direction and oversight to the delivery of clinical services

• Promoting, developing and supporting clinical and other staff for whom they are responsible to realise their professional potential and effect clinical practice improvement

• Providing key support to the SMD and Operations Manager in providing services across the DonateLife Network

• Contributing to the provision of timely reporting according to the requirements of the State and Territory funding agreements

• Assisting with the development and implementation of strategic and business plans and operational policies and procedures within the context of the national strategic plan

• Working with the Operations Manager (according to the jurisdictional structure) and the SMD to identify and manage risks, resolve complex problems and improve the quality and performance of the clinical services across the DonateLife Network

• Supporting the DonateLife leadership in ensuring there are systems and processes in place to support hospital staff in the implementation of the CPIP and the Hospital Activity Plan (HAP)

• Managing and supporting the implementation of the CPIP/DLC in jurisdictional hospitals

• Leading the implementation of the best-practice consent model

• Attending the core and practical Family Donation Conversation (FDC) workshops and ensuring all donation specialist staff attend the FDC workshops and meet repeat attendance requirements (according to Appendix A)

• Ensuring the EDR and the DonateLife Audit are utilised in accordance with agreed clinical and administrative polices and protocols

• Contributing to jurisdictional reporting against mutually agreed performance targets and goals using standardised reporting processes (according to Appendix A)

• Supporting effective liaison between the DonateLife Agency and hospital based staff

• With the DonateLife Network leadership, engaging with hospital executive and other key stakeholders in the Jurisdiction (see Appendix A)

• Ensuring compliance with all relevant Commonwealth and State legislation, standards and guidelines, etc. as they relate to clinical governance



Current registration with AHPRA as a Division 1 Registered Nurse.

Previous experience in a complex health environment in a leadership/senior role.

Clinical and managerial qualifications.

16


Organ and Tissue Donation Clinical Manager Key performance outcomes and measures


Manage the DonateLife Network clinical team providing leadership, strategic direction, professional support and advice according to the terms of the funding agreement

100% of clinical staff comply with relevant state and territory funding agreement requirements

Communicate with the public and private sector on behalf of the DonateLife Network as required

Documented evidence of engagement with the clinical and public community, availability for media requests and community consultation and participation in relevant DonateLife activities, as required

Report to the SMD and Operations Manager on any matters that impact on the clinical services funded by the OTA

SMD and Operations Manager advised of any matters that impact on the clinical services funded by the OTA within agreed timeframes

Provide timely and informative reporting as required by the State and Territory funding agreements and as requested

Reports provided as required by the State and Territory funding agreements and as requested

Manage the implementation of the CPIP and DLC and the delivery of clinical services of the DonateLife Network

CPIP and DLC implemented, measured and reported in accordance with locally developed systems.

Clinical services delivered to the DonateLife Network


CPIP reports are used to inform discussion with hospital-based staff regarding strategies to improve clinical practice







Implement, monitor and evaluate the DonateLife Audit and EDR in the Jurisdiction (including any EDR system changes to accommodate the eye and tissue EDR modules) (see Appendix A)



17



Liaise with relevant staff, validate nationally agreed data related to the organ donation process to identify factors that limit donor retrieval or organ quality

Accurate completion of all data collection and validation of data e.g. DonateLife Audit with submission to the OTA within one month of peer review meeting








75% attendance at Clinical Governance Committee meetings in person or by teleconference

18


ORGAN AND TISSUE DONATION AGENCY MANAGER

This document functions as a general guide to the role and responsibilities of the position and is provided to inform the development of position descriptions within relevant Jurisdictions. Additionally, the key performance outcomes and measures articulate the expected areas of focus and outcomes for the positions. It is the role of the Jurisdiction to develop and manage the position description and incumbent according to the key performance measures.

Accountability

The Agency Manager is an employee of the State/Territory health department or health service as applicable and is accountable to the State/Territory Medical Director (SMD) to ensure the efficient management of DonateLife Network operations.

Recruitment

A Senior Executive of the Organ and Tissue Authority (OTA) is involved in the selection of the Agency Manager.

Responsibilities

Specifically, within the context of the Clinical Practice Improvement Program (CPIP) and the DonateLife Collaborative (DLC), the position is responsible and accountable for:

• Managing the business and operational functions, including clinical services, of the DonateLife Network to ensure delivery of an integrated and effective service

• Providing key support to the SMD in providing leadership, direction and operational management to the DonateLife Network

• Facilitating the professional leadership of staff, including leadership of the development, implementation and review of local operational service plans

• Assuming responsibility for the environmental and occupational health and safety management of the DonateLife Agency

• Assisting with the development and implementation of strategic and business plans and operational policies and procedures within the context of the national strategic plan

• Contributing practical and innovative recommendations to the SMD to manage risks, resolve complex problems and improve the quality and performance of the organisation and its services

• Supporting the SMD in ensuring there are systems and processes in place to support hospital staff in the implementation, measuring and reporting of the Hospital Activity Plan (HAP), CPIP and the DLC

• Implementing, monitoring and evaluating the DonateLife Audit and the Electronic Donor Record (EDR) in the Jurisdiction, including standardised adoption of endorsed clinical and administrative policies and protocols, and relevant education and professional programs

• Jurisdictional reporting against mutually agreed performance targets and goals using standardised reporting processes (according to Appendix A)

• Providing expert advice, clinical direction and oversight to the delivery of clinical services to effect clinical practice improvement

• Promoting, developing and supporting clinical staff to realise their professional potential

• Ensuring effective liaison between the DonateLife Agency and hospital-based staff

• With the SMD, engaging with hospital executive and other key stakeholders in the Jurisdiction (see Appendix A)

• Ensuring compliance with all relevant Commonwealth and State legislation, standards and guidelines, etc. as appropriate


• Leading the implementation of the best-practice consent model

• Attending the core and practical Family Donation Conversation (FDC) workshops and ensuring all donation specialist staff attend the FDC workshops and meet repeat attendance requirements (according to Appendix A).


Previous experience in a complex health environment in a leadership/senior role.

Clinical and managerial qualifications.

19


Organ and Tissue Donation Agency Manager Key performance outcomes and measures


Ensure there are systems in place for the implementation of, measuring and reporting of the HAP/CPIP and DLC (see Appendix A)

Manage the operations and business practices of the DonateLife Network including providing leadership, strategic direction, support and advice

Management of operations and business functions of the DonateLife Network according to terms of the state and territory funding agreement


Implement, monitor and evaluate the CPIP/DLC, DonateLife Audit and Electronic Donor Record in the Jurisdiction, including any EDR system changes to accommodate the eye and Tissue EDR modules (see Appendix A)

The CPIP/DLC, DonateLife Audit and EDR are implemented and maintained in relevant DonateLife Network hospitals in the Jurisdiction in accordance with agreed national policies and protocols (see Appendix A)

Liaise with relevant staff to validate nationally agreed data related to the organ donation process to identify factors that limit donor retrieval or organ quality

Accurate completion of data collected and validation of data e.g. DonateLife Audit with submission to the OTA within one month of peer review meeting





Support the oversight of organ and tissue donation referral, coordination and retrieval processes










Provide reporting as required by the State and Territory funding agreements and as requested

Timely and informative reports provided as required by the State and Territory funding agreements and as requested


75% attendance at Clinical Governance Committee meetings in person or via teleconference


20


DONATION SPECIALIST COORDINATOR


Accountability

The Donation Specialist Coordinator is an employee of the State/Territory health department or health service as applicable and is accountable to the State/Territory Medical Director (SMD) reporting to the Operations/Clinical/Agency Manager (depending upon the Jurisdiction).

Responsibilities

Specifically, within the context of the Clinical Practice Improvement Program (CPIP), the Donation Specialist Coordinator facilitates organ and tissue donation by:

• Working closely and collaboratively with DonateLife Network staff, as well as hospital staff to facilitate the process of organ donation and retrieval from deceased donors

• Receiving notification of potential donors

• Completing patient medical and social history

• Coordinating the surgical retrieval team/s to undertake surgical retrieval of organs

• Coordinating tissue typing and serology of the potential donor

• Managing the offer of retrieved organs to the transplant team(s)

• Referring eye and tissue donors to the eye and tissue banks

• Assisting the Donation Specialist Medical, Donation Specialist Nursing and/or treating staff with family liaison or facilitating the consenting process

• Contributing to the family donation conversation (FDC) in accordance with the best-practice consent model

• Attending the core and practical FDC workshops and meeting repeat attendance requirements (according to Appendix A)

• Assisting the Donation Specialist Medical, Donation Specialist Nursing and/or treating staff in the management of the potential/actual donor to maintain physiological stability

• Working with the Donation Specialist Medical, Donation Specialist Nursing and/or treating staff to provide initial support services in the hospital, consistent with the National DonateLife Family Support Service (NDFSS) Guidelines, and information on transplantation outcomes to donor families, prior to handing over management of ongoing support to the Donor Family Support Coordinator

• Communicating and collaborating with the national DonateLife Network to maximise organ and tissue donation rates

• Collecting and providing data to the Organ and Tissue Authority (OTA) as required

• Participating in, and providing education regarding organ and tissue donation

• Demonstrating/maintaining competency in the use of the Electronic Donor Record (EDR) including an understanding of the Acceptable Use Policy and breach notification processes.


Current registration with AHPRA as a Division 1 Registered Nurse with at least five years post registration experience and preferably 3 years’ experience in a relevant speciality, e.g. ICU.


Post registration qualifications in a specialty field relevant to organ and tissue donation.

21


Donation Specialist Coordinator Key performance outcomes and measures


Receive referral of potential donors Referral recorded and reported to DonateLife Network management as appropriate

Confirm the Australian Organ Donor Register (AODR) has been accessed to establish if a potential donor has registered consent or objection to donating organs and/or tissues for transplantation

AODR accessed for 100% of referred potential donors

Assess in consultation with hospital staff and Donation Specialist Medical/Donation Specialist Nursing (or by other processes as determined by the SMD and agreed by the DonateLife Network) the medical suitability of potential donors (including advising on relevant investigations)

100% of referred potential donors assessed for medical suitability

Liaise with Donation Specialist Medical/Donation Specialist Nursing and ICU specialists regarding physiological management of potential donors.

Support and advice provided to ensure that all potential donors receive appropriate physiological management consistent with the national guidelines

Implement the best-practice model and contribute to the promotion, adoption and evaluation of the model.




Provide support and information to donor families throughout the donation process to meet the needs of the family

All families provided with adequate support and information throughout the donation process as directed by the family

Provide information and support to the Donor Family Support Coordinator to meet the bereavement counselling needs of the family as required

All families offered bereavement counselling as requested by the family

Offer and facilitate viewing of the body by family following donation

All families offered viewing of the body following donation as directed by the family

Follow up with donor families to inform them regarding the outcomes of their donation

Support the Donor Family Support Coordinator with provision of follow up according to the NDFSS Framework

In consultation with the Donation Specialist Medical, Donation Specialist Nursing and hospital staff, discuss organ donation with, and/or request consent for donation from, potential donor families

Organ donation discussed with, and/or consent requested for donation from, potential donor families

In consultation with Donation Specialist Medical, Donation Specialist Nursing and hospital staff ensure legal requirements for consent for organ and tissue donation for transplantation are met

All donations meet legal requirements


22



Collect all relevant clinical information, including medical and social history, in preparation for offering organs to transplant units

Transplants units are provided with comprehensive referral to enable assessment of organs and allocation to suitable recipients

Offer and coordinate allocation of organs for transplantation as per the ATCA/TSANZ Rotation

All medically suitable organs offered for transplantation are allocated to transplant units as per the ATCA/TSANZ Rotation

Coordinate the organ and tissue retrieval process including, but not limited to:

confirmation of operating theatre time,

arrival of retrieval teams,

confirmation of donor details with theatre staff,

providing advice and support for operating theatre staff,

providing advice on physiological management of donor,

assisting with organ perfusion as required,

packaging of organs for transportation to transplanting hospital,

transportation of organs, and

preparing the donor’s body for viewing with assistance from operating theatre staff

All operating theatre staff provided with advice and support as requested

All consented and medically suitable organs and tissues are retrieved for transplantation

All organs and tissues packaged and transported according to national guidelines

Participate in national education and training activities including the Professional Education Package and national induction and orientation programs

Involvement in all relevant education and training activities

As directed by the SMD or Operations/Clinical/Agency Manager and led by the Communications Coordinator, provide education to the community on issues relating to organ and tissue donation for transplantation, as required

Provide information to Communications Coordinator as requested on community education activities

Support and educate outreach hospital staff at the direction of the SMD or Operations/Clinical/Agency Manager

Evidence of Donation Specialist Coordinator providing timely and relevant support and education to outreach staff

As directed by the SMD or Operations/Clinical/Agency Manager and led by the Education Coordinator and, in liaison with the Donation Specialist Medical and Donation Specialist Nursing, provide education for hospital staff* involved in organ and tissue donation for transplantation

All staff involved in organ and tissue donation are provided with education

Provide information to Education Coordinator as requested on number of sessions and participants recorded. Sessions evaluated and reported monthly according to established reporting system

* Hospital staff may include: Donation Specialist Medical, Donation Specialist Nursing, Donation Specialist Coordinator and relevant staff from other areas for example: ED, OT, neurosurgery, executive, clinical governance unit, palliative care, eye and tissue, transplant units, social work, aboriginal liaison, pastoral care and volunteers

Donation Specialist Coordinator | Key performance outcomes and measures (continued)

23



Core hospital team of Donation Specialist Coordinator, and/or Donation Specialist Medical/Donation Specialist Nursing to communicate and meet regularly with the SMD

Attendance at and contribution to all team meetings, either in person or by teleconference



Participate in the on-call roster to facilitate the organ and tissue donation process

When rostered on call, provide 24 hour service to facilitate organ and tissue donations during this period

Demonstrate/maintain competency in the use of the EDR including an understanding of the Acceptable Use Policy and breach notification processes




Upload data to the ANZOD in a timely manner

Liaise with transplant unit staff to ensure sufficient information is available to inform an organ acceptance/rejection decision

24


DONATION SPECIALIST NURSING COORDINATOR


Accountability

This role combines the functions and responsibilities of the Donation Specialist Coordinator and the Donation Specialist Nursing.

The Donation Specialist Nursing Coordinator is an employee of the State/Territory health department or health service as applicable and is accountable to:

• a senior administrator (e.g. hospital Director of Nursing or senior nurse in a relevant unit) on a daily operational basis when based in a hospital;

• the Operations/Clinical/Agency Manager in an organ and tissue donation program capacity, including performance and compliance with the national framework; and

• ultimately to the State/Territory Medical Director (SMD).

Responsibilities

Within the context of the Clinical Practice Improvement Program (CPIP), the Donation Specialist Nursing Coordinator is responsible for raising awareness of, and providing educational services on organ and tissue donation to all medical, nursing and allied health staff that come into contact with the donation process, as well as the community. The position also works with hospital teams to identify and convert potential organ donors to actual donors. Specifically, the position is responsible for:

• Championing the use of nationally consistent clinical triggers to improve the identification of potential organ and tissue donors

• Facilitating organ and tissue donation by working with hospital teams to ensure that potential donors are identified

• Implementing, monitoring and evaluating the CPIP in their hospital

• Implementing the best-practice consent model and actively encouraging adoption of the model at the hospital level


• Educating medical, nursing and allied health staff in intensive care units (ICUs), emergency departments (EDs), operating theatres (OTs), the health service and the local community in accordance with programs as agreed by the DonateLife Network

• Liaising between ICUs, EDs, OTs, DonateLife Agency staff, eye and tissue banks, transplant and retrieval teams and private hospitals, to manage barriers to organ and tissue donation

• Collecting data and reporting against the performance targets and goals set by the Organ and Tissue Authority (OTA).

25


In addition the position facilitates organ donation by:

• Working closely and collaboratively with DonateLife Network staff, as well as hospital staff to facilitate the process of organ donation and (in SA and NT) retrieval from deceased donors

• Receiving notification/referral of potential donors

• Evaluating medical suitability with agreed scope of practice and guidelines

• Completing patient medical and social history

• Coordinating the tissue typing and testing of the potential donor

• Assisting the Donation Specialist Medical (where employed) and/or treating staff with family liaison or facilitating the consenting process at the time of donation

• Assisting the Donation Specialist Medical (where employed) and/or treating staff in the management of the potential/actual donor to maintain physiological stability

• Working with the Donation Specialist Medical (where employed) and/or treating staff to provide support services and information on transplantation outcomes to donor families

• Ensuring that all families of potential and actual organ and/or tissue donors receive the support in the hospital consistent with the National DonateLife Family Support Service (NDFSS) Guidelines

• Communicating and collaborating with the national DonateLife Network to maximise organ and tissue donation rates

• Coordinating the surgical retrieval team to the donor

• Managing the offer of retrieved organs to the transplant team(s)

• Referring eye and tissue donors to the eye and tissue banks

• Demonstrating/maintaining competency in the use of the EDR including an understanding of the Acceptable Use Policy and breach notification processes.


Current registration with AHPRA as a Division 1 Registered Nurse with at least five years post registration experience and preferably 3 years’ experience in a relevant speciality, e.g. ICU.



26


Donation Specialist Nursing Coordinator Key performance outcomes and measures


Support and focus the DonateLife Network and clinical staff to meet national targets for request, consent and organ donation rates as identified in the DonateLife Audit Standard Operating Procedure and User Guide

DonateLife Network and clinical staff are supported and focussed upon meeting the targets as identified in the DonateLife Audit Standard Operating Procedure and User Guide

Attend team meetings to support open and consistent communication

80% attendance at team meetings



Implement the best-practice model and contribute to the promotion, adoption and evaluation of the model.




Educate hospital staff* involved in organ and tissue donation for transplantation.



Number of sessions and participants recorded. Sessions evaluated and reported to the SMD

Report of participation to hospital executive via hospital meeting structure

Participate in jurisdictional and national education and training activities including the national induction and orientation programs and professional development sessions


>80% of jurisdictional formal education forums attended (over a 12 month period)

Attend case review meetings scheduled regularly at the direction of the SMD

>80% of inter-hospital case review meetings attended by Donation Specialist Nursing Coordinator (over a 12 month period)

Reconcile and submit case data reviewed at case review meeting within 1 month

Implement protocols for the identification, routine request and referral of eye and tissue donors in hospitals as appropriate to the relevant agency


Provide donor family support according to the National DonateLife Family Support (NDFSS) Framework

NDFSS Framework provided


* Hospital staff may include: Donation Specialist Medical, Donation Specialist Nursing, Donation Specialist Coordinator, Donation Specialist Nursing Coordinator (where applicable) and relevant staff from other areas for example: ICU, ED, OT, neurosurgery, neurology, executive, clinical governance unit, palliative care, eye and tissue, transplant units, social work, aboriginal liaison, pastoral care and volunteers

27



Receive referral of potential donors Referral recorded and reported to DonateLife Network management as appropriate

Confirm the Australian Organ Donor Register (AODR) has been accessed to establish if a potential donor has registered consent or objection to donating organs and/or tissues for transplantation

AODR accessed for 100% of referred potential donors

Assess in consultation with hospital staff and Donation Specialist Medical (where employed) or by other processes as determined by the SMD and agreed by the DonateLife Network, the medical suitability of potential donors (including advising on relevant investigations)

100% of referred potential donors assessed for medical suitability

Liaise with relevant clinical and DonateLife Network staff regarding physiological management of potential donors

Support and advice provided to ensure that all potential donors receive appropriate physiological management consistent with the national guidelines

Offer and facilitate viewing of the body by family following donation

All families offered viewing of the body following donation as directed by the family

Follow up with donor families to inform them regarding the outcomes of their donation

Support the Donor Family Support Coordinator with provision of follow up according to the NDFSS Framework

In consultation with the Donation Specialist Medical (where employed) and hospital staff, discuss organ donation with, and/or request consent for donation from, potential donor families

Organ donation discussed with, and/or consent requested for donation from, potential donor families

Ensure legal requirements for consent for organ and tissue donation for transplantation are met


Collect all relevant data and identify and communicate any relevant clinical information, including medical and social history, in preparation for offering organs to transplant units


Ensure legal requirements for consent for organ and tissue donation for transplantation are met


Collect all relevant data and identify and communicate any relevant clinical information, including medical and social history, in preparation for offering organs to transplant units


Offer and coordinate allocation of organs for transplantation as per the ATCA/TSANZ Rotation

All medically suitable organs offered for transplantation are allocated to transplant units as per the ATCA/TSANZ Rotation

28



Coordinate the organ and tissue retrieval process including, but not limited to:

confirmation of operating theatre time,

arrival of retrieval teams,

confirmation of donor details with theatre staff,

providing advice and support for operating theatre staff,

providing advice on physiological management of donor,

assisting with organ perfusion as required,

packaging of organs for transportation to transplanting hospital,

transportation of organs, and

preparing the donor’s body for viewing with assistance from the operating theatre staff

All operating theatre staff provided with advice and support as requested

All consented and medically suitable organs and tissues are retrieved for transplantation

All organs and tissues are packaged and transported according to national guidelines

Support education of outreach hospital staff at the direction of the SMD

Evidence of Donation Specialist Nursing Coordinator providing timely and relevant support and education to outreach staff

Participate in the on-call roster to facilitate the organ and tissue donation process

When rostered on call, provide 24 hour service to facilitate organ and tissue donations during this period

As directed by the SMD and led by the Data and Audit Coordinator, collect and validate data related to the organ donation process and identification of factors that limit donation opportunities, as required

Provide timely and accurate data to the Data and Audit Coordinator within agreed timeframes

As directed by the SMD and led by the Data and Audit Coordinator, prepare reports for presentation to relevant groups, as requested

Provide timely and accurate completion of reports for presentation to relevant groups

Demonstrate/maintain competency in the use of the EDR including an understanding of the Acceptable Use Policy and breach notification processes




Upload data to the ANZOD in a timely manner

Liaise with transplant unit staff to ensure sufficient information is available to inform an organ acceptance/rejection decision

Donation Specialist Nursing Coordinator | Key performance outcomes and measures (continued)

29


DONOR FAMILY SUPPORT COORDINATOR


Accountability

The Donor Family Support Coordinator (DFSC) is an employee of State/Territory health department or health service as applicable and is accountable to the State/Territory Medical Director (SMD), reporting to the Operations/Clinical/Agency Manager (depending upon the Jurisdiction).

Responsibilities

The DFSC, through participation in the national Donor Family Support Implementation Group (DFSIG) and within the context of the Clinical Practice Improvement Program (CPIP), is responsible for:

• Contributing to the development, implementation, monitoring and reporting of the National DonateLife Family Support Service (NDFSS) Guidelines

• Coordinating the NDFSS within the agency and Jurisdiction

• Ensuring that all families of potential and actual organ and/or tissue donors receive the support they need consistent with the NDFSS Guidelines

• Reporting and evaluating all national and local donor family support activities in the Jurisdiction in accordance with agreed national performance measures

• Working with the Organ and Tissue Authority (OTA) to support research projects such as the Donor Family Study

• Organising and/or participating in the DonateLife Services of Remembrance

• Undertaking an educational role (in collaboration with the Education Coordinators) to ensure that DonateLife Network staff (agency staff and hospital specialist medical and nursing positions) are aware of, and are utilising the NDFSS Guidelines including processes and resources

• Contributing to the delivery of the Introductory Donation Awareness Training (IDAT) workshop

• In Jurisdictions where the Electronic Donor Record (EDR) is used for donor family support services, demonstrating/maintaining competency in the use of the EDR including an understanding of the Acceptable Use Policy and breach notification processes.


If the DFSC is providing direct support services to families they must have qualifications in social work, psychology or counselling.

Experience providing support in trauma debriefing, bereavement and counselling services with end of life care.

30


Donor Family Support Coordinator Key performance outcomes and measures


Implement and manage provision of the NDFSS Guidelines within the Jurisdiction, including:

Contributing to the development, implementation, monitoring and reporting of the NDFSS Guidelines

Supporting the Donor Family Study and other research projects

Follow up with donor families to offer and provide support in accordance with the NDFSS Guidelines

Donor family support is implemented within the Jurisdiction in line with national consistency

Support is offered and all donor families are:

– Offered follow up information and support

– Offered referral to appropriate services to manage ongoing issues

100% achievement of agreed national performance measures

Active participation in the DFSIG

Active participation in the Donor Family Study

Advice and support is provided for research projects

Educate DonateLife Network staff so they are aware of, and are utilising, the NDFSS including processes and resources, and contribute to the delivery of IDAT workshops

All DonateLife Network staff within the Jurisdiction:

– Are aware of the available donor family support services

– Are providing support to donor families in accordance with the NDFSS Guidelines

– Have access to and are using the NDFSS Resources

Co-facilitation of IDAT workshops

In Jurisdictions where the EDR is used for family support services, demonstrate/maintain competency in the use of the EDR including an understanding of the Acceptable Use Policy and breach notification processes






The following table details the specific key performance outcomes and measures as they relate to the roles and responsibilities described above and should be read in conjunction with the nationally agreed NDFSS Guidelines.

31


EDUCATION COORDINATOR


Accountability

The Education Coordinator is an employee of the State/Territory health department or health service as applicable and is accountable to the State/Territory Medical Director (SMD), reporting to the Operations/Clinical/Agency Manager (depending upon the Jurisdiction).

Responsibilities

The Education Coordinator, through participation in the national Education Coordinators Network (ECN), and within the context of the Clinical Practice Improvement Program (CPIP), is responsible for:

• Contributing to the development and review of national DonateLife education programs and resources

• Managing and overseeing all education activities within the Jurisdiction

• Providing on-the-ground education, training and support for DonateLife Network staff within the Jurisdiction

• Ensuring that all DonateLife Network staff within the Jurisdiction are aware of and have access to national education, training and resources

• Evaluating and reporting on all national and local education activities within the Jurisdiction

• Liaising continually with the Organ and Tissue Authority (OTA) in relation to implementation, monitoring and reporting of national education programs and resources

• Liaising continually with the OTA and other Education Coordinators to share local education initiatives and ensure national consistency of education delivery

• Collaborating with and supporting other DonateLife staff including Donor Family Support Coordinators, Donation Specialists Medical, Donation Specialists Nursing, Donation Specialist Nursing Coordinators and Communications Coordinators to deliver wider hospital, community and schools education initiatives

• Attending the core and practical Family Donation Conversation (FDC) workshops and meeting repeat attendance requirements (in accordance with Appendix A)


Post graduate qualifications in critical care and/or education/training.

Registered nurse with at least 5 years post graduate experience preferably in critical care, organ and tissue donation or education.

32


Education Coordinator Key performance outcomes and measures


Contribute to the development, implementation, monitoring and reporting of nationally consistent professional education programs and resources for DonateLife Network staff

All DonateLife Network staff within the Jurisdiction are aware of and supported to access nationally-consistent education and training activities and resources

Ensure that all local DonateLife Network staff complete the DonateLife Network Orientation Package

All DonateLife Network staff within the Jurisdiction complete the DonateLife Network Orientation Package

Manage and support the facilitation and administration of the Professional Education Package (PEP) including:

Introductory Donation Awareness Training (IDAT)

Core FDC workshops (and complimentary elearning program)

Practical FDC workshops

All DonateLife Network staff within the Jurisdictions attendance at PEP and training relevant to their role in the best practice consent model is monitored and documented

Promote applications for the Janette Hall Professional Training and Development Scholarship Program

All DonateLife Network staff within the Jurisdiction are aware of the Janette Hall Professional Training and Development Scholarship Program

Provide support and resources to relevant DonateLife Network staff for delivery of education to hospital staff involved in organ and tissue donation for transplantation and the wider community

All DonateLife Network staff within the Jurisdiction are provided with appropriate support and resources for education of hospital staff and the wider community


Documented evidence of attendance at Education Coordinators Network meetings and ongoing professional development related to organ and tissue donation




33


NATIONAL TRAINING COORDINATOR


Accountability

The National Training Coordinator (NTC) is an employee of the State/Territory health department or health service/agency as applicable and is accountable to the Director, Clinical Programs, Organ and Tissue Authority (OTA).

Responsibilities

The NTC supports the OTA in the development and national delivery of the Professional Education Package (PEP), and is primarily responsible for:

• Contributing to the ongoing development and delivery of the PEP and associated resources

• Supporting, mentoring and providing advice to PEP workshop facilitators

• Coordinating schedules for Family Donation Conversation (FDC) workshop facilitators to deliver the Core and Practical FDC Workshops in all Jurisdictions

• Facilitating Core and Practical FDC Workshops

• Facilitating Train-the-Trainer sessions for PEP workshops.


Qualification in the delivery of adult education and training.

Clinical experience in organ and tissue donation, preferably in a leadership role.

Experience in providing support to families of organ and tissue donors.

34


National Training Coordinator Key performance outcomes and measures


Contribute to the development and review of all PEP workshops and training resources

NTC input provided on development and finalisation of workshops and training resources

PEP is maintained and up to date to meet professional training demand

Participate in advisory and/or working groups relevant to the development and delivery of the PEP such as the Family Conversations Steering Group (FCSG) and the Education Coordinators Network (ECN)

Documented evidence of attendance at the FCSG, ECN and other groups as required

Seek feedback from PEP workshop facilitators on the strengths and weaknesses of workshops and opportunities for improvement

Clear communication process established and operating between the NTC and PEP workshop facilitators

Monitor participant feedback from the Core and Practical FDC Workshops and provide advice to the OTA with recommendations for quality improvement of workshops

Participants report positive feedback on their experience at workshops

Mentor and support PEP workshop facilitators in their preparation and delivery of workshops

FDC Workshop facilitators have access to the advice and experience of the NTC

Provide advice to the OTA on the ability and confidence of FDC workshop facilitators in the delivery of workshops in the expected manner

NTC attendance at cFDC workshops as an observer to assess FDC workshop facilitators’ ability

Identify training needs and opportunities for FDC workshop facilitators (for recommendation and consideration by the OTA

FDC workshop facilitators complete relevant training as required

Coordinate a central management process for the scheduling of FDC workshop facilitators

Accurate schedule of Core and Practical FDC workshops is maintained and a clear booking process is established

Ensure FDC workshop facilitators have the opportunity to facilitate workshops in their home Jurisdiction and organise a FDC workshop facilitator for workshops held in Jurisdictions without a local facilitator available

FDC workshop facilitators are booked and deliver the national allocation of core and practical FDC Workshops

Liaise with workshop organisers and presenters (as required) including the OTA, Education Coordinators and local presenters

Clear communication process established

Facilitate core and practical FDC Workshops in agreed locations across Australia

Deliver a minimum of one core and practical FDC workshops each year

Identify relevant professional development opportunities to maintain skills to perform NTC role

Documented evidence of completion of relevant training


35


COMMUNICATIONS COORDINATOR


Accountability

The Communications Coordinator is an employee of State/Territory health department or health service as applicable and is accountable to the State/Territory Medical Director (SMD), reporting to the Operations/Clinical/Agency Manager (depending upon the Jurisdiction).

Responsibilities

The Communications Coordinator, through participation in the national Communications Reference Group and in the context of the Clinical Practice Improvement Program (CPIP), is responsible for:

• Developing and implementing the local components of the national DonateLife Community Awareness and Education Program and Plans within the Jurisdiction, in liaison with the Organ and Tissue Authority (OTA)

• Establishing and maintaining jurisdictional media and stakeholder relationships to implement strategic media programs, generate ongoing publicity and manage potential media issues

• Identifying and utilising awareness and promotional activity and event opportunities in the Jurisdiction that are in alignment with the national DonateLife Community Awareness and Education Program and Plan

• Exploring innovative and strategic media and communication programs within the Jurisdiction to support the national reform program

• Ensuring compliant use and management within the Jurisdiction of the DonateLife brand and name

• Ensuring compliant use and management within the Jurisdiction of DonateLife key messages

• Supporting the OTA in identification and management of communications opportunities to further enhance the DonateLife Community Awareness and Education Program and Plans within the Jurisdiction and at the national level

• Supporting the OTA in identification and management of donor family and transplant recipient case studies for media and event activity

• Supporting the OTA by providing information from the Jurisdiction to assist with the compilation of national documents

• Supporting the OTA by providing content for national media and social media engagement.


Tertiary qualifications in journalism, media and communications.

Experience in public affairs, journalism, media, communications and marketing.

36


Communications Coordinator Key performance outcomes and measures


Develop and implement a state/territory communications plan of activities that directly align with and support the DonateLife Community Awareness and Education Program and Strategy

Communications activities aligned with the national strategy are implemented at jurisdictional level

Attend and actively contribute to communications planning including workshops organised and led by the OTA

Provision of communications plan to OTA and regular updates of activities implemented

Ensure correct and consistent use and promotion of the DonateLife Brand, key messages and website

Consistent reputational management of the DonateLife brand and key messages

Promote the Community Awareness Grants program within the Jurisdiction

Increased diversity and reach of applicants for community awareness grants

Identify spokespeople including donor and recipient families in a timely manner

Nationally consistent and accurate media coverage of the DonateLife Network and organ and tissue donation activities and issues

Provide a minimum of 24 hours notice of all planned media releases and press conferences where possible

Documented evidence of increased state-wide media coverage aligned with national key messages

Implement a proactive media engagement plan at state/territory, regional and local levels that is aligned with the DonateLife Community Awareness and Education Program and Strategy

Documented evidence of increased number of proactive media stories generated

Inform the OTA of requested interviews for national media outlets

Documented evidence of increased number of media enquiries

Implement targeted media and community outreach activities with cultually and lingusitically diverse audiences

Documented evidence of increased coverage in culturally and linguistically diverse media

Participate in relevant meetings, seminars, conferences across the DonateLife Network

Documented evidence of attendance and ongoing professional development related to developing and implementing the local components of the national DonateLife Community Awareness and Education Program and Strategy

The following table details the specific key performance outcomes and measures as they relate to the roles and responsibilities described above and should be read in conjunction with the national Community Awareness and Education Program and Strategy.

37


DATA AND AUDIT OFFICER


Accountability

The Data and Audit Officer is an employee of the State/Territory health department or health service as applicable and is accountable to the State/Territory Medical Director (SMD), reporting to the Operations/Clinical/Agency Manager (depending upon the Jurisdiction).

Responsibilities

The Data and Audit Officer, through participation in the national Data and Audit Working Group and within the context of the Clinical Practice Improvement Program (CPIP), is responsible for:

• Ensuring the conduct of the DonateLife Audit within the Jurisdiction is consistent with national processes

• Providing oversight, support and training to Donation Specialists Nursing and other DonateLife Network staff (as applicable) in performing the DonateLife Audit and ensure familiarity with the DonateLife Audit Standard Operating Procedure and User Guide and consistent use of the data audit tool, including patient classification

• Coordinating and overseeing the case review meetings and ensuring feedback and outcomes are provided to hospital-based staff

• Liaising and meeting regularly with the Organ and Tissue Authority (OTA), jurisdictional counterparts and audit experts to review the audit processes and ensure consistency of practice

• Communicating national, jurisdictional and hospital level DonateLife Audit results to the hospital executive and DonateLife Network staff

• Preparing jurisdictional data for reporting to relevant committees

• Participating in data review and analysis with the DonateLife Network executive.


Clinical experience in organ and tissue donation.

Experience in data management, analysis and data systems.

Experience in developing data collection, reporting and evaluation tools.

Tertiary qualifications in statistics and data.

38


Data and Audit Officer Key performance outcomes and measures


Ensure auditors e.g. Donation Specialists Nursing /DonateLife Network staff (as applicable) are reviewing and collecting the agreed information on all hospital deaths

All hospital deaths in participating hospitals are reviewed daily/weekly

Ensure auditors are detecting patients that have met clinical trigger

Emergency departments and intensive care units visited frequently to identify patients that fulfil the requirements to be entered into the DonateLife Audit

A local system is in place for identifying potential donors

Ensure timely entry of data into the DonateLife Audit All data for a month is entered by the end of the following month

All incomplete records are finalised within 30 days of the case review meeting when applicable

Validate data entered into the DonateLife Audit Jurisdictional and hospital level data is validated on a monthly basis – including a check of the validity of the data and the completeness of the data

Invalid or incomplete data is followed up with the user responsible for that record

Organise regular case review meetings at the direction of the SMD

>80% of inter-hospital case review meetings are attended by Donation Specialists Medical or delegates (over a 12 month period)

A single page summary of relevant information is prepared for each case to be reviewed

Case review summaries are prepared within 1 month after the end of each month

A summary report of case review activity is provided to the OTA after each case review meeting

The DonateLife Audit records are updated based on the case review outcomes

Provide feedback from clinical case review meetings to relevant hospital staff

Feedback to hospital staff is provided within 14 days of case review meeting

Communicate national, jurisdictional and hospital level DonateLife Audit results to the relevant DonateLife hospital and Agency staff

Feedback is provided to DonateLife hospital and Agency staff within 2 months of the end of each quarter

The following table details the specific key performance outcomes and measures as they relate to the roles and responsibilities described above and should be read in conjunction with the nationally agreed definitions, data set and guidelines outlined in the DonateLife Audit Standard Operating Procedure and User Guide and the OTA Data Dictionary.

39



Report DonateLife Audit hospital performance to hospital executive and DonateLife Network staff

Summary documents prepared to support reporting of DonateLife Audit hospital performance to hospital executive by the DonateLife leadership

Ensure auditors are appropriately trained in conducting the hospital DonateLife Audit in a nationally consistent manner

Contribute to the development of training programs which include familiarity with the DonateLife Audit Standard Operating Procedure and User Guide and the OTA Data Dictionary

100% of audit staff is appropriately trained in all aspects of the DonateLife Audit tool, including completion of all training scenarios

Liaise and meet regularly with the OTA and jurisdictional counterparts, including participating in working groups as necessary

Actively represent the Jurisdiction at Data and Audit Working Group meetings


Participation in peer meetings, seminars, conferences across the DonateLife Network

Documented ongoing professional development related to organ and tissue donation

40


ELECTRONIC DONOR RECORD (EDR) TRAINER


Accountability

The EDR Trainer is an employee of State/Territory health department or health service as applicable and is accountable to the State/Territory Medical Director (SMD), reporting to the Operations/Clinical/Agency Manager (depending upon the Jurisdiction).

Responsibilities

The EDR Trainer, through participation in the national EDR Working Group and within the context of the Clinical Practice Improvement Program (CPIP), is responsible for:

• Ensuring the utilisation of the EDR within the Jurisdiction is consistent with national policies and protocols

• Providing training to Donation Specialists Nursing and other DonateLife Network staff (as applicable) in utilising the EDR and ensuring familiarity with the EDR Standard Operating Procedure (SOP) and User Guide and consistent use of the EDR

• Providing oversight, and ongoing support to Donation Specialists Nursing and other DonateLife Network staff (as applicable) to ensure consistent use of the EDR to support clinical practice

• Liaising and meeting regularly with the Organ and Tissue Authority (OTA) and jurisdictional counterparts to review the SOP processes and ensuring consistency of practice

• Communicating changes and updates to the EDR to the relevant users and contacts including transplant coordinators and others who utilise the EDR output.


Current Donation Specialist with:

• High level skills and experience in utilisation of the EDR training and production instances

• A comprehensive knowledge of national and jurisdictional EDR standard operating procedures

• Completion of the EDR Trainer training program.


Post registration qualifications in a specialty field relevant to organ and tissue donation

41


Electronic Donor Record (EDR) Trainer Key performance outcomes and measures


Facilitate and manage the three training components of new users as per the training guidelines:

Pre-training preparation

Face to face training

Proficiency training

Training is delivered to all new users prior to access being granted to the production instance of the EDR.

All EDR users are trained commensurate with their level of access

Assess the progress of new users ensuring that training timeframes are achieved

Users are monitored and supported through each phase of the training program

Progress is evaluated and attainment of competency assessed

Feedback is provided to users on data entry of mock cases

Provide support and assistance with problem solving for new and existing users

All staff utilising the EDR are provided with appropriate and timely support in utilisation of the EDR

Develop and maintain jurisdictional training resources:

clinical currency of the EDR mock cases

sample/mock files for attachment in mock cases

The EDR mock cases with associated attachments are clinically current and accessible by users

Contribute to the creation and updating of national and jurisdictional resources for the EDR, specifically for users with log in access

Active participation is undertaken in the ongoing development and maintenance of currency of the EDR

Provide feedback to the OTA where a majority of users are having issues with the EDR application via the EDR Working Group teleconferences or directly to the National System Administrator

The Jurisdiction is always represented at the bi-monthly EDR Working Group meetings

Provide feedback to the OTA and the ANZOD on the utility of the EDR system including data quality issues and areas where potential changes to the functionality of the system may be required

The OTA is informed of any EDR system issues which arise

Participate in the timely testing of system updates to the EDR

Communicate changes and updates to the relevant users and contacts

Users are informed of any changes and updates to the EDR and receive training in any new functionality where required

The following table details the specific key performance outcomes and measures as they relate to the roles and responsibilities described above and should be read in conjunction with the nationally agreed definitions, data set and guidelines outlined in the EDR Standard Operating Procedure and User Guide and the OTA Data Dictionary.

42


ELECTRONIC DONOR RECORD (EDR) SYSTEM ADMINISTRATOR


Accountability

The EDR System Administrator is an employee of State/Territory health department or health service as applicable and is accountable to the State/Territory Medical Director (SMD), reporting to the Operations/Clinical/Agency Manager (depending upon the Jurisdiction).

Responsibilities

The EDR System Administrator, through participation in the national EDR Working Group and within the context of the Clinical Governance Improvement Program (CPIP), is responsible for:

• Providing first tier 24/7 helpdesk support to EDR users

• Maintaining the currency of users, contacts and organisations within the EDR

• Ensuring business continuity processes are in place and are accessible to all active users of the EDR in the event that the system should become unavailable

• Ensuring user access to referrals is monitored and breaches of the Acceptable Use Policy are reported.

• Ensuring processes are in place to monitor data quality and take action where data quality issues have been identified

• Ensuring all users have access to the current EDR SOP and User Guide

• Ensuring all users are notified in advance of any planned EDR downtime

• Liaising and meeting regularly with the OTA and jurisdictional counterparts to review the SOP processes to ensure consistency of practice

• Ensuring there are systems in place to support the timely upload of the ANZOD XML files.

• Ensuring system updates to the EDR which affect the administration of the system are reviewed, tested and produce the expected outcome


Current Donation Specialist with:

• High level skills and experience in utilisation of the EDR training and production instances

• A comprehensive knowledge of national and jurisdictional EDR standard operating procedures.

• Completion of the EDR jurisdictional Administrator training program.



43


Electronic Donor Record (EDR) System Administrator Key performance outcomes and measures


Provide first tier 24/7 helpdesk support to EDR users Users are able to access first tier helpdesk support 24/7

Maintain the EDR system

Within the EDR application, add, deactivate and reactivate users, organisations, and contacts; administer the manufacturer and tissue agency lists

Current users are able to access the EDR and utilise the application as required in their clinical practice

All users, organisations and contacts entered into the EDR are current

Drop down lists associated with manufacturers and tissue agencies are accurate and current

Monitor data quality within the EDR through review and actioning of the Data Quality Exception Report and Business Continuity Report

Data quality is continuously monitored ensuring that data within the EDR is accurate, entered in a timely manner and suitable for clinical use.

Missing data is identified and completed.

Ensure the most current Business Continuity Report is available to all active users of the EDR in the event that the system should become unavailable

All users have access to the current Business Continuity Report in the event that the EDR system should become unavailable

Ensure user access to referrals is monitored and breaches of the Acceptable Use Policy are reported

Audit reports are reviewed each week and breaches of the Acceptable Use Policy are actioned as per agreed policies

Ensure all users:

Have access to the current EDR SOP and User Guide

Are notified in advance of any planned EDR downtime

Users have access to the current EDR SOP and User Guide

Users are notified of any EDR downtime

Liaise between transplant units, DonateLife Agencies and the OTA

Issues which arise regarding the EDR are actively communicated to all relevant stakeholders

Ensure systems are in place to support the timely upload of XML files to the ANZOD

XML files are uploaded to the ANZOD by the third working day after the end of each month

Participate in the testing of system updates to the EDR EDR system updates are tested and timely feedback on any issues identified is provided to the OTA

Participate in the EDR Working Group teleconferences/meetings

The Jurisdiction is always represented at the bi-monthly EDR Working Group meeting

The following table details the specific key performance outcomes and measures as they relate to the roles and responsibilities described above and should be read in conjunction with the nationally agreed definitions, data set and guidelines outlined in the EDR System Administrator Guide.

44


ADMINISTRATIVE OFFICER


Accountability

The Administrative Officer is an employee of the State/Territory health department or health service as applicable and is accountable to the State/Territory Medical Director (SMD), reporting to the Operations/Clinical/Agency Manager (depending upon the Jurisdiction).

Responsibilities

The position is responsible for:

• Providing administrative support to the SMD, Operational/Clinical/Agency Manager and the DonateLife Network

• Providing local administrative support to DonateLife projects and contributing to key initiatives aimed at improving the operational efficiency of the DonateLife Agency

• Preparing and distributing papers, agendas, reports as required

• Providing operations and business support as requested

• Developing and maintaining effective communication networks and working relationships with key internal and external stakeholders

• Supporting DonateLife Week and local Services of Remembrance (or similar) to ensure success each year

• Providing administrative support in the preparation of training / induction programs and events including venue hire, catering and equipment needs

• Organising travel and accommodation as required

• Managing the administrative processes of staff recruitment, including overseeing advertising, candidate enquiries, and interview processes in accordance with local policy and procedures

• Providing other administrative/office duties as requested.


Certificate 4 in Business Management or equivalent.

Recent experience in a health service administrative role.

45


Administrative Officer Key performance outcomes and measures


Prepare and distribute documentation as requested in a timely manner

All documents are prepared, distributed and managed in an efficient and timely manner

Provide operations and business support as requested Operations and business support provided efficiently as requested

Develop and maintain effective communication networks and working relationships with key internal and external stakeholders

All professional relationships and communication networks are managed effectively

Support DonateLife Week and local Services of Remembrance (or similar) to ensure success each year

Support provided for DonateLife Week and local Services of Remembrance (or similar) as required

Organise and prepare training / induction programs and events including venue hire, catering, travel and equipment needs

Venue hire, catering, travel, equipment and program preparation organised in a timely and efficient manner

Manage the administrative processes of staff recruitment, including overseeing the advertising, candidate enquires, and interview processes in accordance with local policy and procedures

Administrative support provided for human resource processes as required

Provide other office duties as requested Other office duties performed as requested


46


Appendix A:

CPIP PHASE 2 KEY PERFORMANCE INDICATORS (KPIs)

KPI METHOD RESPONSIBILITY

1 Regular jurisdictional network meetings are held at a minimum of six meetings per year (face to face meetings where possible) with an expectation of 80% attendance by each individual member of the DonateLife Network

Six monthly progress report – report attendance at jurisdictional network meetings by craft group:

DSC/DSN/DSNC

DSM

x/y and %

DL Agency Executive

2 Monitoring and reporting mechanisms are in place to record attendance of DonateLife Network staff at Family Donation Conversation (FDC) training. All DonateLife Network staff are to attend – at a minimum – the core FDC workshop (as soon as possible after recruitment) and the practical FDC workshop every two years.

Six monthly OTA Learning Management System (LMS) reports

Six monthly CPIP KPI survey

OTA

3 Trained Requesters participate in 100% of FDCs DonateLife Audit Report; and six monthly CPIP KPI survey

OTA, DLN hospitals and DL Agency Executive

4 Annual hospital visits by DonateLife Agency executive to meet hospital donation specialists and hospital executive to review Clinical Practice Improvement Program (CPIP)/Hospital Activity Plan (HAP) implementation

Six monthly progress report:

Hospitals visited

Who attended

DL Agency Executive

5 Six monthly reporting of DonateLife Audit hospital performance to hospital executive is undertaken

Six monthly progress report:

Hospitals visited

Who attended

DL Agency Executive

6 All DonateLife Network staff attend the core and practical FDC and the online orientation program at employment

Six monthly OTA LMS reports OTA

7 Meetings are scheduled and a calendar issued to DonateLife Network staff 12 months in advance

Annual calendar provided to OTA at the end of each year

DL Agency Executive

8 SMDs/Managers commit to attending and observing other Jurisdictions’ network meetings

Six monthly progress report DL Agency Executive

9 DonateLife Network leadership and staff from other Jurisdictions are invited to contribute to/speak at other Jurisdictions’ network meetings

Six monthly progress report DL Agency Executive

10 Donation Specialist Medical (DSM) roles (fractionated where possible) undertake donation work only (not clinical or other work) and have clear accountability for tasks under the HAP

Six monthly CPIP KPI survey and progress reports

DLN hospitals and DL Agency Executive

11 Processes are in place to manage DonateLife Network staff performance

Six monthly progress report – TBD DL Agency Executive

DonateLife Network ROLE AND RESPONSIBILITIES GUIDELINES Roles and... · ROLE AND RESPONSIBILITIES GUIDELINES Version 3 – February 2016. ... eye and tissue bank(s), transplantation

Documents