Case Studies
Case studies showcase real-world applications of policies and innovations, offering insights into improving outcomes and efficiency. They enhance problem-solving skills, highlight best practices, and engage through storytelling for education and transparency.
Interest(s): Cultural Perspectives, Diversity, Equity and Inclusion, Ethics, Finance, Growth in Transplantation, Hospital Donation Process & Education, Immunosuppression / Transplant Pharmacology, NASEM Recommendations, Patient Safety, , Quality Assurance and Performance Improvement (QAPI), Transplant Financial Coordinator, , Waitlist Management
Organ(s): Liver
Patient Group(s): Adult
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Addressing Perceived Bias in Transplant Eligibility: Institutional Strategies to Promote Equity and Restore Trust
Elizabeth
Schmidt
, UW Health
The Challenge
Our liver transplant program, located within a 505-bed Level 1 trauma and academic medical center, performs approximately 110 liver transplants annually and has completed over 3,300 transplants to date. The program is supported by a multidisciplinary team, including dedicated ICU and transplant unit staff, a Clinical Nurse Specialist, and program leadership.
In late 2023, an anonymous report submitted through our institution’s internal safety monitoring system raised concerns about perceived racial bias in transplant candidate selection. The report referenced two concurrently hospitalized patients with alcohol-related liver disease—one approved for transplant and the other declined—prompting ICU team members to question whether race may have influenced the decision-making process. Although the concern was based on perception rather than confirmed bias, it underscored potential gaps in interdisciplinary communication and transparency. In response, the liver transplant program initiated a structured review of internal processes and communication strategies to promote equity, trust, and understanding within the clinical team.
This effort was guided in part by the 2022 National Academies of Sciences, Engineering, and Medicine (NASEM) report, which calls for targeted education and trust-building within the transplant ecosystem. Our goal was to apply these principles internally to enhance transparency and address perceived inequities within our multidisciplinary care environment.
The Approach
In alignment with NASEM’s recommendations for culturally targeted education to address misconceptions in organ donation and transplantation, our liver transplant program launched a comprehensive multidisciplinary initiative aimed at addressing perceived inequities in transplant practices within our institution. Objectives included enhancement of staff understanding of the transplant process, critical evaluation of institutional policies for bias, clinical team education on patient demographics and workflows, and encouraged both individual and systemic reflection on bias in transplantation.
Key components of the approach included:
Equity-Focused Policy Review:
In collaboration with the Vice President of Social Impact, a thorough review of liver transplant protocols and decision-making processes was conducted. This review encompassed case-specific analyses as well as a broader evaluation of institutional policies through an equity lens to identify and address potential biases.
Targeted Staff Education:
Development and delivery of an educational miniseries, complemented by a required electronic learning module, designed to demystify the liver transplant evaluation and patient selection process. Delivery of the miniseries occurred across all shifts to maximize accessibility.
Demographic Analysis and Benchmarking:
Utilizing data from the Scientific Registry of Transplant Recipients (SRTR) alongside local, regional, state, and national demographic benchmarks, we conducted a comprehensive analysis of equity in access to liver transplantation.
Bias Awareness and Cultural Reflection:
To cultivate transparency and dialogue, we hosted internal town hall discussions addressing equity and inclusion within the transplant program.
Led collaborative mock selection committee simulations with ICU staff using real patient cases, significantly deepening multidisciplinary team members’ understanding of transplant evaluation criteria and fostering critical self-reflection on implicit bias.
The Results
This initiative led to meaningful improvements in interdisciplinary communication, collaboration, and transparency within the liver transplant program. A key element was structured rounding with the ICU team, which provided consistent, real-time opportunities for shared decision-making and alignment on patient care goals. These rounds increased the transplant team’s visibility, enhanced understanding of roles and workflows, and bridged gaps between critical care and transplant services.
Regular rounding and open communication channels expanded access to transplant leadership, fostering trust, accountability, and greater ICU nurse engagement in transplant discussions. Town halls and informal debriefings created safe spaces to address complex cases, perceptions of bias, and opportunities for ongoing improvement.
Ongoing collaboration among unit and program management, nursing leadership, and providers cultivated a culture of psychological safety and mutual respect. Anonymous staff feedback reflected increased engagement and deeper insight into the transplant evaluation process.
Together, these efforts promoted a more unified, equitable, and transparent care environment, underscoring the value of multidisciplinary collaboration in achieving high-quality transplant outcomes.
Insights & Lessons Learned
This initiative underscored the importance of confronting adversity, perception, trust, and communication in transplant decision-making. The concern raised by ICU staff, while ultimately determined not to reflect bias in clinical rationale, revealed a gap in shared understanding and transparency between teams. By responding with humility, structured education, and open dialogue, the liver transplant program reinforced a culture of psychological safety, interdisciplinary trust, with mutual accountability.
The outcomes of this work demonstrate that proactive, equity-centered efforts can strengthen collaboration and dismantle misperceptions, even in high-stakes and emotionally charged clinical environments. Creating space for honest conversation—supported by policy review, education, and shared clinical experiences—enabled staff to reflect on personal and systemic bias, ask questions with confidence, and participate more meaningfully in the transplant process.
As a result, key elements—such as standardized education, structured interdisciplinary rounding, and collaborative leadership engagement—have been sustained as part of routine program operations. While this initiative was localized, it provides a replicable model for other transplant programs seeking to address equity, improve communication, and build trust within diverse care teams.