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.
Organ Offer Review to Increase Heart Transplants and Organ Offer Acceptance Metrics
Nicole
Platt
, MS, CCTC
, Clinical Manager Organ Procurement Team
, Hospital of the University of Pennsylvania
The Challenge
Organ offer acceptance (OOA) metrics are critical indicators used by national governing bodies to assess transplant center practices and ensure donor organs are utilized efficiently and equitably.
According to the current SRTR Report (July 1, 2024 to June 30, 2025), our heart transplant program’s Offer Acceptance Ratio was 0.73, indicating that we were accepting donor heart offers at a rate lower than expected compared to other programs receiving similar offers for similar candidates. Lower than expected acceptance rates are directly associated with increased waitlist mortality, prolonged wait times, reduced organ utilization, and diminished patient access to transplantation. In an increasingly competitive regional environment, where multiple transplant centers pursue the same donor pool, suboptimal acceptance practices further limit our ability to secure high-quality organs for patients on our waitlist. Improving our acceptance performance and expanding our acceptance practices represent both a quality imperative and a strategic necessity.
This metric highlights an important opportunity for a systematic review of current decision-making workflows, selection criteria, and operational barriers to improve the program’s ratio. The initial goal of this project was to increase the heart program’s organ offer acceptance ratio from 0.73 to greater than 1.0 within 6 months. As an immediate measure, the team aimed to raise our offer acceptance rate, measured using UNOS’ CARE tool, from 5% in April 2025 to greater than 10% by July 2025.
The Approach
Given the multiplicity of factors that impact OOA rates, the program implemented a structured Plan–Do–Study–Act (PDSA) framework beginning in May 2025. This approach supported rapid-cycle learning, iterative testing of changes, and continuous performance monitoring.
Plan – To support continual learning and real-time practice change, we launched a weekly heart offer review meeting. The sessions included leadership and key stakeholders including the Medical and Surgical Directors, Clinical and Procurement Managers and Directors, and the Quality Team.
Do: During each review meeting, the team conducted a case-by-case evaluation of every heart offer that was declined by our program but transplanted elsewhere. Discussions focused on:
*the clinical rationale for the decline,
*opportunities that could have made the organ acceptable,
*process breakdowns that influenced the acceptance decision,
*potential variability among accepting providers, and
*opportunities for new perfusion and preservation technologies.
This multidisciplinary format promoted open discussion of differing perspectives, reduced siloed decision-making, and created a shared understanding of how acceptance decisions were being made across the program.
Study: Information from the weekly reviews was aggregated to identify recurring themes and drivers of missed acceptance opportunities. The team assessed patterns related to recipient factors, donor type, infectious disease considerations, procurement logistics, and call-coverage variation. Trends were monitored in real time to evaluate the impact of emerging process changes using two primary metrics, the UNOS CARE Tool acceptance rate and the SRTR Offer Acceptance Ratio.
Act: Insights from these reviews were rapidly translated into practice changes. Over the subsequent three months, four major interventions were implemented:
*Individualized waitlist acceptance criteria: Tailored acceptance profiles were created for each patient on the waitlist to minimize inactionable donor offers and reduce decision burden.
*Reduction in practice variation: Call expectations were standardized and the number of accepting providers was reduced to improve consistency in donor offer assessments.
*Expanded DCD acceptance criteria: The program broadened its utilization of donation-after-circulatory-death donors. This expansion was supported by improving national outcomes data and favorable institutional experience, enabling more transplant opportunities without compromising safety.
*Enhanced Infectious Disease collaboration: An efficient consultation pathway was established to support timely risk assessment and reduce avoidable declines related to donor infectious findings.
*Optimization of Logistics Coordination: A focused review of logistics processes was conducted with external procurement agencies. This included assessing opportunities to leverage organ preservation and perfusion technologies to improve organ viability and broaden acceptance capabilities.
The Results
The PDSA guided interventions produced rapid, measurable, and sustained improvements in organ offer acceptance practices. Significant positive trends and improvements were observed in the following:
Organ Acceptance Rates – Organ acceptance rates increased sharply following the interventions. CARE Tool acceptance rose from 5% in April 2025 to 16.1% in July and 14.3% in August, representing a more than threefold improvement. Despite a short-term downward fluctuation in September and October, the overall upward trend demonstrates sustained change.
Offer Process Efficiency and Acceptance Yield: Operational data demonstrated improved efficiency in the acceptance process. Between January and April 2025, the program reviewed 265 donor heart offers and accepted 15 (5.7% acceptance rate). In contrast, during the postintervention period (May–August 2025), the program received 171 offers and accepted 18 (10.5% acceptance rate). Despite receiving fewer total offers, the program had more total acceptances, indicating that the new processes enabled more effective screening of offers. This increased efficiency reduced offer burden and decision fatigue, allowing the clinical team to allocate more time to direct patient care, waitlist management, and proactive transplant readiness activities.
National Performance Metrics (SRTR): The observed internal improvements were corroborated by national performance data. In the first SRTR reporting cycle following implementation, the program’s four month Offer Acceptance Ratio (OAR) increased markedly from 0.74 to 1.74. This shift reflects a move from below-expected to above-expected performance compared with peer programs. The magnitude of improvement suggests that the interventions addressed both clinical decision-making variability and operational inefficiencies that had previously limited acceptance.
Transplant Volumes: Enhanced acceptance practices translated directly into increased transplant activity. The program performed 24 heart transplants in the first half of 2025. Following implementation of the revised processes, the number increased to 33 transplants in the second half of the year (37.5% increase). Notably, a substantial portion of this volume growth was attributable to expansion of the program’s DCD acceptance criteria, facilitated by increased use of organ preservation and perfusion technologies. By broadening eligibility for DCD donors, the program accessed previously underutilized high-quality organs, contributing directly to the observed increase in completed transplants.
Insights & Lessons Learned
The structured PDSA approach, coupled with consistent multidisciplinary review, enabled timely identification and implementation of high impact changes in organ acceptance practices. Individualized acceptance criteria helped reduce nonactionable offers, while expanded donor acceptance practices, including broadened DCD criteria, meaningfully increased transplant opportunities. Implementation success was supported by foundational strategies that enabled cohesive teamwork, faster decision-making, and adoption of improved acceptance practices:
*Multidisciplinary Collaboration: Each discipline brought essential clinical and operational insights into the review process. Weekly review sessions provided a structured forum for open discussion of declined offers, shared learning, and real-time identification of opportunities. The use of individualized acceptance criteria, early and consistent consultation with other specialties, and logistics coordination with third party vendors for organ recovery, organ preservation and perfusion fostered alignment and strengthened collaboration across teams.
*Change Management and Data Transparency: Effective change management strategies, centered on transparent communication, regular data sharing, and rapid PDSA feedback loops reinforced adoption of new practices. These strategies helped ensure that stakeholders understood the rationale for each intervention and could see the direct impact of changes on performance metrics.
*Leadership Endorsement: Active leadership engagement ensured accountability, protected necessary time for participation in review sessions, and sustained momentum throughout the improvement period. Leadership support also reinforced the importance of standardized acceptance practices and multidisciplinary collaboration.
As program performance improved and the volume of declined offers decreased, review meetings transitioned from weekly to biweekly demonstrating a maturing and efficient process. This evolution reflects both increased efficiency in offer evaluation and the sustained impact of the interventions on decision-making processes. As acceptance performance remains above expected levels, future efforts will include monitoring of balancing measures such as waitlist time, posttransplant outcomes, and equity of access to ensure that increased acceptance does not compromise patient safety. Continued data collection and real-time performance monitoring will support transparency and shared accountability. Findings will be reviewed through QAPI structures and leadership forums and communicated to frontline staff to maintain engagement and reinforce a culture of continuous improvement.