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.
Vulnerability, Support Systems and Trust-Based Feedback: A framework for the donation and transplantation community
Katie
McKee
, MPH
, Transplant Administrator
, Mayo Clinic
The Challenge
To Forgive, Divine. A June 29, 2024 New England Journal of Medicine Perspective Piece by Victoria Johnson, MD, MPH, concludes, “In the connections we form in our shared struggle, as we gather in call rooms, hallways, and empty exam rooms, huddling over the stories of our worst judgment calls and misses, we acknowledge to the universe the reality of our limitations. And then we get back to work.” Dr. Johnson is referencing medical errors in particular, and the crucial message of shared connections to reflect on, cope with, and learn from human limitations applies broadly. This message applies to teaching and is a well-timed reminder with new trainees who started July 1. It applies to adverse event reviews. It applies to how peers show up for each other in moments of challenge and self-doubt.
This review considers how it can specifically apply to the field of donation and transplantation in our current moment, one in which our shared connections are at risk in the midst of significant disruption. It would seem to be a time in which acknowledging the reality of our human limitations is required to forge a path forward.
The past five years have seen an increased focus on vulnerability, support systems and trust-based feedback in medical and surgical adverse event review. A focus on moral injury, human-centered approaches to root-cause analyses and quality methodology, and structured peer support are several key ways this has been achieved. These approaches, while emerging with significant work and spreading needed, offer a framework essential to our field if we are to truly work toward optimizing performance in the new now.
The purpose of this review to summarize what has made these approaches successful and offer these as potential models for our community.
The Approach
We conducted a literature review along with several interviews and case study reviews to understand how medical and surgical adverse event review have evolved. We focused in particular on the work of the American Society for Transplant Surgery led in part by Dr. Sunil Geevarghese out of Vanderbilt, and work out of the University of Wisconsin and NIH National Center for Advancing Translational Sciences to apply a human-factors approach to root cause analyses. We also reviewed approaches and models for review and support within our own organizations.
We summarized critical inputs to increasing vulnerability, effectiveness and adoption of support systems, and trust-based feedback. Key themes that will be discussed and expanded upon include the following.
Focus on moral injury. This is about community acknowledgement. Moral injury has specific definitions we will discuss in the context of moral distress and burnout. We will outline how vulnerability creates a required foundation for validation of experiences, creating a culture for enhanced learning, and building individual and team resilience.
Human-centered approaches to root-cause analyses and quality methodology. The Human Factors Analysis and Classification System (HFACS) for Healthcare provides a useful framework for acknowledging complexities and interdependencies that make up the systems in which we conduct our work. Based on the Theory of Active and Latent Failures, this framework allows discussion and learning to move from destructive to redemptive, with additional focus on systems, iterative and collaborative improvement.
Structured peer support. Effective models for structured support utilize peer support as a culture change tool, move from personal invulnerability to shared acknowledgment, move from isolation to community and camaraderie, normalize reactions to significant events, and move from perceptions of selfcare as selfish to selfcare as required to care for patients and community.
The Results
Those leading in donation and transplant have an opportunity and responsibility to elevate vulnerability, support systems and trust-based feedback in our field. We have asked individuals in interviews to describe our field of donation and transplantation, and their poignant descriptions provide a call to action. Our field of limited life-saving resources, of daily conversations about whether people are resilient enough, strong enough, “good” enough to steward the gift of a donated organ, while many professionals are at the same time questioning whether they are resilient enough, strong enough, “good” enough to keep going, especially after errors or setbacks. Our field of required interdependence among Transplant, OPOs, Hospitals, Industry, Government all of whom have good intent and conflicting priorities. Our field dependent on altruism and generosity, constant balancing of the greater good with regulatory outcomes requirements, imperfect policies, and multifaced partnerships. Our field of significant tumult at the moment, and for the foreseeable future. Our field at risk of abandoning the collaboration that has defined us, and driven success and progress on behalf of patients.
The community of donation and transplantation forms a broader, meaningful peer group, in which the elements of focus on moral injury, human-centered approaches to how we consider policy and industry changes, and structured peer support can be applied to repair and strengthen culture for optimizing performance.
Insights & Lessons Learned
The purpose of this overview will be to invite thought, consideration, discussion about how we acknowledge the reality of our limitations in the context of an industry in the midst of disruptive and foundational changes to how we save and heal lives together.
A summary of effective approaches from medical and surgical adverse event review, paired with suggested frameworks for application in the donation and transplant community, may serve as calls to action broadly applicable by stakeholders across our field.
We assert that venues such as the Alliance National Critical Issues Forums, which invite diverse representatives, open dialogue and translation of insight into action, are an ideal venue for such discussions.