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Analysis

Organ Transfer Protocols Borrow from Logistics Industry for Safety, Efficiency

By Tinker Ready  
   June 02, 2016

Organ delivery teams won't be showing up in brown trucks, but they will be using tablets and small printers to identify and track donated organs. The approach is modeled on the United Parcel Service labeling system.

The nation's organ procurement agencies, working with the federal Health Resources and Services Administration, is in the process of rolling out a new system to streamline the transfer of organs from donors to transplant recipients.

And while the organ delivery teams won't be showing up in brown trucks or wearing brown uniforms, they will be working on an approach modeled on the United Parcel Service's labeling system.

Instead of hand-written labels, some programs are now using tablets and small printers to generate electronic labels that will allow them to identify and track donated organs.


Related: 5 Keys to a Successful Organ Transplant Program


The approach was developed by the Health and Human Services Idea Lab, an organization that seems to defy the image of a slow-moving, uninventive government agency.

That was what David Cartier thought when he saw a notice looking for an entrepreneur to work with HHS on the plan. "It sure seemed like an oxymoron. It's not typically what they do."

An industrial engineer with an expertise in process design, Cartier worked for UPS for many years before turning his attention to electronic medical records systems.

In 2013, the agency set up to Idea Lab "to improve how the Department delivers on its mission. This effort was started as a response to input from the workforce and public to promote advances in organizational management."

One of its stated core beliefs: "There is a solution to every problem."

After issuing a department-wide call for project ideas, the need to improve the organ transfer system emerged. The lab had an internal team working on the challenge, but they was missing a skill set, says Julie Schneider, a program manager with the Idea Lab.

Cartier, with his supply-side logistics background was just the person they needed.

"He really understood from the get-go that if he didn't dive down into the process of organ procurement, the technology would never be accepted," she said.

Safe But Inefficient

To prepare, Cartier watched roughly 70 transplant recoveries and many transfers so he could understand how the process worked and how it could be done better.

"So many times people make big decisions about a policy or process without seeing what the issues are," he says.

Organs were being labeled by hand with the donor name and blood type. Because so many checks were built into the system, it was safe. But it was also inefficient, he said.

Several efforts to develop a bar-coding system for organs had failed in the past.

Cartier found that "everyone did it differently." In some cases, staff had been working for 15 hours, so there were readability issues and transcription errors.

Still, a plan for the implementation of the system that went out for comment noted: "Between 2012 and June 2015, labeling errors accounted for 11% and packaging/shipping errors made up an additional 11% of all voluntary safety reports. During the same period, there were 136 unique labeling and 82 unique packaging/shipping safety situations reported. At least 22 organs associated with these errors were either not recovered or not transplanted."

Tinker Ready is a contributing writer at HealthLeaders Media.


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