HRSA Transplant Center Growth and Management Collaborative:
Best Practices Evaluation

Final Report

U.S. Department of Health and Human Services
Health Resources and Services Administration
Healthcare Systems Bureau, Division of Transplantation

September 2007

Executive Summary

Introduction

The U.S. Department of Health and Human Services (HHS) has devoted considerable effort to achieving increased organ donation and transplantation rates by developing public awareness campaigns and identifying and replicating organ procurement organization (OPO), donor hospital, and transplant center best practices. Between 1995 and 2006, there was a 67 percent increase in organ donors for all donor types from 8,854 to 14,756.¹ During this time, organ transplants also increased from 19,393 to 28,932, an increase of over 49 percent.² Despite this trend toward increased numbers of organ donors and transplants, a disparity remains between the demand for and supply of donor organs. Currently, there are more than 96,827 patients waiting for an organ transplantation in the United States.³ Further, of those on the waiting list, each day 79 will receive a life-saving organ transplantation, and 17 individuals die waiting.^{4, 5} Although there were over 4,500 organ donors and over 9,200 transplants between January and April of 2007, the gap between the supply of and demand for donor organs still remains.^{6, 7}

HHS’s Health Resources and Services Administration (HRSA) is committed to addressing this unmet need and has done so by implementing several initiatives. Two recent initiatives, the Organ Donation Breakthrough Collaborative and the Organ Transplantation Breakthrough Collaborative, have identified “breakthrough” best practices that are associated with increases in organ donation and transplantation in high-performing OPOs, hospitals, and transplant centers.^{8, 9} Together, the Organ Donation and Transplantation Breakthrough Collaboratives have resulted in an increase in the number of deceased donors and in organ availability. For example, in the 1st year of the Organ Donation Breakthrough Collaborative, organ donation increased by 10.8 percent in the United States.¹⁰ Other initiatives, such as The Workplace Partnership for Life, Strengthening Donor Registries, and the Driver’s Education Curriculum have also served to increase organ donation consent rates by educating the public about organ donation.

As these and other initiatives assist in increasing the supply of donor organs and the number of organs transplanted per donor, HRSA now seeks to identify and spread the best practices of transplant centers that are quickly adapting to the increased supply of donor organs in order to help transplant programs across the country effectively grow. This report presents observations of the best practices of selected high-performing transplant centers that have achieved high organ transplantation rates and efficiency in recovered organ use, while maintaining expected or higher than expected patient and graft survival outcomes.

Study Design

This study employs a qualitative, case study approach to identifying transplant center practices that are associated with high organ transplantation rates, while maintaining expected or higher than expected patient and graft survival outcomes. A sample of 15 transplant centers and 34 organ programs that are among the National leaders in number of organs transplanted with expected or higher than expected outcomes was selected for this study. The primary sources of data on the factors that contribute to success in high organ transplantation rates were face-to-face interviews with staff of transplant centers. In total, 465 people were interviewed for this study. Following the data collection phase of the study, the findings were analyzed, and best practices were assembled.

The high-performing transplant centers and organ programs that were selected for the study included the following:

This study is an initial phase of identifying and sharing “what works” across transplant centers to obtain higher numbers of organs accepted and transplanted. For the purpose of identifying true best practices (i.e., that are known to be causally related to high performance in transplantation and outcomes), this study has several limitations, including the following.

• Small sample. Due to time and resource constraints, only a limited number of site visits could be conducted for this study. Given that, the results may not be generalizable to other institutions.
• No control group. Including a control group of lower-performing centers would have enabled a more valid distinction between practices that co-exist with, but do not contribute to, higher performance and those that exist more often in higher-performing centers.
• Limited perspectives. Although a wide range of transplant center staff were interviewed, it is possible that some best practices were overlooked by not involving other parties with perspectives not encompassed in this study.
• Halo effect.¹¹ In this best practices study, transplant center staff were aware that they were participating in a study based on their high performance and may have categorized some practices not associated with higher numbers of organs transplanted and expected or higher than expected patient and graft survival outcomes as “best” practices.
• Hawthorne effect.¹² Many interviewees have noted that, as a result of being interviewed and having the opportunity to reflect on their work, they identified what they had previously considered to be certain typical routine practices as being likely best practices.

Strategies/Drivers and Key Change Concepts

Site visits to 15 transplant centers and 34 organ programs revealed six strategies/drivers (i.e., best practices) and 23 accompanying key change concepts associated with high performance in organ acceptance, transplantation, and outcomes among the centers. A summary of the strategies/drivers and corresponding key change concepts follows.

Strategy/Driver 1: Institutional Vision and Commitment

The first strategy/driver describes a factor that is fundamental to the success of a transplant center – vision and commitment from the institution. Hospitals cannot dabble in organ transplantation; they must commit to it fully and provide the resources and support necessary for the transplant programs to be successful. The 15 hospitals featured in this study all view transplantation as one of their institutions’ priority service areas and all have established and successfully worked toward goals of growing their programs.

Key Change Concept 1.1: Establish transplantation as a strategic priority.

All of the hospitals featured in this study have provided strong support to their transplant centers, and several of them have even established organ transplantation as one of a handful of strategic priorities for their institutions. In addition to making significant investments in staffing and other resources in order to facilitate the growth of the transplant center or one of its transplant programs, these institutions regularly monitor their programs’ progress toward achieving their goals.

Key Change Concept 1.2: Develop and implement business/strategic plan to secure institutional resources.

Even when hospitals have established organ transplantation as a strategic priority, transplant center administrators and physician leaders will need to work to continually demonstrate the value of transplantation to the hospital in order to secure resources needed on an ongoing basis to operate high-performing transplant programs. To help secure these resources, the centers visited have developed business and strategic plans that identify the targets, goals, and resources required to grow their programs.

Key Change Concept 1.3: Actively educate internally about goals, expected outcomes and accountabilities.

For transplant centers, educating hospital staff and leadership about organ transplantation can be important to securing institutional support for resources needed to operate successful and growing transplant programs. Among various areas of health care services, organ transplantation is unique in terms of the resources required to run a high-performing program (including information technology and nurse coordinators) and the accountabilities of the program to stakeholders outside the hospital.

Key Change Concept 1.4: Commit to providing a comprehensive, multi-disciplinary approach to the full continuum of transplant care.

The centers visited identified three key components of transplant care in which any hospital offering transplant services should invest. These components include providing care and support to patients across the continuum of transplant services from pre- to post-transplant care; providing transplant services as part of a broader spectrum of end-stage organ disease care; and integrating and sharing expertise among the transplant programs because many transplant patients develop problems with multiple organ systems.

Key Change Concept 1.5: Organize transplant services into a service line.

Some of the transplant centers visited have made a strategic decision to organize transplant services into a service line with designated budget and decision-making authority. For these centers that have been able to break down the traditional silos and streamline transplant services into a service line, the benefits have been an improved and more efficient decision-making process and greater accountability of staff toward achieving transplant center goals.

Strategy/Driver 2: Dedicated Team

On its own, institutional vision and commitment to transplantation is not enough to achieve effective or successful growth of a transplant program with expected or higher than expected patient and graft survival outcomes. Another critical component is creating and supporting a collaborative and rewarding work environment to attract and retain highly dynamic, committed, and skilled specialists in transplantation, including transplant surgeons, physicians, nurses, coordinators, social workers, financial managers and coordinators, medical specialists (e.g., infectious disease physicians, anesthesiologists, etc.), administrative staff, and allied health staff.

Key Change Concept 2.1: Organize around and empower committed surgeons and physicians who are aligned with the institution’s vision to build and grow the transplant program.

At all of the centers visited, successful transplant teams are built and organized around proactive, committed, experienced, and high-performing surgeons and physicians who have a passion for building and growing the transplant program. Most centers recruit experienced surgeons and physicians from other centers. However, given the limited pool of experienced and proactive transplant surgeons and physicians, some centers use their residency and fellowship training programs to “grow their own.”

Key Change Concept 2.2: Recruit, train, and retain program staff that are specialized, dedicated, and committed.

It is not enough to organize a transplant team around proactive and committed surgeons and physicians. Although surgeons and physicians can catalyze a growth spurt, in order to sustain a successful transplant program, surgeons and physicians need to be supported by a talented and experienced multi-disciplinary team of nurses, coordinators, socials workers, financial managers and coordinators, medical specialists, administrative staff, and allied health staff. Each team member possesses a unique set of skills, expertise, and knowledge that is needed to comprehensively treat transplant patients.

Key Change Concept 2.3: Establish and live by a collegial, non-hierarchical team approach to quality care.

In a field that integrates so many types of specialized providers and staff, a collegial, non-hierarchical team environment is essential. Given the multi-disciplinary nature of transplant medicine, collaboration and communication among various hospital departments and staff members is necessary. At the transplant centers visited, all staff members work together as an integrated team toward the common goal of providing the best possible patient care.

Strategy/Driver 3: Aggressive Clinical Style

Because of the perpetual shortage of organs, transplant centers must be aggressive in soliciting, listing, and caring for patients and in accepting and rehabilitating organs. This aggressiveness is manifested in a variety of ways, reflecting the diverse needs of the various transplant centers visited. However, at each site visited, there was an emphasis on evidence-based aggressiveness; physicians and surgeons were willing to innovate and take risks, but only if such actions were grounded in sound scientific and medical research and only if such risks were rigorously monitored and reviewed to assess safety and efficacy.

Key Change Concept 3.1: Create high threshold for rejecting organ offers and potential recipients.

The transplant centers visited employed aggressive patient and organ acceptance practices. By assessing patients and organs as a whole (instead of relying on heuristics), surgeons and physicians are often able to match the right organ to the right patient, even if the organ is marginal or the patient has multiple co-morbid conditions that could negatively impact the transplant’s success. Furthermore, transplant doctors recognize that just as certain techniques can improve the functionality of an organ, patients with potentially exclusionary co-morbidities can be treated to a point where they are eligible for transplantation.

Key Change Concept 3.2: Maintain preparedness by building, managing and optimizing your waitlist.

Effective management of transplant waitlists can have a profound impact on organ acceptance, patient waiting times, and patient outcomes. Transplant center staff stressed the importance of building a list that is large and diverse enough to accommodate incoming organ offers, without being so large as to hinder proper pre-transplant patient management. To facilitate the growth of the list, transplant centers have implemented a variety of practices to streamline the patient evaluation and listing processes. In addition, while on the waitlist, patients receive attention from a variety of actors (e.g., physicians, nurses, social workers, financial coordinators) to ensure that they are physically, financially, and psychologically prepared for transplantation.

Key Change Concept 3.3: Reach out and collaborate with referring community and professional staff.

Transplant physicians at the centers visited recognized the important role referring physicians play in the pre- and post-transplant care provided to patients and are eager to work collaboratively with these doctors to ensure that this care is delivered as efficaciously as possible. Through outreach efforts ranging from making themselves available to referring physicians at all times to developing protocols for them on how to care for transplant patients, transplant physicians build constructive relationships with the referring community, which can lead to improved patient care and increased patient referrals.

Key Change Concept 3.4: Partner with OPOs to implement best practices.

While the extent to which transplant centers rely on their local OPOs for organs is highly variable, they are almost uniformly benefited by improvements in local OPO performance. Many transplant programs offer their expertise to their local OPOs by developing protocols, holding trainings, and offering support on issues that may arise. Additionally, some centers use their OPOs to organize meetings and facilitate communication with other local transplant centers, while others reach out to more distant OPOs with high organ export rates.

Key Change Concept 3.5: Actively market program to increase referrals and organ offers.

Although superior outcomes may attract some patients, the transplant centers visited noted that aggressive outreach and marketing is often necessary to sustain growth. Transplant center representatives visit clinics and hospitals throughout the area to educate health workers and patients about their programs and transplantation as a possible treatment option, while transplant surgeons and physicians personally seek out community doctors to establish connections, maintain communication, and collaborate on patient care. Outreach is also aimed at local and regional OPOs.

Strategy/Driver 4: Patient and Family Centered Care

Several of the high-performing transplant centers visited for this study are part of a growing movement across the health care system to organize health care services around the needs of patients and their families, instead of around the needs of institutions. These centers have looked at the transplant process through the patient lens and identified ways to make the transplant process, from referral and evaluation to post-transplant care, easier and less stressful for patients and their families.

Key Change Concept 4.1: Remove patient access barriers and streamline workflow to provide more efficient care.

One component of patient- and family-centered care includes providing patients with a well-coordinated opportunity to be evaluated as a potential transplant candidate, as well as ensuring that they are given the most streamlined, efficient care possible once they are selected as transplant patients. Streamlining processes reduces unnecessary burden on patients and their families and allows patients to focus on caring for themselves across the continuum of care. In addition to lowering strain on patients, streamlining care can also create a more continuous workflow for transplant staff.

Key Change Concept 4.2: Educate patients and their “families” early and often.

While patients are dependent on transplant staff for their medical care, pre- and post-transplant success is also dependent on how well patients and their families are able to manage patient care outside of the hospital. Transplant centers visited stressed the importance of patient education from the patient’s initial evaluation and for the rest of his/her life. Patients must learn to manage their health by adhering to treatment plans, following dietary guidelines, taking their medication correctly, and knowing when to call the center for help. Providing clear, consistent, and constant education during every patient interaction ensures patients and their families understand their roles and responsibilities.

Key Change Concept 4.3: Don’t forget the “family”: Involve and support “families” throughout the entire transplant process.

Supporting the families of transplant patients was a common theme across the transplant centers visited. Recognizing that transplantation is stressful not only for the patients, but also for their families, many of these centers have made it a goal to be as family-friendly as possible. One of their primary goals is to make it easier for families to support and be with the patients throughout the transplant process by providing comfortable spaces for families while their loved ones are in the hospital and providing support groups and other services to ease the emotional strain.

Strategy/Driver 5: Financial Intelligence

Financial awareness and management was cited by the high-performing transplant centers as a critical component in optimizing organizational performance across transplant-related services. Key enablers contributing to transplant center financial intelligence include sound financial planning, focus on accurate cost accounting and cost management, maximizing third-party reimbursement through effective payer contracting, establishing mutually beneficial payer relationships, and providing transplant-specific financial counseling and coordination to patients and families early and often.

Key Change Concept 5.1: Track and understand your program finances, reimbursement mechanisms, performance, and volume.

It is important that transplant programs have an accurate picture of the full range of services they provide and the support they receive from other hospital departments that influence their financial performance. Tracking and understanding their costs and revenues on a payer and service-specific basis allows programs to identify areas of profit and loss and to develop plans to better optimize future performance.

Key Change Concept 5.2: Negotiate payer contracts with awareness of program strategy, finances, and strengths.

Given the inherent complexity of the transplant continuum of care, centers and payers often negotiate payment arrangements for covering transplant-related services, while managing financial risk for both parties. A relatively common contracting approach is to negotiate global payment rates that feature a single payment for all transplant-related services provided. To minimize transplant center financial risk, a keen understanding of patient resource use and program cost is essential in developing and updating global payment rates.

Key Change Concept 5.3: Develop and maintain constructive, mutually beneficial payer relationships.

Building and maintaining solid professional relationships with payers is a high priority among transplant center staff whom we interviewed. This involves proactive communication and transparency of financial and clinical data. Effective communication is critical in view of the complexity of transplant center-payer interactions.

Key Change Concept 5.4: Provide transplant-specific counseling and coordination to patients and families.

Aside from the considerable clinical challenges facing transplant patients and their families, financial challenges loom large. This is particularly burdensome for the many patients who, along with their families, have been compromised financially, as well as physically and emotionally by the time they are eligible for transplantation. The centers that we visited demonstrate “patient-centered” approaches and other means to provide financial counseling, coordination, and assistance during all aspects of the transplant experience, beginning at the first point of contact with the patient.

Strategy/Driver 6: Aggressive Management of Performance Outcomes

In order to maintain their high-performing transplant center status, the transplant centers visited repeatedly stressed the importance of aggressively managing program performance outcomes. According to the centers, transplant program performance and growth can be optimized through the implementation and use of protocols, research and innovation, and data-driven quality improvement. Collectively, these components create a pathway for transplant programs to become leaders in the field of organ transplantation by increasing the number of transplants performed and the patients served, while maintaining high quality outcomes.

Key Change Concept 6.1: Implement protocol-driven, standardized care.

Across several of the transplant centers visited, the development, maintenance, and use of protocols has been instrumental in the centers’ abilities to increase transplant volume and growth, without compromising patient and graft survival outcomes, by providing a standardized and efficient way of providing transplant services and care. Protocols allow for clear decision making and also assist in academic research because with protocols, one variable can be changed while all others are held constant, thereby allowing outcomes to be reliably assessed and compared.

Key Change Concept 6.2: Be on the cutting edge: be a research leader and innovator.

Research and innovation serve the dual purpose of advancing the field of transplantation and driving transplant volume and growth by pushing the envelope in terms of transplant procedures and practices and by attracting patients, payers, and staff. Given the young field of transplantation, conducting research to advance the field is critical. At all of the transplant centers visited, staff members are encouraged to actively keep abreast of the latest research and innovations in transplantation through regular review of literature, attending professional conferences, taking continuing medical education courses, and participating in other professional development activities.

Key Change Concept 6.3: Implement data-driven continual quality improvement.

According to the transplant centers visited, the aggressive collection and review of transplant program data plays a vital role in having a successful transplant program. Careful monitoring of outcomes and benchmarks allows transplant programs to identify areas for improvement and to remedy problems before they become serious and compromise patient care. As transplant patients become more informed consumers through the review of the Organ Procurement and Transplantation Network (OPTN) and the Scientific Registry of Transplant Recipients (SRTR) program data, continual quality improvement will become increasingly important.

Implementation Considerations

Transplant centers seeking to adopt the best practices presented in this report must consider certain matters of implementation. The sites visited for this study reported having to overcome certain barriers within the transplant system and to capitalize on particular opportunities in order to achieve high performance in organ acceptance, transplantation, and outcomes. These barriers and facilitators included the following:

Barriers:

• OPTN Organ Allocation Policy. Several interviewees observed that the organ allocation system can be a barrier to maximizing the number of organs transplanted. While interviewees supported the allocation system’s role in protecting the interests of all recipients, several noted that the current system presents obstacles to finding appropriate matches for organs in unstable donors or for marginal organs because it often requires OPOs to offer organs to a list of centers that they know, based on experience, are unlikely to accept. During the interviews, there also was speculation about what impact DonorNet will have on current organ allocation practices.
• Limited Availability of Skilled Transplant Staff. Transplant programs require access to a diverse array of surgeons, physicians, nurses, and other clinicians who are skilled in transplant services. Many of the transplant center staff interviewed noted that one of the barriers to growth is the shortage of certain types of qualified transplant clinicians and other staff, particularly transplant hepatologists. Smaller transplant programs or transplant programs that do not have much flexibility in terms of negotiating salaries or offering financial incentives during the recruitment process may find it even more difficult to recruit and retain staff for these positions for which there are shortages of qualified individuals.
• Reimbursement. One of the barriers for transplant centers seeking to increase the number of transplant surgeries they perform can be inadequate reimbursement from insurance companies, particularly for certain types of complex cases. Several of the administrative and financial staff interviewed noted that hospitals often are not reimbursed for the full cost of transplant care. This is particularly true when the cases are complex or when the case involves a public payer. Looking ahead, some of the centers are concerned that insurance companies will impose lifetime maximum payments on transplant services that are not adequate to cover the surgeries, as well as the pre- and post-transplant services.
• Market Saturation. While the staff of many of the high-performing transplant centers speculated that operating in a competitive market in close proximity to another strong transplant center likely drives them to perform better, competition could be a barrier to growing a transplant program if the market has reached saturation. In other words, in a market in which, for a particular type of organ, there is no excess supply of organs, it may be difficult for any transplant center in the region to launch or grow a program.

Facilitators:

• Institutional Capacity. One of the keys to the success of a high-performing transplant center is access to institutional resources, such as clinic space, office space, operating rooms, administrative staff, and financial resources. Hospitals in better financial health may be more likely to invest in their transplant centers’ staffing and operating needs or may be better able to absorb the losses on medically complex cases.
• Healthy Competition. Several surgeons and other transplant center staff interviewed noted that in the field of transplantation, competition can actually be good for business. In an effort to provide the best available care, high-performing transplant centers in close proximity push each other to continually strive to improve their performance and to engage in innovative practices.
• Strong OPO and Donor Hospital Performance. The most significant limitation to increasing the number of transplants performed in the United States is the limited supply of organs available for donation. As reflected in previous best practices studies conducted by HRSA, some regions of the country have had more success than others in maximizing the potential supply. Transplant centers operating in DSAs where the donor hospitals and OPOs are collaborating to maximize the supply of organs for transplantation are at an advantage in terms of maintaining and increasing their transplant volumes.

Conclusions

For most of the high-performing transplant centers visited, a critical success factor has been the vision and commitment of their hospitals’ leadership to making transplantation an institutional priority and to assuring the necessary resources and infrastructure to grow their transplant programs. At some of the centers, transplant programs have grown directly as a result of the executive leadership’s decision to seek out innovative and committed transplant surgeon and physician leaders and providing them with the necessary resources to achieve transplant growth. At other centers, transplant program administrators and clinical leaders have gained institutional support by first building a case for the value of transplant services to both the hospital and patients. In either case, organ transplantation has been established as a strategic priority at all of these centers, and significant investments in staffing and other resources have been made to facilitate growth of the transplant programs.

Another critical success factor of the 15 high-performing transplant centers is the existence of a collaborative and rewarding work environment that attracts and retains highly dynamic, committed, and skilled specialists in transplantation. Across all of the centers visited, transplant teams are led by proactive and committed surgeons and physicians who are aligned with the institution’s vision to build and grow the transplant program. However, in order to be successful, these surgeons and physicians need to be supported by a highly specialized and dedicated multi-disciplinary team of nurses, coordinators, social workers, financial managers and coordinators, medical specialists (e.g., infectious disease physicians, anesthesiologists, etc.), administrative staff, and allied health staff. Each team member possesses a unique set of skills, expertise, and knowledge that is needed to effectively manage patients and to provide high quality patient care.

Given the perpetual shortage of organs, aggressive patient and organ acceptance practices are critical components for optimizing transplant growth and volume, while maintaining expected or higher than expected patient and graft survival outcomes. Across the centers visited, evidence-based practices are employed to create a high threshold for rejecting less than optimal organ offers (including ECD and DCD organs), as well as higher-risk recipients. This aggressive approach also applies to patient evaluation and management while on the waitlist. By actively marketing their high quality transplant programs among patients, referring physicians in the community, OPOs, and payers, these centers are able to build and grow their transplant waitlists to an optimal size that allows them to effectively identify appropriate donor-recipient matches for every viable organ offer and to achieve increased transplant volume and growth, without sacrificing patient and graft outcomes.

In an effort to provide the best possible care to every patient and family everyday, the high-performing transplant centers visited have established institution-wide practices, systems, and mechanisms to organize care around the needs of patients and families. By looking at the transplant process through the patient lens, these centers have identified ways to make the entire transplant process easier and less stressful for both patients and their families. Centers have accomplished this by removing patient access barriers and streamlining staff workflow to provide more efficient care; providing patients and their families with a high level of education and support throughout the transplant process so that they have the information to make informed decisions about their care; and by creating a family-friendly, “normal” environment in order to make patients and their families feel at home while at the hospital for extended periods of time.

Achieving and maintaining transplant program financial strength has been another critical success factor of the high-performing transplant centers visited. Centers have employed various strategies including having a detailed understanding of program finances, sound financial management, and excellent payer relations. Financial staff at centers actively track and monitor their program finances and payer reimbursement mechanisms, negotiate payer contracts with rates that are based on transplant program actual costs and patient resource use, develop constructive and mutually beneficial relationships with payers, and provide transplant-specific financial counseling and coordination to patients and their families.

Finally, all of the transplant centers visited optimize their performance by aggressively monitoring and managing their program performance outcomes. From pre-, peri-, to post-transplant care, protocols are used to deliver standardized, efficient, and high quality care. In addition, all of the centers visited engage in clinical research both to advance the field of transplantation and to improve patient outcomes. By being on the cutting edge of research and innovative practices, these centers are able to foster transplant volume and growth by attracting patients and payers. Lastly, all of the centers visited regularly collect and review data on various transplant program outcome measures and use the data to identify problem areas and to implement appropriate process improvement strategies.

¹Donors recovered in US by donor type. Richmond, VA: Organ Procurement and Transplantation Network (not a U.S. Government Web site), 2007. Accessed July 9, 2007.
²Transplant by Donor Type. Richmond, VA: Organ Procurement and Transplantation Network (not a U.S. Government Web site), 2007. Accessed July 9, 2007.
³Waiting List Candidates. Richmond, VA: Organ Procurement and Transplantation Network (not a U.S. Government Web site), 2007. Accessed July 9, 2007.
⁴Transplants by Donor Type. Richmond, VA: Organ Procurement and Transplantation Network (not a U.S. Government Web site), 2007. Accessed July 9, 2007.
⁵Removal Reasons by Year. Richmond, VA: Organ Procurement and Transplantation Network (not a U.S. Government Web site), 2007. Accessed July 9, 2007.
⁶Donors recovered in US by donor type. Richmond, VA: Organ Procurement and Transplantation Network (not a U.S. Government Web site), 2007. Accessed July 9, 2007.
⁷Transplant by Donor Type. Richmond, VA: Organ Procurement and Transplantation Network (not a U.S. Government Web site), 2007. Accessed July 9, 2007.
⁸The Organ Donation Breakthrough Collaborative: Best Practices. The Lewin Group, 2003
⁹The Organ Transplantation Breakthrough Collaborative: Best Practices Evaluation. The Lewin Group, 2005.
¹⁰Burdick, J. Memo to ASTS membership: Organ Transplantation Breakthrough Collaborative. Health Resources Service Administration, June 17, 2005. Accessed July 19, 2006.

¹¹ The halo effect refers to a bias in observation or measurement that reflects an observer’s tendency to rate, perhaps unintentionally, a person or event or other phenomenon in a manner that is consistent with what the observer anticipated.
¹²In the Hawthorne effect, the act itself of observing people may prompt them to change their behavior. This might result, for instance, in subjects improving their performance due to their knowledge of being observed rather than due to an intervention such as training or use of some technology.

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