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As a health-care executive, Josh Floren understands the importance of establishing and maintaining relationships, and he has taken that understanding to make great organizational strides in applying the Collaborative concepts to increase organ donation.

In January, Floren became vice president of medicine services at Parkland Health and Hospital System in Dallas. For six years, he had been an associate administrator of Charleston Area Medical Center (CAMC) in Charleston, W. Va.

The challenges he faces at Parkland are unique, Floren says. "One of the biggest challenges is meeting the county mandate of the hospital -- to furnish medical aid and hospital care to indigent and needy persons residing in the hospital district. It's a bit different from a private institution, because we have limited tax dollars and funding for services but an unlimited supply of patients needing our services. Also, the increasing age of the population along with the increasing expectation of services makes our work even more difficult," he adds.

How does one handle such a daunting challenge? Floren approaches this challenge by setting clear expectations for the entire hospital staff.

"Constantly tying everyone's work to the organizational goals can produce an outcome that is in direct alignment with the strategic direction of the hospital," Floren explains.

One such expectation Floren refers to is promoting organ donation. "Most hospitals do not have donation on their list of highest priorities. But setting the expectation that donation is important in your facility - and creating awareness throughout the organization by spreading information on conversion rates and yield - will automatically help drive success," Floren emphasizes.

While at CAMC, Floren had raised awareness about organ donation through staff education, focusing on why it's important to increase rates and how doing so would impact the transplant program. "One of the things we did was report monthly organ donation consent rates to the hospital's quality-improvement committee," Floren says. "The board of trustees saw quarterly statistics and started supporting efforts for the cause."

The increases were astounding. Before Floren left for Texas in December, CAMC's conversion rates had risen from 27 percent to 76 percent.

Floren also led efforts to strengthen the relationship between CAMC and its OPO, the Center for Organ Recovery and Education (CORE).

By building trust and educating hospital staff on the appropriate style of requesting, senior leaders set a clear expectation that CAMC would follow the Collaborative's evidence-based approaches, such as team huddles and early reporting of imminent death. CAMC also worked with CORE to place an in-house OPO coordinator at the hospital, a procedural change that contributed to significant improvements in conversion rates.

While at CAMC, Floren also recognized the lack of training among medical and hospital staff about donation after cardiac death (DCD).

"Though DCD was an accepted practice, the working relationship between the OPO and hospital had waned and DCD training events had become infrequent. Staff members also became concerned about pursuing donations after cardiac death. Since the staff members weren't familiar with the DCD procedure and rationale, we had to spend a lot of time conducting training on DCD," Floren says.

He credits the OPO and hospital staff for working together to learn about each other's organization. The senior leaders at the two organizations contacted each other regularly to learn whether they were meeting each other's expectations and to assess if the DCD educational efforts were satisfactory.

"Having that open line of communication really helped facilitate the speed for change," Floren says. Floren now also serves as a Collaborative faculty member in the Organ Donation and Transplantation Breakthrough Collaborative. At the National Learning Congress in October, 2006, he moderated a breakout session on involving senior leaders in the change process.

"The Collaborative has provided a tremendous opportunity for a large number of organizations to make changes very rapidly. No one has to reinvent the wheel as the Collaborative has facilitated the opportunity for rapid learning. "It is exciting to be a part of this, especially being able to improve the care provided to those waiting for an organ transplant," Floren says.

"And, now," he adds, "I have the opportunity to continue this work at Parkland Health and Hospital System."