2020

LifeBridge Organ 

and Tissue Sharing, 

Year 2 Case Study

nonprofit

www.nist.gov/baldrige
Baldrige Performance Excellence Program

National Institute of Standards and Technology (NIST) • United States Department of Commerce

July 2020

To order copies of this publication or obtain other Baldrige Program products and services, contact 

Baldrige Performance Excellence Program

Administration Building, Room A600, 100 Bureau Drive, Stop 1020, Gaithersburg, MD 20899-1020

www.nist.gov/baldrige | 301.975.2036 | baldrige@nist.gov

The Baldrige Program welcomes your comments on the case study and other Baldrige products and services. 

Please direct your comments to the address above.

The Baldrige Program is very grateful to an actual organ procurement organization that allowed its own Baldrige-based award application 

to be the basis for this case study. From that real application, names and data have been fictionalized, and elements have been intentionally 

edited to be less mature, less beneficial, and missing in order for this case study to score lower than the real application. Such editing 

was done so that Baldrige examiners being trained using the case study can more easily identify opportunities for improvement and 

general feedback. 

The LifeBridge Organ and Tissue Sharing Case Study, Year 2, is a fictitious Baldrige Award application prepared for use in the 2020 Malcolm 

Baldrige National Quality Award Examiner Preparation Course. The fictitious case study organization is intended to be a regional 

organ and tissue procurement organization for people living in a federally assigned territory within the made-up states of North and 

South Takoma. The case study illustrates the format and general content of an award application. However, since the case study 

serves primarily as a tool for training examiners to evaluate organizations against the 2019–2020 Baldrige Excellence Framework and 

its Criteria for Performance Excellence, it may not address all Criteria requirements or demonstrate role-model responses in all Criteria 

areas. Please refer to the LifeBridge Organ and Tissue Sharing Feedback Report, Year 2, to learn how the organization scored and to 

see its strengths and opportunities for improvement.

This case study is a work of fiction, created and produced for the sole purpose of training regarding the use of the Baldrige Excellence 

Framework. There is no connection between the fictitious LifeBridge Organ and Tissue Sharing and any other organization, named 

either LifeBridge Organ and Tissue Sharing or otherwise. The names of several national and government organizations are included to 

promote the realism of the case study as a training tool, but any data and content about them may have been fictionalized, as appropriate; 

all other organizations cited in the case study are fictitious or have been fictionalized. 

BALDRIGE EXCELLENCE FRAMEWORK®, BALDRIGE CRITERIA FOR PERFORMANCE EXCELLENCE®, BALDRIGE PERFORMANCE 

EXCELLENCE PROGRAM®, BALDRIGE COLLABORATIVE ASSESSMENT®, BALDRIGE EXAMINER®, BALDRIGE EXCELLENCE BUILDER®, 

PERFORMANCE EXCELLENCE®, THE QUEST FOR EXCELLENCE®, and the MALCOLM BALDRIGE NATIONAL QUALITY AWARD® medal 

and depictions or representations thereof are federally registered trademarks and service marks of the U.S. Department of Commerce, 

National Institute of Standards and Technology. The unauthorized use of these trademarks and service marks is prohibited.

NIST, an agency of the U.S. Department of Commerce, manages the Baldrige Program. NIST has a 100-plus-year track record of 

serving U.S. industry, science, and the public with the mission to promote U.S. innovation and industrial competitiveness by advancing 

measurement science, standards, and technology in ways that enhance economic security and improve our quality of life. NIST carries 

out its mission in three cooperative programs, including the Baldrige Program. The other two are the NIST laboratories, conducting 

research that advances the nation’s technology infrastructure and is needed by U.S. industry to continually improve products and 

services; and the Hollings Manufacturing Extension Partnership, a nationwide network of local centers offering technical and 

business assistance to small manufacturers.

Suggested citation: Baldrige Performance Excellence Program. 2020. 2020 Baldrige Case Study: LifeBridge Organ and Tissue Sharing, 

Year 2. Gaithersburg, MD: U.S. Department of Commerce, National Institute of Standards and Technology. https://www.nist.gov/baldrige.

Baldrige Performance Excellence Program

National Institute of Standards and Technology (NIST) • United States Department of Commerce

July 2020

To order copies of this publication or obtain other Baldrige Program products and services, contact 

Baldrige Performance Excellence Program

Administration Building, Room A600, 100 Bureau Drive, Stop 1020, Gaithersburg, MD 20899-1020

www.nist.gov/baldrige | 301.975.2036 | baldrige@nist.gov

The Baldrige Program welcomes your comments on the case study and other Baldrige products and services. 

Please direct your comments to the address above.

The Baldrige Program is very grateful to an actual organ procurement organization that allowed its own Baldrige-based award application 

to be the basis for this case study. From that real application, names and data have been fictionalized, and elements have been intentionally 

edited to be less mature, less beneficial, and missing in order for this case study to score lower than the real application. Such editing 

was done so that Baldrige examiners being trained using the case study can more easily identify opportunities for improvement and 

general feedback. 

The LifeBridge Organ and Tissue Sharing Case Study, Year 2, is a fictitious Baldrige Award application prepared for use in the 2020 Malcolm 

Baldrige National Quality Award Examiner Preparation Course. The fictitious case study organization is intended to be a regional 

organ and tissue procurement organization for people living in a federally assigned territory within the made-up states of North and 

South Takoma. The case study illustrates the format and general content of an award application. However, since the case study 

serves primarily as a tool for training examiners to evaluate organizations against the 2019–2020 Baldrige Excellence Framework and 

its Criteria for Performance Excellence, it may not address all Criteria requirements or demonstrate role-model responses in all Criteria 

areas. Please refer to the LifeBridge Organ and Tissue Sharing Feedback Report, Year 2, to learn how the organization scored and to 

see its strengths and opportunities for improvement.

This case study is a work of fiction, created and produced for the sole purpose of training regarding the use of the Baldrige Excellence 

Framework. There is no connection between the fictitious LifeBridge Organ and Tissue Sharing and any other organization, named 

either LifeBridge Organ and Tissue Sharing or otherwise. The names of several national and government organizations are included to 

promote the realism of the case study as a training tool, but any data and content about them may have been fictionalized, as appropriate; 

all other organizations cited in the case study are fictitious or have been fictionalized. 

BALDRIGE EXCELLENCE FRAMEWORK®, BALDRIGE CRITERIA FOR PERFORMANCE EXCELLENCE®, BALDRIGE PERFORMANCE 

EXCELLENCE PROGRAM®, BALDRIGE COLLABORATIVE ASSESSMENT®, BALDRIGE EXAMINER®, BALDRIGE EXCELLENCE BUILDER®, 

PERFORMANCE EXCELLENCE®, THE QUEST FOR EXCELLENCE®, and the MALCOLM BALDRIGE NATIONAL QUALITY AWARD® medal 

and depictions or representations thereof are federally registered trademarks and service marks of the U.S. Department of Commerce, 

National Institute of Standards and Technology. The unauthorized use of these trademarks and service marks is prohibited.

NIST, an agency of the U.S. Department of Commerce, manages the Baldrige Program. NIST has a 100-plus-year track record of 

serving U.S. industry, science, and the public with the mission to promote U.S. innovation and industrial competitiveness by advancing 

measurement science, standards, and technology in ways that enhance economic security and improve our quality of life. NIST carries 

out its mission in three cooperative programs, including the Baldrige Program. The other two are the NIST laboratories, conducting 

research that advances the nation’s technology infrastructure and is needed by U.S. industry to continually improve products and 

services; and the Hollings Manufacturing Extension Partnership, a nationwide network of local centers offering technical and 

business assistance to small manufacturers.

Suggested citation: Baldrige Performance Excellence Program. 2020. 2020 Baldrige Case Study: LifeBridge Organ and Tissue Sharing, 

Year 2. Gaithersburg, MD: U.S. Department of Commerce, National Institute of Standards and Technology. https://www.nist.gov/baldrige.
	 	

	 	 	 	 	

	 	 	 	 

CONTENTS 

2020 Eligibility Certification Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E1 

Organization Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O1 

2020 Award Application Form, page A-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A1 

Glossary of Terms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G1 

Preface: Organizational Profile 

P.1	 Organizational Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
 

P.2	 Organizational Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
 

Category 1: Leadership 

1.1	 Senior Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
 

1.2	 Governance and Societal Contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
 

Category 2: Strategy 

2.1	 Strategy Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
 

2.2	 Strategy Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
 

Category 3: Customers 

3.1	 Customer Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
 

3.2	 Customer Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
 

Category 4: Measurement, Analysis, and Knowledge Management 

4.1	 Measurement, Analysis, and Improvement of Organizational Performance . . . . . . . .17
 

4.2	 Information and Knowledge Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
 

Category 5: Workforce 

5.1	 Workforce Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
 

5.2	 Workforce Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
 

Category 6: Operations 

6.1	 Work Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
 

6.2	 Operational Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
 

Category 7: Results 

7.1	 Product and Process Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
 

7.2	 Customer Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
 

7.3	 Workforce Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
 

7.4	 Leadership and Governance Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47
 

7.5	 Financial, Market, and Strategy Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
 
2020	ELIGIBILITY	

CERTIFICATION	

FORM
Eligibility package due February 12, 

2020 Award package due April 21, 2020

Eligibility package due February 12, 2020 

Award package due April 21, 2020

	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	

	 	 	

	 	 	

	 	 	 	

 

	 	 	 	 	 	 	

2020 Eligibility Certification Form 

Malcolm Baldrige National Quality Award 

OMB Control No. 0693-0006 

Expiration Date: 07/31/2022 

Page E-1 of 12 

1. Your Organization 

Official name LifeBridge Organ and Tissue Sharing 

(if changed within the past 5 years) 

Headquarters 444000 Georgie Blvd, Suite 100

address Columbia, NT 01011 

Other name

Prior name

2. Highest-Ranking Official 

 Mr.  Mrs.  Ms.  Dr.

Name Marie Jamerson 

Chief Executive Officer 

marie.jamerson@LOTS.opo 

123-555-0001 

252-555-1000 

Address  Same as above

Job title

Email

Telephone

Fax

3. Eligibility Contact Point 

Designate a person who can answer inquiries about your organization. Questions from your organization and requests from the 

Baldrige Program will be limited to this person and the alternate identified below. 

 Mr.  Mrs.  Ms.  Dr.

Name Bart Wilson 

Director, Quality 

bart.wilson@LOTS.opo 

252-555-0072 (office); 

123-555-2715 (cell) 

123-555-1000 

Address

Job title

Email

Telephone Overnight

(office and cell, mailing

if possible) address

Fax

 Same as above

 Same as above (Do not use a P.O. box 

number.) 

4. Alternate Eligibility Contact Point 

 Mr.  Mrs.  Ms.  Dr.

Name Lisa Renaldo Telephone 123-555-0007 

E-mail lisa.renaldo@LOTS.opo Fax 123-555-1000 
Eligibility package due February 12, 2020 

Award package due April 21, 2020

	 	 	 	 	 	 	 	

	 	

	 	 	

	 	 	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 		

	 	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	

		 	

 

	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 		 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 		 	

2020 Eligibility Certification Form 

Malcolm Baldrige National Quality Award 

OMB Control No. 0693-0006 

Expiration Date: 07/31/2022 

Page E-2 of 12 

5. Application History 

a.	 Has your organization previously submitted an eligibility certification package?

 Yes. Indicate the year(s). Also indicate the organization’s name at that time, if different. 

Year(s)
 

Name(s)
 

2018, 2019
 

 No

 Don’t know

b.	 Has your organization ever received the Malcolm Baldrige National Quality Award®?

 Yes.

Did your organization receive the award in 2014 (the year you submitted award-winning application) or earlier?

 Yes. Your organization is eligible to apply for the award. 

 No. If your organization received an award between 2015 and 2019, it is eligible to apply for feedback only. 

Contact the Baldrige Program at (877) 237-9064, option 3, if you have questions. 

 No

c.	 Has your organization participated in a regional/state/local or sector-specific Baldrige-based award process?

 Yes. Years: State Quality Award, 2015, 2016, 2017 

 No

d.	 Is your organization submitting additional materials (i.e., a completed Organizational Profile and two results measures for

each of the five Criteria results items [option 8 in section 6k]) as a means of establishing eligibility?

 No. Proceed to question 6. 

 Yes. In the box below, briefly explain the reason your organization chose this eligibility option. (This information will be 

shared with the Alliance leadership, without revealing your organization’s identity.) 

6. Eligibility Determination 

See also Is Your Organization Eligible? (https://www.nist.gov/baldrige/baldrige-award/your-organization-eligible/). 

a.	 Is your organization a distinct organization or business unit headquartered in the United States?

 Yes  No. Briefly explain. 

b.	 Has your organization officially or legally existed for at least one year, or since April 1, 2019?

 Yes  No
Eligibility package due February 12, 2020 

Award package due April 21, 2020

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	

	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	

		 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	

	 	

	 	 	 	 	 	

		 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	

		 	

	 	

2020 Eligibility Certification Form 

Malcolm Baldrige National Quality Award 

OMB Control No. 0693-0006 

Expiration Date: 07/31/2022 

Page E-3 of 12 

c.	 Can your organization respond to all seven Baldrige Criteria categories? Specifically, does your organization have processes

and related results for its unique operations, products, and/or services? For example, does it have an independent leadership

system to set and deploy its vision, values, strategy, and action plans? Does it have approaches for engaging customers and the

workforce, as well as for tracking and using data on the effectiveness of these approaches?

 Yes  No

d.	 If some of your organization’s activities are performed outside the United States or its territories and your organization

receives a site visit, will you make available sufficient personnel, documentation, and facilities in the United States or its

territories to allow a full examination of your worldwide organization?

 Yes  No  Not applicable

e.	 If your organization receives an award, can it make sufficient personnel and documentation available to share its practices at

the Quest for Excellence® Conference and at your organization’s U.S. facilities?

 Yes  No

If you checked “No” for 6a, 6b, 6c, 6d, or 6e, call the Baldrige Program at (877) 237-9064, option 3. 

Questions for Subunits Only 

f.	 If your organization is a subunit in education or health care, does your subunit provide direct teaching and instructional
 

service to students or direct health care services to people?
 

 Yes. Proceed to item 6k . 

 No. Continue with 6g. 

g.	 Does your subunit function independently and as a discrete entity, with substantial authority to make key administrative and

operational decisions? (It may receive policy direction and oversight from the parent organization.)

 Yes. Continue with 6h. 

 No. Your subunit probably is not eligible to apply for the award. Call the Baldrige Program at (877) 237-9064, option 3. 

h.	 Does your subunit have a clear definition of “organization” reflected in its literature? Does it function as a business or
 

operational entity, not as activities assembled to write an award application?
 

 Yes. Continue with 6i. 

 No. Your subunit probably is not eligible to apply for the award. Call the Baldrige Program at (877) 237-9064, option 3. 

i.	 Is your subunit in manufacturing or service?

 Yes. Does it have 500 or fewer employees? Is it separately incorporated and distinct from the parent organization’s other

subunits? Or was it independent before being acquired by the parent, and does it continue to operate independently under

its own identity?

 Yes. Your subunit is eligible in the small business category. Attach relevant portions of a supporting official document 

(e.g., articles of incorporation) to this form. Proceed to item 6k. 

 No. Continue with 6j. 
Eligibility package due February 12, 2020 

Award package due April 21, 2020

	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	

	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	

	 	 	 	

		 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	

	 	

					

	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	

	 	

	 	 	 	

	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	

	 	

	 					

	 	 	

		 	 	 	 	

	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	

	 	

	 	

	 	 	 	 	 	 	

	 	 	 	 	

	 	

	 	

	 	

2020 Eligibility Certification Form 

Malcolm Baldrige National Quality Award 

OMB Control No. 0693-0006 

Expiration Date: 07/31/2022 

Page E-4 of 12 

j.	 Is your subunit self-sufficient enough to be examined in all seven categories of the Criteria?

• Does it have its own senior leaders?

• Does it plan and implement its own strategy?

• Does it serve identifiable customers either inside or outside the organization?

• Is it responsible for measuring its performance and managing knowledge and information?

• Does it manage its own workforce?

• Does it manage its own work processes and other aspects of its operations?

• Can it report results related to these areas?

 Yes. Proceed to 6k (table below). 

 No. Your organization probably is not eligible to apply for the award. Call the Baldrige Program at (877) 237-9064, 

option 3. 

k.	 Does your organization meet one of the following conditions?
 

1.	 My organization has won the Baldrige Award

(prior to 2015).

Yes



Your organization

is eligible.

No



Continue with

statement 2.

2. Between 2015 and 2019, my organization applied

for the national Baldrige Award, and the total of

the process and results band numbers assigned in

the feedback report was 8 or higher.

Yes



Your organization

is eligible.

Year:

Total of band

scores:

No



Continue with

statement 3.

3.	 Between 2015 and 2019, my organization applied

for the national Baldrige Award and received a

site visit.

Yes



Your organization

is eligible.

Year of site visit:

2018

No



Continue with

statement 4.

4.	 Between 2015 and 2019, my organization

received the top award from an award program

that is a member of the Alliance for Performance

Excellence.

Yes



Your organization

is eligible.

Award program:

Year of top

award:

No



Continue with

statement 5.

5.	 More than 25% of my organization’s workforce

is located outside the organization’s home state.

Yes



Your organization

is eligible.

No



Continue with

statement 6.

6.	 There is no Alliance for Performance Excellence

award program available for my organization.

Yes



Your organization

is eligible.

No



Continue with

statement 7.
Eligibility package due February 12, 2020 

Award package due April 21, 2020

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	

	 	

	 	 	

	 	

	 	 	

	 	 	

	 	 	

	 	 	 	

	 	

	 	

	 	 	 	

	 	 	 	

	 	

	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	

	 	

	 	

	 	

	 	

	 	 	

	 	

	 	 	 	

	 	

	 	 	 	 	 	

	 	

	 	

	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

2020 Eligibility Certification Form 

Malcolm Baldrige National Quality Award 

OMB Control No. 0693-0006 

Expiration Date: 07/31/2022 

Page E-5 of 12 

7.	 Between 2016 and 2019, my organization applied Yes Your organization  No, my Continue with

for the national Baldrige Award through the  is eligible. organization did statement 8.

alternate method (option 8 below) and the total

of the process and results bands assigned in the

Year: 2019 not apply using

this method. Your organization

is not eligible. Call

feedback report was 6 or higher.  No, my

organization

applied using this

method, but did

NOT receive a

total of 6 or higher.

877-237-9064,

option 3, if you

have questions.

8.	 My organization will submit additional Yes The Baldrige No Call 877-237-9064,

eligibility screening materials (i.e., a complete  Program will  option 3, if you

Organizational Profile and two results measures review the have questions.

for each of the five Criteria results items). The materials and

Baldrige Program will use the materials to contact your ECP

determine if my organization is eligible to apply after determining

for the award this year (as described in the fact your eligibility.

sheet at Eligibility FAQs).

7. Award Category 

a.	 Award category (Check one.) 

Your education or health care organization may use the Business/Nonprofit Criteria and apply in the service, small business, 

or nonprofit category. However, you probably will find the sector-specific (Education or Health Care) Criteria more 

appropriate. 

For-Profit	 Nonprofit 

 Manufacturing	  Nonprofit

 Service	  Education

 Small business (# 500 employees)	  Health Care

 Education

 Health Care

b.	 Industrial classifications. In table below, list up to three of the most descriptive NAICS codes for your organization (see

NAICS list included at the end of this document). These are used to identify your organizational functions and to assign 

applications to examiners. 

6219 
Eligibility package due February 12, 2020 

Award package due April 21, 2020

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

2020 Eligibility Certification Form 

Malcolm Baldrige National Quality Award 

OMB Control No. 0693-0006 

Expiration Date: 07/31/2022 

Page E-6 of 12 

8. Organizational Structure 

a.	 For the preceding fiscal year, the organization had	 in

 up to $1 million	  $1.1 million–$10 million  sales

 $10.1 million–$100 million	  $100.1 million–$500 million  revenue

  budget $500.1 million–$1 billion	  more than $1 billion

b.	 Attach a line-and-box organization chart that includes divisions or unit levels. In each box, include the name of the unit or

division and the name of its leader. Do not use shading or color in the boxes.

 The chart is attached.

c.	 The organization is _____ a larger parent or system. (Check all that apply.) 

 not a subunit of (See item 6 above.) 

 a subsidiary of	  controlled by	  administered by	  owned by

 a division of	  a unit of	  a school of	  other _____________________

Parent

organization

Address

Total number of

paid employees*

Highest-ranking

official

Job title

Telephone

*Paid employees include permanent, part-time, temporary, and telecommuting employees, as well as contract employees 

supervised by the organization. Include employees of subunits but not of joint ventures. 

Attach a line-and-box organization chart(s) showing your organization’s relationship to the parent’s highest management

level, including all intervening levels. In each box, include the name of the unit or division and its leader. Do not use

shading or color in the boxes.

 The chart is attached.

d.	 Considering the organization chart, briefly describe below how your organization relates to the parent and its other

subunits in terms of products, services, and management structure.
Eligibility package due February 12, 2020 

Award package due April 21, 2020

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

2020 Eligibility Certification Form 

Malcolm Baldrige National Quality Award 

OMB Control No. 0693-0006 

Expiration Date: 07/31/2022 

Page E-7 of 12 

e.	 Provide the title and date of an official document (e.g., an annual report, organizational literature, a press release) that

clearly defines your organization as a discrete entity.

Title Date

Attach a copy of relevant portions of the document. If you name a website as documentation, print and attach the relevant

pages, providing the name only (not the URL) of the website.

 Relevant portions of the document are attached.

f.	 Briefly describe the major functions your parent or its other subunits provide to your organization, if appropriate.

Examples are strategic planning, business acquisition, research and development, facilities management, data gathering 

and analysis, human resource services, legal services, finance or accounting, sales/marketing, supply chain management, 

global expansion, information and knowledge management, education/training programs, information systems and 

technology services, curriculum and instruction, and academic program coordination/development. 
Eligibility package due February 12, 2020 

Award package due April 21, 2020

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

 

	 	 	 	

2020 Eligibility Certification Form 

Malcolm Baldrige National Quality Award 

OMB Control No. 0693-0006 

Expiration Date: 07/31/2022 

Page E-8 of 12 

9. Site Listing 

You may attach or continue your site listing on a separate page as long as you include all the information requested here. You may

group sites by function or location (city, state), as appropriate. Please include the total for each column (sites, employees/faculty/

staff, volunteers, and products/services). If different sites are located on the same campus (e.g., medical building and acute care

hospital), please indicate that in the “Sites” column. See the ABC HealthCare example below. If your organization has any joint

ventures, please list and describe those in the second table below.

Please include a detailed listing showing all your sites. If your organization receives a site visit, an examiner team will use this 

information for planning and conducting its visit. Although site visits are not conducted at facilities outside the United States or its 

territories, these facilities may be contacted by teleconference or videoconference. 

Your Organization 

Sites (U.S. and Foreign) 

List the city and the state or country. 

Workforce*

List the numbers at 

each site. 

List the % at 

each site, 

or use “N/A” 

(not applicable). 

Relevant Products, Services, 

and/or Technologies 

Check one 

or more. 

 Employees 

 Faculty 

 Staff 

Volunteers 

(no. or 

N/A) 

Check one. 

% of 

 Sales 

 Revenue 

 Budget 

Columbia, NT 150 100% Regional organ and tissue 

procurement 

Total 150 N/A 100% 

*The term workforce refers to all people actively involved in accomplishing the work of an organization. The workforce includes 

paid employees (e.g., permanent, part-time, temporary, telecommuting, and contract employees supervised by the organization) 

and volunteers, as appropriate; it also includes team leaders, supervisors, and managers at all levels. 

LOTS has no joint ventures.
Eligibility package due February 12, 2020 

Award package due April 21, 2020

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	

2020 Eligibility Certification Form 

Malcolm Baldrige National Quality Award 

OMB Control No. 0693-0006 

Expiration Date: 07/31/2022 

Page E-9 of 12 

10. Key Business/Organization Factors 

List or briefly describe where necessary the following key business/organization factors (we recommend using bullets). Please be

concise, but be as specific as possible. Provide full names of organizations (i.e., do not use acronyms). The Baldrige Program uses 

this information to avoid conflicts of interest when assigning examiners to your application. Examiners also use this information 

in their evaluations. 

a.	 Main products and/or services and major markets served (local, regional, national, and international)

LOTS has served as the regional organ and tissue procurement organization (OPO) for 3.2 million people living 

within a federally assigned territory inclusive of 62 counties located within the states of North Takoma (NT) and 

South Takoma (ST). From its founding goal to assist in the coordination of organ donations, LOTS has grown to 

become a multifaceted, nonprofit organization dedicated to saving and improving lives. Its delivery of services 

requires the careful coordination of partners, collaborators, and key suppliers to ensure that organs and tissues 

are available for use by the organization’s key customer groups. 

b.	 Key competitors (those that constitute 5 percent or more of your competitors)
 

As the federally designated OPO within its service area, LOTS does not have traditional competitors. Much 

like a utility company, LOTS is a regulated “monopoly” that operates solely within the borders of its designated 

service area (DSA); no other OPOs may procure organs within this boundary. 

c.	 Key customers/users (those that constitute 5 percent or more of your customers/users)
 

Local organ transplant centers (Premier Health, Columbia University Hospital, Premier Children’s Hospital, and 

Columbia Children’s Hospital), tissue processors (Tissue Transformations, LifeBank, and Advantage Life), and 

an eye bank (VisionMax) 

d.	 Key suppliers/partners (those that constitute 5 percent or more of your suppliers/partners)
 

Excel Employee Engagement, Guardian Ambulance, Learning Development Institute, LinkingSmart, 

Survey System Success, Titan Technology (TT), Transplant Technologies, and Wright Brothers Charter 

e.	 Financial auditor	 Fiscal year (e.g., October 1–September 30)
 

Brother, Sister, & Auditor January 1–December 31 

f.	 Parent organization (if your organization is a subunit).
 

N/A 
Eligibility package due February 12, 2020 

Award package due April 21, 2020

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

2020 Eligibility Certification Form 

Malcolm Baldrige National Quality Award 

OMB Control No. 0693-0006 

Expiration Date: 07/31/2022 

Page E-10 of 12 

11. Nomination to the Board of Examiners 

If your organization is eligible to apply for the Baldrige Award in 2020, you may nominate one senior member from your

organization to the 2020 Board of Examiners.

Nominees are appointed for one year only. Nominees

■	 must not have served previously on the Board of Examiners and

■	 must be citizens of the United States, be located in the United States or its territories, and be employees of the
 

applicant organization.
 

The program limits the number of examiners from any one organization. If your organization already has representatives on the

board, nominating an additional person may affect their reappointment.

Board appointments provide a significant opportunity for your organization to learn about the Criteria and the evaluation

process. The time commitment is also substantial: examiners commit to a minimum of 200 hours from April to August,

including approximately 40–60 hours in April/May to complete self-study, four days in May to attend Examiner Preparation,

and 95–130 hours from June through August to complete an Independent and Consensus Review. If requested by the program,

examiners also participate in a Site Visit Review of approximately nine days. The nominee or the organization must cover travel

and housing expenses incurred for Examiner Preparation.

 Mr.  Mrs.  Ms.  Dr.

Lisa Renaldo from our organization will serve on the 2020 Board of Examiners.

lisa.renaldo@LOTS.opo Email address

 I understand that the nominee or the organization will cover travel and hotel costs associated with participation in Examiner

Preparation. I also understand that if my organization is determined to be ineligible to apply for the Baldrige Award in 2020,

this examiner nomination will not be considered for the 2020 Board of Examiners.

12. Self-Certification and Signature 

I state and attest the following:

(1) I have reviewed the information provided in this eligibility certification package.

(2) To the best of my knowledge,

■ this package includes no untrue statement of a material fact, and

■ no material fact has been omitted.

(3) Based on the information herein and the current eligibility requirements for the Malcolm Baldrige National Quality

Award, my organization is eligible to apply.

(4) I understand that if the information is found not to support eligibility at any time during the 2019 award process, my

organization will no longer receive consideration for the award and will receive only a feedback report.

Marie Jamerson Marie Jamerson Feb. 10, 2020 

Signature of highest-ranking official Printed name	 Date
 
Eligibility package due February 12, 2020 

Award package due April 21, 2020

	 	 	 	 	 	 	 	 	 	 	 	 

	 	 	 	

	 	 	 	 	

	 	 	 	

	 	 	 	

	 	

	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 		 	

	 	 	 	 	 	 	 	

	 	 	

	 	 	 	

	 	

	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

2020 Eligibility Certification Form 

Malcolm Baldrige National Quality Award 

OMB Control No. 0693-0006 

Expiration Date: 07/31/2022 

Page E-11 of 12 

13. Submission 

To be considered for the 2020 award, your complete eligibility certification package must be postmarked no later than 

February 12, 2020, to

Malcolm Baldrige National Quality Award
 

c/o ASQ—Baldrige Award Administration
 

600 North Plankinton Avenue
 

Milwaukee, WI 53203
 

(414) 298-8789, ext. 7205

Include proof of the mailing date. Send the package via

■	 a delivery service (e.g., Airborne Express, Federal Express, United Parcel Service, or the United States Postal Service

[USPS] Express Mail) that automatically records the mailing date or the USPS (other than Express Mail), with a dated

receipt from the post office.

Do you authorize ASQ to return copies of your date-stamped eligibility forms (required to be included in your application

package) via email? If you check “no” below, the copies will be returned to you via Federal Express. 

 Yes  No

14. Fee 

Indicate your method of payment for the $400 eligibility certification fee.

 Check (enclosed)	  Money order (enclosed) Make payable to the Malcolm Baldrige National Quality Award. 

 ACH payment	  Wire transfer	 Checking ABA routing number: 075-000-022

Checking account number: 182322730397

Before sending an ACH payment or wire transfer, notify the American Society for Quality (ASQ; [414] 298-8789, ext. 7205, or 

mbnqa@asq.org). Reference the Baldrige Award with your payment. 

 Visa  MasterCard  American Express

Card number Authorized signature

Expiration date Printed name

Card billing address Today’s date

W-9 Request: If you require an IRS Form W-9 (Request for Taxpayer Identification Number and Certification),

contact ASQ at (414) 298-8789, ext. 7205 . 
Eligibility package due February 12, 2020 

Award package due April 21, 2020

 	 	 	 	 	

 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	

 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

 	 	 	 	 	 	 	 	 	 	 	 	 	

 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

 	 	 	 	 	 	 	 	 	 	 	 	 	 	

 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

 	 	 	 	 	 	 	 	

	 	 	 	

	 	

	 	 	

	 	

	 	 	

 	 	 	 	 	 	 	 	 	 	 	 	

2020 Eligibility Certification Form Checklist 

Malcolm Baldrige National Quality Award 

OMB Control No. 0693-0006 

Expiration Date: 07/31/2022 

1. Eligibility Certification Form* 

 I have answered all questions completely.

 I have included a line-and-box organization chart showing all components of the organization and the name of each unit

or division and its leader.

 The highest-ranking official has signed the form.

For Organizations Submitting Additional Eligibility Screening Materials (to meet the alternative eligibility 

condition no. 8 for question 6k; see the table on page E-4) 

 I have enclosed a complete Organizational Profile.

 I have enclosed data for two results measures for each of the five Criteria results items.

For Subunits Only 

 I have included a line-and-box organization chart(s) showing the subunit’s relationship to the parent’s highest

management level, including all intervening levels . 

 I have enclosed copies of relevant portions of an official document clearly defining the subunit as a discrete entity.

*Please do not staple the pages of this form. 

2. Fee 

 I have indicated my method of payment for the nonrefundable $400 eligibility certification fee.

 If paying by check or money order, I have made it payable to the Malcolm Baldrige National Quality Award and

included it in the eligibility certification package.

3. Submission and Baldrige Examiner Nomination 

 I am nominating a senior member of my organization to the 2020 Board of Examiners.

 I am not nominating a senior member of my organization to the 2020 Board of Examiners.

 I am sending the complete eligibility certification package to

Malcolm Baldrige National Quality Award
 

c/o ASQ—Baldrige Award Administration
 

600 North Plankinton Avenue
 

Milwaukee, WI 53203
 

(414) 298-8789, ext. 7205

 I have included proof of the mailing date. (See Application Form and Content instructions at
 

https://www.nist.gov/baldrige/application-content-and-format/.)
 
ORGANIZATION
 

CHART
 
Tissue Procurement 

Supervisors

Kris DanielsMarvin Torre

Tissue Procurement 

Elaine Hart

Coordinators

Reed Anderson

Director, 

Tissue Procurement 

Donation Coordinators Family Support Performance Hospital Services 

Abigail Newton

Manager, 

Family Services 

Communications 

Lisa Renaldo

Chief Operating Officer 

Delane Oberly

Director, 

Hospital Services 

Bart Wilson

Director, 

Quality/Regulatory 

Floyd Bailey

Manager, 

Communications Center 

Talia Marshfield

Director, 

Marketing/

Public Relations

HR Coordinators 

IT Technicians 

Mona JoyceLucinda Phelps

Benefits Coordinator

Kim Lewis

Bethany Orr

Chief Human Resources Officer 

Garrett BurnsRoland EastonKaren LenDavid Wayans 

Alex Wharton

Chief Financial Officer

Susan Cooke

Director, Information 

Systems/Cybersecurity 

George Mateo, MD

Chief Medical Officer 

O1 

Accounting Clerks

Mary MeyersPaige Clark

Facilities Specialist

Miles Richards 

Specialists

Avery AmesLea BentonBrittany CarterAndrew ChenCasen EdwardsNina FosterWendy JasperEverett RousellLinda Underwood

Aftercare Coordinators

Tony HalseyDiane JeffersonEmily Strickland 

Coordinators

Darcy BennettQuincy NoonanJanice Potter

Supervisor

Fiona George

Hospital Services

Specialists

Efram BakerBlair BatesWanda ColemanAnna FishReva GordonDamon OwensRuth Anne PayneAlan QuinnPearl RenateLucy RipponIvy Shelton 

Improvement

Specialists

Carole FrewinLenny Keller

Quality Control

Specialists

Jordan KornblatPahal Singh

Medical Records

Reviewers

Henry MarshallRaymond WatsonKaty Yates 

Harold CarterCarlyn DavisDalton JeffersonPeter JohannsonPaula MartinJenny PettitFran RoseCreighton SmithFelicity Stephens

Triage Coordinators

Victor CharlesGrayson EdwardsLeon FrankEnya KarrHope Stanton

Receptionist/

Switchboard Operator

Connie Evers 

Marie Jamerson

Chief Executive Officer Jai Merrion

Executive Assistant

Fern BarnesWayne JohnsEva KarnesThomas LoweMike MannisHorace MillerGail NolenRachel RoperHelen Sharp 

Markus Weber

Director, 

Organ Procurement

Organ Procurement

Supervisors

Sam LewisYvette Sayer

Organ Procurement

Coordinators

Smitty EadsNick HallCindy HanoverKenzie HarrisonAbe JainsSunny NewkirkCalvin SchneiderJulien St. JamesRaul SommersHal TeasdaleBen UhlesKelly Zenk

Administrative Assistant

Joby Leathers

List of 50 additional employees AOS 
PAGE	A-1	

OF	THE	

2020	AWARD	

APPLICATION	FORM
	 	

		 	 	 	 	 	 	 	 

 		 	

	 	

	 	

	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	

	 	 	

 

	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	

	 	

	 	 	

2020 Award Application Form 

Malcolm Baldrige National Quality Award 

OMB Clearance #0693-0006 

Expiration Date: 07/31/2022 

Page A-1 

1. Your Organization 

Official name

Mailing address

LifeBridge Organ and Tissue Sharing 

444000 Georgie Blvd, Suite 100 

Columbia, NT 01011 

2. Award Category and Criteria Used 

a.	 Award category (Check one.) 

 Manufacturing

 Service

 Small business. The larger percentage of sales is in

(check one)  Manufacturing  Service

 Education

 Health care

 Nonprofit

b.	 Criteria used (Check one.) 

 Business/Nonprofit

 Education

 Health Care

3. Official Contact Point 

Designate a person with in-depth knowledge of the

organization, a good understanding of the application, and

the authority to answer inquiries and arrange a site visit, if

necessary. Contact between the Baldrige Program and your 

organization is limited to this individual and the alternate 

official contact point. If the official contact point changes 

during the application process, please inform the program. 

 Mr.  Mrs.  Ms.  Dr.

Name

Title

Mailing address

Overnight

mailing address

Telephone

Fax

E-mail

Bart Wilson 

Director, Quality 

 Same as above

 Same as above

(Do not use a P.O. box number.) 

252-555-0072 (office); 

123-555-2715 (cell) 

123-555-1000 

bart.wilson@LOTS.opo 

4. Alternate Official Contact Point 

 Mr.  Mrs.  Ms.  Dr.

Name

Telephone

Fax

E-mail

Lisa Renaldo 

123-555-0007 

123-555-1000 

lisa.renaldo@LOTS.opo 

5. Release and Ethics Statements 

Release Statement 

I understand that this application will be reviewed by members

of the Board of Examiners.

If my organization is selected for a site visit, I agree that the

organization will

■	 host the site visit,

■	facilitate an open and unbiased examination, and

■	 pay reasonable costs associated with the site visit (see

Baldrige Award Process Fees on our website [https:/

/www.nist.gov/baldrige/baldrige-award/award-process-fees]).

If selected to receive an award, my organization will share

nonproprietary information on its successful performance

excellence strategies with other U.S. organizations.

Ethics Statement and Signature of 

Highest-Ranking Official 

I state and attest that

(1) I have reviewed the information provided by my

organization in this award application package.

(2) To the best of my knowledge, this package contains no

untrue statement of a material fact and omits no material

fact that I am legally permitted to disclose and that affects

my organization’s ethical and legal practices. This includes

but is not limited to sanctions and ethical breaches.

Marie Jamerson April 19, 2020 

Signature Date

 Mr.  Mrs.  Ms.  Dr.

Printed name

Job title

Applicant name

Mailing address

Telephone

Email

Fax

Marie Jamerson 

Chief Executive Officer 

LifeBridge Organ and Tissue Sharing 

 Same as above

123-555-0001 

marie.jamerson@LOTS.opo 

252-555-0100 
	 	

	 	

GLOSSARY OF
 

TERMS AND
 

ABBREVIATIONS
 
	 	 	 	 	 	

	 	 	 	

	 	 	

	 	

	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	

	 	 	

	 	 	

	 	

	 	

	 	 	 	 	

	 	

	 	

	 	 	

	 	 	

	 	

	 	

	 	 	 	 	

	 	

	 	 	 	 	 	 	

	 	

	 	

	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	

	 	 	

	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	

	 	

	 	 	 	 	 	 	 	

	 	 	

	 	

24/7 

C 

Glossary of Terms and Abbreviations
 

24 Hours a Day/7 Days a Week

A 

AATB 

American Association of Tissue Banks

ADA 

Americans with Disabilities Act

AED 

Automated External Defibrillators

AOPO 

Association of Organ Procurement Organizations

AOS 

Available On-Site

AP(s) 

Action Plan(s)

Authorization 

Permission or power granted by an authority (first person

or next-of-kin) for organ and/or tissue donation

B 

BOD 

Board of Directors

CAP 

College of American Pathologists

CAPA 

Corrective Action Preventive Action

C&C 

Capability and Capacity

CC 

Core Competency: Mission-driven workforce

CCP 

Corporate Compliance Program

CDC 

Centers for Disease Control and Prevention

CDP 

Career Development Planning

CEO 

Chief Executive Officer

CFO 

Chief Financial Officer

CHNA 

Community Health Needs Assessment

CHRO 

Chief Human Resources Officer

CLIA 

Clinical Laboratory Improvement Amendments

CMO 

Chief Medical Officer

CMS 

Centers for Medicare and Medicaid Services

COI 

Conflict of interest

Conversion Rate 

Percentage of actual donors divided by potential donors

COO 

Chief Operating Officer

CSF 

Cyber Security Framework

CSS 

Community Support System

D 

DART Rate 

Days away, restricted, or transferred (OSHA Form 300a)

Data Mall 

Repository of predefined reports that allow the user to

access valuable organizational data for decision making

DCD 

Donation after Cardiac Death-type of donation for organ

procurement that occurs after cardiac cessation

DHHS 

U.S. Department of Health and Human Services

DMV 

Department of Motor Vehicles

DoL 

Department of Labor

DonorNet 

Facilitates organ placement and acceptance by rapidly and

efficiently providing key information to organ transplant centers

DOR 

Department of Revenue (for state of NT)

DSA 

Designated Service Area

E 

EEOC 

Equal Employment Opportunity Commission

ELT 

Executive Leadership Team consisting of the CEO, CMO,

CHRO, CFO, and COO

EMR 

Electronic Medical Record

G1 
	 	

	 	

	 	 	

	 	 	

	 	 	 	 	

	 	

	 	 	 	 	 	

	 	 	 	 	

	 	

	 	 	 	 	 	

	 	

	 	 	 	

	 	

	 	 	 	

	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	

	 	

	 	

	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	

	 	 	 	

	 	

I 

EPA L
 

Environmental Protection Agency

ERP 

Emergency Response Plan

F 

FDA 

Food and Drug Administration

FLSA 

Fair Labor Standards Act

Four As 

Complaint Resolution Process: Acknowledge, Apologize,

Ask, Act

FSS 

Family Support Services

FTE 

Full-Time Employee

G 

Gift of Life 

Organs and tissues donated by donor families

GPR 

National organization providing comparative satisfaction

and engagement data.

H 

HHS 

U.S. Department of Health and Human Services

HLA 

Human Leukocyte Antigen

HR 

Human Resources

HRSA 

Health Resources and Services Administration

ICU 

Intensive Care Unit

IMP 

Innovation Management Process

Individual Scorecards 

Measurement system tool tracked at the individual level

IPP 

Information Protection Program

IT/IS 

Information Technology/Information Systems

Improvement, improvement, improvement

LDS 

Learning and Development System

LOTS 

LifeBridge Organ and Tissue Sharing

LS 

Leadership System

LT 

Leadership Team

M 

ME 

Medical Examiner

N 

NT 

State of North Takoma

O 

OAC(s) 

Organ Acquisition Charge(s), the cost that is billed to the

transplant centers for the procurement of organs; includes

all direct and indirect costs

OD(s) 

Operational Discussions

OMP 

Operational Management Process

OPC 

Organ Procurement Coordinator

OPO 

Organ Procurement Organization

OPTN 

Organ Procurement and Transplantation Network

OR 

Operating Room

Organ 

Refers to kidneys, lungs, liver, heart, intestines, and pancreas

Organ Conversion 

Percentage of actual organ donors divided by potential

organ donors

Organ Yield 

Organs transplanted per donor

OSHA 

Occupational Safety and Health Administration

OWS 

Organ Work System

G2 

III 
	 	

	 	

	 	

	 	

	 	

	 	

	 	 	 	

	 	

	 	

	 	 	

	 	

	 	

	 	

	 	 	 	

	 	 	

	 	 	 	 	

	 	

	 	 	 	 	 	

	 	 	

	 	

	 	 	 	 	 	

	 	

	 	 	

	 	 	 	

	 	 	

	 	 	

	 	 	

	 	

	 	

	 	

P
 

PDSA 

Plan-Do-Study-Act problem-solving performance improvement

tool/methodology

PEP 

Performance Evaluation Process

PHI 

Personal Health Information

PHS 

Public Health Services

PI 

Performance Improvement

PII 

Personally Identifiable Information

PMS 

Performance Measurement System

PSA 

Public service announcement

Q 

QAPI 

Quality Assessment and Performance Improvement

QS 

Quality Systems

R 

RFO 

Rounding for Outcomes

ROI 

Return on Investment

S 

SA(s) 

Strategic Advantage(s)

SaaS 

Software as a Service

SC(s) 

Strategic Challenge(s)

SD(s) 

Strategic Discussion(s)

SO(s) 

Strategic Objective(s)

SOP(s) 

Standard Operating Procedure(s)

SPP 

Strategic Planning Process

SQA 

State Quality Award

SRTR 

Scientific Registry of Transplant Recipients

ST 

State of South Takoma

SWOT 

Strengths, Weaknesses, Opportunities, Threats analysis,

part of environmental scanning

T 

Tissue 

Refers to musculoskeletal, skin, cardiovascular, and eye

Tissue Yield 

Tissue procured per donor

TPC 

Tissue Procurement Coordinator

Topline Scorecard 

Performance measurement tool reflecting status of key

organizational metrics

TT 

Titan Technology

TWS 

Tissue Work System

U 

UAGA 

Uniform Anatomical Gift Act

UNOS 

United Network for Organ Sharing

V 

V/M 

Vision/Mission

V/M/V 

Vision/Mission/Values

VOC 

Voice of the Customer

VOS 

Voice of the Stakeholder

Yield 

Outcomes of donation activities

YTD 

Year to Date

W 

WPFL 

Workplace for Life

WPMS 

Workforce Performance Management System

G3 
ORGANIZATIONAL
 

PROFILE
 
	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

 

 

Organizational Profile
	

P.1 Organizational Description 

P.1a Organizational Environment 

P.1a(1) For more than 25 years, LifeBridge Organ and Tissue

Sharing (LOTS) has served as the regional organ and tissue

procurement organization (OPO) for 3.2 million people living

within a federally assigned territory inclusive of 62 counties

located within the states of North Takoma (NT) and South

Takoma (ST). From its founding goal to assist in the coordination of organ donations, LOTS has grown to become a multifaceted, nonprofit organization dedicated to saving and improving

lives (Figure P.1-1). Located in Columbia, NT, LOTS is one

of the 58 federally designated organizations of its kind in the

United States. Regulations mandate that LOTS may not operate

outside of its designated area, and no other OPO may operate

within LOTS’s area.

LOTS’s main service offering is the facilitation of organ and

tissue donation, accomplished through the organization’s two

work systems: Organ and Tissue. The delivery of services for

both work systems requires the careful coordination of partners,

collaborators, and key suppliers to ensure that organs and tissues

are available for use by the organization’s key customer groups

(Figure P.1-6). Both service lines (organ and tissue) are critical

to LOTS’s success, which is measured by the number of lives

saved and improved. The Partnership Model (Figure P.1-2)

highlights the organization’s coordination to ensure that organs

and tissues are always available for key customers.

Donor families come from the community at large and are identified as potential collaborators once a partner notifies LOTS of

a patient’s death. At this point, assuming the patient is medically

suitable for donation, the family is presented with the opportunity for donation by a member of the LOTS’s workforce. Due to

the limiting criteria governing organ and tissue donation, each

donation opportunity must be maximized to its fullest potential.

Of the approximately 15,000 deaths occurring annually within

LOTS’s designated service area (DSA), approximately 100

patients have the opportunity to become organ donors due to

the special circumstances of brain death under which an organ

donor must die. Tissue donation opportunities occur approximately 2,000 times annually (Figure P.1-3).

LOTS partners with the 80 hospitals and several nonhospital

referral organizations (medical examiner [ME] and hospice

offices) located within its DSA to gain access to potential donor

family collaborators, a critical control point of the Procurement

Process (Figure 2.1-2). LOTS provides ongoing educational

offerings to these partners to ensure that this introduction occurs

in a timely manner. Once a referral is made, LOTS prescreens

the potential donor for medical eligibility for donation. Patient

families are compassionately approached by Family Support

Services (FSS) staff in the Organ Work System (OWS) and by

the Communication Center staff in the Tissue Work System

(TWS). During the approach, families are presented with the

opportunity for donation or to honor their loved one’s previous

decision to become a donor(Figure 3.2-1, Pre-Donation Phase).

Figure P.1-1: Vision, Mission, Values 

VISION Organs and tissues are always available 

MISSION We save and improve lives 

VALUES Compassion Teamwork Honesty 

Quality Innovation 

Figure P.1-2: Partnership Model 

Figure P.1-3: Finding the Heroes 

Clinical staff members assist the donor hospital partners with

the medical management of the donor until transportation to

the LOTS facility occurs and the donated gifts are recovered

(Figure 3.2-1, Donation Phase).

In the OWS, recovery is performed by the transplant surgeon

assisted by Organ Procurement Coordinators (OPCs); in the

TWS, recovery is performed by Tissue Procurement Coordinators (TPCs). LOTS acts as a responsible steward of the “Gift

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of Life” by coordinating the placement of donated organs

and tissues to its key customer groups: local organ transplant

centers and tissue processors. The donated organs and tissues

are used for the betterment of the communities served, which

include donor families and transplant recipient patients and their

families (Figure P.1-6).

P.1a(2) LOTS’s vision is Organs and tissues are always available (Figure P.1-1). The vision was developed in light of the

belief that the organization’s ultimate goal will only be realized

when organs and tissue are readily available to patients when

they need them. Central to the LOTS’s culture is a strong drive

to meet the mission: We save and improve lives. 

According to the Health Resources and Services Administration

(HRSA), the number of people on the national waiting list for

organ donation and tissue transplantation continues to be much

larger than both the number of donors and transplants available,

and the trend is continuing. For example, in 1991, there were

23,198 people on the national waiting list, 15,756 transplants

were performed, and there were 6,953 donors. In 2017, there

were 115,000 people on the waiting list, 34,770 transplants

were performed, and there were 16,473 donors. In 2018, 36,528

transplants were performed nationally—a new record high

for the sixth consecutive year. In 2018, more than 145 million

people over the age of 18 had registered as national organ

donors, which is about 54 percent of all U.S. adults.

By definition, the mission affirms that LOTS plays a role in the

life-saving gift of donation. Whether it is the “literal life save”

of an organ recipient or a “quality of life improvement to a

tissue recipient,” at its core, LOTS is all about transplantation

and saving and improving lives. Values of compassion, innovation, honesty, teamwork, and quality serve as a guiding force

for how the workforce lives the culture on a daily basis. The

vision, mission, and values (V/M/V) of LOTS, validated during

the Strategic Planning Process (SPP; Figure 2.1-1), serve as

the foundation for the culture and form the basis for how the

organization is managed. The mission of LOTS could not be

accomplished without the organization’s core competency (CC)

of a mission-driven workforce.

Mission-Driven Workforce: The work of LOTS, by its very

nature, requires a level of care and compassion that can only

be delivered by the “human touch.” Therefore, the actions

and behaviors demonstrated by the staff are directly linked to

creating a positive donation experience for the donor family

(collaborators), which is essential to the accomplishment of the

mission and the success of the organization. This CC was identified using several cycles of LOTS’s workforce survey results,

which noted that overall engagement and overall job satisfaction

continue to show strong results (Figures 7.3-12, 7.3-12A, and 

7.3-13).

P.1a(3) LOTS is a 24/7 business in which many of the employees are decentralized. For example, members of the Hospital

Services staff spend most of their time at donor hospitals. The

Workforce Profile (Figure P.1-4) reflects the employee profile

and includes job type, tenure, gender, and ethnicity. To date, the

organization has not experienced any reductions in workforce.

Conversely, as the need for donations has increased, so has the

need for expansion of both clinical and nonclinical staff to support operational efficiencies. In addition, LOTS recently hired a

professional in public relations communication to lead its communications and outreach initiatives, as well as an IT specialist

to address cybersecurity issues. For the purpose of reporting and

comparing data, the workforce is segmented by work system

and department. The OWS manages the Procurement Process

for organs, the TWS manages the Procurement Process for tissues, and the support departments provide the infrastructure to

maximize organizational performance (Figure 2.1-2). The organization does not utilize the assistance of volunteers. Workforce

educational requirements, including applicable certifications,

may vary by work system and department and are included in

all job descriptions. In addition, the Learning and Development

System (LDS; Figure 5.2-2) includes components that allow

the tracking of personal goals and certifications in the online

Performance Evaluation Process (PEP; Figure 5.1-2). Utilizing

the Communication Process (Figure 1.1-3), LOTS routinely

underscores that every role in the organization contributes to

the success of the mission. Multiple workforce survey cycles

have validated three of the highest-scoring survey attributes:

the workforce connection to the mission, followed closely by

employee benefits and relationships with coworkers.

LOTS has no organized bargaining units. All employees

require a healthy, safe, and secure work environment. LOTS’s

approaches to address these requirements include systemwide programs focusing on risks in particular settings. Many

members of the workforce carry out clinical duties in a hospital,

rather than perform work in an office. Health and safety issues

related to working in hospitals also apply to the nonclinical

workforce. Similarly, typical office-related safety requirements

apply to the nonclinical workforce. At LOTS, such issues

are addressed through annual training and standard operating

procedures (SOPs). Due to the 24-hour nature of some work, for

“after-hours” staff members, special safety requirements exist

that include reserved office parking spots, secured parking, and

sensor lighting (5.1b[1]).

P.1a(4) LOTS owns a custom-built facility in Columbia, NT,

which houses a critical care unit where organ donor management occurs and with a fully equipped operating room (OR).

The key clinical technologies and equipment include x-ray,

ultrasound, and typical OR equipment. Utilizing technology,

Figure P.1-4: Workforce Profile (Employees) 

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LOTS provides its workforce with collaborative tools, realtime access to key data including an electronic medical record

(EMR) system (Transplant Technologies), and reporting

services that provide customized reports.

P.1a(5) The field of organ and tissue donation is one of the

most regulated areas of health care. Both state and federal

regulations have been put in place to provide the safest and most

equitable system for allocation, distribution, and transplantation

of donated organs and tissue. In addition, local environmental

and regulatory initiatives address both fire and sanitation

measures; biohazard trash disposal meets all local and state

regulations. LOTS’s key regulatory requirements are identified

in Quality Compliance Management (Figure P.1-5).

P.1b Organizational Relationships 

P.1b(1) Incorporated in the state of North Takoma, LOTS

is a private, nonprofit 501(c)(3) organization. A voluntary,

community-based governance Board of Directors (BOD) sets

policy for the organization and is composed of hospital executives, medical professionals, transplant recipients, donor family

members, and community representatives. Representatives from

LOTS’s key donor hospitals (partners) and transplant centers

(customers) are appointed, allowing these senior leaders to

represent customer and partner requirements. Reporting to the

governance board, the Chief Executive Officer (CEO) directs

an Executive Leadership Team (ELT) composed of the Chief

Medical Officer (CMO), Chief Human Resources Officer

(CHRO), Chief Financial Officer (CFO), and Chief Operating

Officer (COO). The Leadership Team (LT) consists of the ELT

and the directors, managers, and supervisors.

The BOD evaluates the performance of the CEO utilizing

ongoing monitoring of performance measures as outlined in the

Scorecard Review Process noted in 1.2a(2). The CEO evaluates

the performance of her direct reports, and those reports evaluate

the performance of the directors, who, in turn, evaluate managers and other members of the workforce.

P.1b(2) Figure P.1-6 outlines LOTS’s key customers, partners,

and stakeholders, as well as the requirements and expectations

for the organization’s services and operations for each group.

LOTS’s key market segment is the organization’s DSA, which

is assigned by the federal government. Local organ transplant

centers (Premier Health, Columbia University Hospital, Premier

Children’s Hospital, and Columbia Children’s Hospital), tissue

processors (Tissue Transformations, LifeBank, and Advantage

Life), and an eye bank (VisionMax) are LOTS’s key customer

groups. LOTS collaborates with the donor families to honor

their loved ones’ decisions to be donors or on behalf of their

loved ones; donor family requirements are the same regardless

of donation type.

P.1b(3) LOTS recognizes that key suppliers, partners, and

collaborators play an important role in supporting it in achieving

its vision, mission, and strategic objectives (SOs). Key suppliers

include Guardian Ambulance, Wright Brothers Charter, Titan

Technology (TT), and Transplant Technologies (Figure P.1-6).

These organizations have made significant business model

accommodations to provide 24/7 availability to ensure that

the donation can proceed smoothly. Guardian Ambulance and

Wright Brothers Charter provide air and ground transportation

services for staff, as well as organ and tissue donors, ensuring

that the donation is expedited. TT provides all routine maintenance and infrastructure support of information technology

(IT), allowing the internal IT staff employed by LOTS to

focus on technologies specific to the OPO industry. Transplant

Technologies provides the EMR system, including the platform

that allows sequel reporting functions, which are a critical part

of the Performance Measurement System (PMS; Figure 4.1-1).

Transplant Technologies also affords the organization the ability

to upload tissue donor records to the processors to ensure timely

release of tissue. These suppliers, partners, and collaborators

provide LOTS with the ability to assess process performance

and enhance competitiveness by exceeding customer requirements. Recent efforts to help educate the public about organ

donation and encourage people to register as donors have led to

the creation of new partnerships with state Department of Motor

Vehicles (DMV) and the Workplace for Life (WPFL).

As LOTS’s key partners and main referral sources, donor

hospitals and nonhospital referral sources are essential to

gaining access to potential donor families. Through ongoing

training, the Hospital Services staff assists with the establishment of systems that initiate the pre-donation Authorization

Process (through the Referral Management Process) and support

the donation decision. Once a referral to LOTS is made, a

LOTS workforce member presents the option of donation to the

potential donor family. As collaborators, donor family members

provide authorization for donation on behalf of their loved ones

or to honor their loved ones’ documented authorization to be an

organ and/or tissue donor. For donor family collaborators, twoway communication occurs during the Pre-Donation Phase via

face-to-face conversations (OWS) and by phone (TWS). The

Figure P.1-5: Quality Compliance Management 

Regulatory Agency 

Mandatory/ 

Voluntary 

CAP Safe Laboratory Practices Mandatory

CMS Billing and Performance Requirements Mandatory

EEOC Employment Practices Mandatory

FDA Compliance with Requirements Mandatory

DoL Employment Practices Mandatory

IRS Nonprofit Requirements Mandatory

HHS/

UNOS/

OPTN

Organ Allocation/Operational

Oversight

Mandatory

Occupational Health and Safety 

OSHA Workplace Safety Mandatory

Accreditation 

AATB Standards for Tissue Banking

Accreditation

Voluntary

AOPO Standards for Organ Procurement

Accreditation

Voluntary

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primary methods for knowledge sharing and communication with suppliers, collaborators, and partners are noted

in Voice of the Stakeholder (VOS; Figure 4.2-1); primary

methods for customer communication are noted in Voice of

the Customer (VOC; Figure 3.1-1).

Supplier and partner communication is mainly conducted

via two-way communication and face-to-face meetings with

follow-up communication via phone and email. Key suppliers and partners promote innovation by bringing forward

process improvement ideas and techniques. Inputs from

partners and collaborators, as well as other key stakeholders, feed into the SPP (Figure 2.1-1) and help drive process

improvement and innovation. LOTS’s key supply-network

requirements for suppliers include timely communication,

accurate information, and service quality (Figure P.1-6).

P.2 Organizational Situation 

P.2a Competitive Environment 

2a(1) As the federally designated OPO within its service

area, LOTS does not have traditional organ procurement

competitors. Much like a utility company, LOTS is a regulated “monopoly” that operates solely within the borders

of its DSA; no other OPOs may procure organs within

this boundary. To maintain this designation, however,

OPOs must meet national performance standards set by

the Centers for Medicare and Medicaid Services (CMS).

Should performance consistently fall short of the national

standards, CMS could choose to award the DSA to another

OPO. While OPOs do not compete for organs, the reassignment of potential future DSAs would be based on performance to the standards. For the TWS, donor hospitals are

required by law to report all deaths to LOTS; however,

they may contract with another tissue bank at their own

discretion for the recovery process. LOTS maintains tissue

recovery contracts with 100% of the 80 donor hospital

partners within its service area. LOTS also has recently

begun partnering with an eye bank, VisionMax, to ensure

eye donation opportunities for families in the DSA.

LOTS ranks 40th among the existing 58 OPOs in terms of

population living within its DSA. Since expansion of the

DSA is not allowed, growth in donation must come from

increases in medically eligible candidates from within the

DSA, from increases in the number of families who say

“yes” (authorization) to donation, or from the identification

of nonhospital referral sources. The constraints of a limited

service area reinforce the importance of maximizing donation for each donor in order to achieve the mission of saving

lives (Figure P.1-3).

P.2a(2) Because LOTS does not have competitors in the

traditional sense, there are no key changes taking place that

affect the organization’s competitive position as an OPO. While

changes to or elimination of the Affordable Care Act will be a

challenge for the health care industry, the scope of changes to

the OPO industry is uncertain at this time. As such, the organization has decided to focus on what it can control:

■	 increasing the number of registered donors within the DSA

through the identification of nonhospital referral sources, and

Figure P.1-6: Key Stakeholder Requirements 

Customers Requirements 

Transplant

Centers—Organ

• Maximize donation and transplantable organs

• Information/relationships/communication

• Competence/efficient high-performance work

Tissue Processors and

Eye Bank

• Maximize Donation and transplantable organs

• Information/relationships/communication

• Performance to projections

Key Partners 

Donor Hospitals

Medical Examiners

Hospices

Marketing Partners

(DMV, WPFL)

• Timely referrals

• Regulatory compliance

• Respect/Sensitivity

• Information/relationships/communication

• Service Quality

Collaborators 

Organ and Tissue

Donor Families

• Compassionate care, emotional support,

aftercare, and follow-up

• Stewardship of the Gift

• Honor for the Donor

Funeral Homes/

Columbia Cremation

• Information/relationships/communication

• Service

Stakeholders 

Communities within

Service Area

• Comply with Legal, Ethical, and Regulatory

Requirements While Providing Quality

Organs and Tissues

• Education, transparency, accessibility

Workforce • Connection with V/M/V

• Excellent Benefits

• Coworkers/Teamwork

Board of Directors • Strategic Planning

• Administration

• Financial Management

Key Suppliers Expectations 

Guardian Ambulance

Wright Brothers Charter

TT

Transplant Technologies

• Accurate Information

• Service Quality

• Timely Communication

■	 utilizing LOTS’s drive and proven ability to improve

and rely on its mission-driven workforce (CC) to achieve

cost-effectiveness and efficiencies to place itself in a strong

financial position to manage future challenges.

Key factors influencing the success of LOTS include

■	 a mission-driven workforce (CC) that is highly motivated

and engaged in saving lives, and

■	 strong relationships formed through partnering and

collaboration to support innovation and performance

improvement.

As stated previously, the OWS and TWS do not currently have

competitors.

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P.2a(3) The Comparative Data Process (Figure 4.1-4) lists the

organization’s key comparative data sources. The organ industry

has national benchmarks available through multiple sources;

however, the lead time before such results become available can

be many months. Comparative data are more limited for tissue

operations, in which tissue processors provide monthly feedback for select results in the form of scorecards. To offset these

limitations, LOTS relies on sharing through collaboration with

other OPOs to obtain comparative data. In addition, based on

Baldrige feedback, LOTS is planning a “Baldrige Benchmark

Project” to seek out benchmarks whenever possible.

P.2b Strategic Context 

Strategic challenges (SCs) and advantages (SAs; Figure P.2-1)

are reviewed annually during step 3 of the SPP (Figure 2.1-1);

steps 5 through 8 ensure that appropriate action plans (APs) are

linked to organizational success.

P.2c Performance Improvement System 

Together with the BOD, the LOTS LT creates an environment

that supports innovation through the creation of strategies, systems, and methods for achieving performance excellence. The

Leadership System (LS; Figure 1.1-1) is used to set and deploy

Figure P.2-1: Strategic Challenges and Advantages 

Strategic Challenges 

Examples of Alignment to 

Strategic Objectives/Goals 

(Figure 2.1-3) 

Business • Industry

changes

• SO 1/Increase Organs

Transplanted, Increase

Bone Donors

Operational • Authorization • SO 2/Increase Tissue

Authorization

Societal

Responsibility

• Increase

Registry

• SO 1/Increase Organ

Donors

Workforce • Retention • SO 3/Improve Workforce

Retention Rate

Strategic Advantages 

Business • Stakeholder

Satisfaction

• SO 3/Sustain Transplant

Center Satisfaction,

Improve Tissue

Processor and Eye Bank

Satisfaction, Sustain

Donor Family Satisfaction

Operational • Facilities and

Equipment

• SO 4/Ensure Supply

Optimization

Societal

Responsibility

• Baldrige

Business Model

• SO 4/Ensure Regulatory

and Legal Compliance,

Increase Results of

Operations, Accomplish

Action Plans

Workforce • Supportive

Mission-Driven

Culture

• SO 4/Ensure Connection

to the Mission

the V/M/V and culture to the workforce via the Communication

Process (Figure 1.1-3). LOTS has developed an organizational

structure, processes, and culture to focus on action and achieve

sustainable performance, to foster innovation, and to seek out

strategic opportunities. An environment that fosters innovation

and continuous process improvement allows LOTS to deliver

a distinctive value stream that benefits both the performance of

customer-focused operations and the lives of organ and tissue

recipients. Based on prior-year learnings, Plan-Do-Study-Act

(PDSA; Figure P.2-2) cycles and feedback loops were added to

many of LOTS’s processes.

LOTS uses the Baldrige Criteria for Performance Excellence as

its business model and its foundation for performance improvement (PI). Ultimately, this model provides ongoing feedback into

the SPP.Additionally, step 3 of the LS (Figure 1.1-1) provides

key business process monitoring to align business strategy to

organizational performance. Operational improvements are

identified and implemented through the SPP and the Operational

Management Process (OMP; Figure 6.1-1). Both processes

bring to the forefront key information to manage the business,

aggregate data, create actions that synthesize information into

knowledge, and ultimately facilitate the sharing of knowledge,

both internally and externally. Performance improvement

staff are part of the Quality/Regulatory Department and help

support the overarching organizational goal of improvement.

To monitor success, the PMS (Figure 4.1-1) is used. The

over-arching approach, formal and informal, to support process

improvement efforts is the PDSA problem-solving methodology (Figure P.2-2). This methodology is embedded in LOTS’s

improvement processes. In addition, LOTS has introduced a

new program known as “III,” which stands for improvement,

improvement, improvement. Every meeting and every process

has a built-in improvement process. All individual performance

reviews have an “III” component, and staff members have goals

related to this philosophy.

Figure P.2-2: PDSA Methodology 

v 
	 	

RESPONSES
 

ADDRESSING ALL
 

CRITERIA ITEMS
 
	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

Category 1: Leadership
 

1.1 Senior Leadership 

1.1a Vision and Values 

1.1a(1) The LS (Figure 1.1-1) provides direction for an

engaged workforce that successfully facilitates organ and

tissue donation in alignment with the vision and values (V/V;

Figure P.1-1). During a recent SPP session, LOTS reviewed

the V/V of the organization and decided to change its value of

improvement to “innovation” because LOTS prides itself on

being open to new ideas and creative thinking that goes beyond

process improvement. This process incorporated employee

input using an internal survey. The V/V were updated, vetted,

and ratified by the BOD.

The LT deploys the V/V and culture to the workforce, as well as

to customers, stakeholders, partners, and suppliers, via multiple

communication mechanisms as managed by the Communication

Process (Figure 1.1-3). Examples include

■ reviewing and emphasizing the V/M/V during board, staff,

and department meetings; and

■ incorporating the stories of donor families, recipients, and

patients waiting for a transplant into multiple communication

methods.

The LTmembers serve as role models and demonstrate their

commitment to the core values by setting the culture via the

LS, including through daily practice and during staff meetings,

during department meetings, and in conversations in Rounding

for Outcomes (RFO). Leaders provide personal acknowledgement to employees for demonstrating behaviors consistent

with the organization’s core values. The LTuses a 360-degree

review to provide systematic feedback to all LTmembers from

peers and direct reports pertaining to each leader’s individual

effectiveness, including exhibiting behaviors consistent with the

V/V. This review process also provides the LT with individual

opportunities for improvement and is used to assess the effectiveness of the LS. The BOD evaluates the CEO’s effectiveness

with operating the organization in alignment with the V/V. In

addition, the LT systematically reviews and improves the LS

process during an annual strategic discussion (SD) using PDSA.

As part of the adoption of PDSA, a gap was found in the use of

operational data in the SPP, so an operational data feedback loop

was added to the OMP(Figure 6.1-1) and into the SPP. Learning has also led to the addition of a feedback path in the LS.

The 360-degree review process is owned by the CEO. Similarly, each LOTS process has an individual as the primary

owner (although many others may “use” the process). Each

owner’s responsibilities for his/her process include (1) define,

(2) measure, (3) hardwire, (4) implement fully, (5) stabilize, and

(6) improve. Improvement for a process is triggered by either a

significant event or (minimally) is done annually.

1.1a(2) The LT’s actions personally demonstrate the highest

standards of ethical behavior by promoting the principles and

Figure 1.1-1: Leadership System (LS) 

ideas reflected in the V/V at staff, work system, and department

meetings, as well as regularly through RFO conversations. The

LT adheres to workplace policies including the Code of Professional Conduct, Donor/Recipient Confidentiality, and Conflict

of Interest (COI) with a signed annual disclosure.

Through the LOTS Corporate Compliance Program (CCP;

Figure 1.1-2), leaders promote an atmosphere that encourages

employees and stakeholders to report any questionable behavior.

An anonymous hotline reporting system isin place to ensure

confidentiality. The entire LOTS workforce, including the LT

and BOD, is trained annually on the CCP policy. Every year,

the LT reviews the CCP using PDSA to identify and implement

opportunities for improvement. In addition, compliance policies

are reviewed by LOTS Quality staff.

1.1b Communication 

LOTS’s LS has gone through several cycles of improvement,

including the addition of new mechanisms to communicate

with the workforce and more opportunities for interaction with

the LT, such as monthly LT rounding with workforce members.

The LTcommunicates with and engages the workforce using the

Communication Process (Figure 1.1-3). As LOTS has grown,

the Communication Process has gone through modifications

to stay current with organizational needs.Key decisions are

disseminated to the entire workforce through various meetings

or electronic communications. For example, workforce survey

feedback about the monthly staff meetings resulted in a new

format, a new schedule, and information-sharing mechanisms

that were then shared via the Communication Process. Completion of the Communication Process is accomplished through

knowledge sharing and feedback.

To promote frank, two-way communication with employees,

the LTuses the Communication Process, which supports an

open-door policy, and the RFO, which refers to the consistent

practice of asking specific questions to obtain actionable

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information. LTmembers “round” with workforce members

to gain knowledge, including the support needed to help the

workforce member achieve his/her goals, additional resource

needs, and peer recognition. This practice is also beneficial in

building relationships among leaders and their direct reports

and ensuring that communication is effective. To close the

communication loop, feedback is provided at staff meetings via

the Stoplight Report, which is a report that collects information

obtained in rounding and identifies suggestions, actions in

progress, or suggestions not taken. Members of the LT reinforce

high performance and a customer and business focus in multiple

ways (Figure 5.2-1, Rewards and Recognition). Personal notes

of recognition can be written by any member of the LT, including the CEO, to acknowledge special achievement. A customer

and business focus and motivation for high performance are also

accomplished using the Communication Process (Figure 1.1-3).

Local organ transplant centers, tissue processors, and an eye

bank are LOTS’s key customers. The LT communicates and

engages with its customers per the VOC (Figure 3.1-1). Communication with key customers is based on one- and two-way

communication and occurs in all phases of the customer life

cycle. Due to the confidential nature of donation, social media

are not used for operational communication. Social media

are used for internal and external communication for broader

nonconfidential messaging that does not incorporate donor

information, such as campaigns and messaging to increase the

number of registered donors within the DSA. In addition, social

media are used to communicate and highlight donor family and

recipient stories via YouTube, Facebook, Instagram, and Twitter,

reinforcing the mission of saving and improving lives . 

1.1c Mission and Organizational Performance 

1.1c(1) The LT creates a successful organization now and

in the future through the SPP (Figure 2.1-1) and the LS

(Figure 1.1-1), which allow a focus on the organization’s

planning and key processes to create integrated work systems.

To ensure sustainability, processes are mapped and documented,

and succession plans are developed; thereby ensuring the

environment to accomplish LOTS’s life-saving mission. Step 1

of the LS (Figure 1.1-1) ensures that LOTS is able to create and

reinforce an organizational culture that fosters workforce and

customer engagement, utilizing the Communication Process

(Figure 1.1-3) and the VOC Process (Figure 3.1-1).

LOTS’s strategy is operationalized via the SPP (Figure 2.1-1),

OMP (Figure 6.1-1), and Communication Process (Figure 1.1-3).

The SPP establishes strategic organizational direction, from

which APs are developed, implemented, and modified as

needed. The OMP is utilized to review, analyze, improve, and

prioritize the organization’s internal and external processes; key

strategic and operational decisions are communicated to the

workforce and key partners via the Communication Process.

The organization’s performance is monitored by the LT using

the PMS (Figure 4.1-1); leadership and employee performance

is monitored via the PEP (Figure 5.1-2). The LOTS culture,

the V/M/V, and the LDS (Figure 5.2-2) create an environment

amenable to employee and organizational learning.

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The commitment to the mission of saving and improving lives, 

along with the value of innovation, drives LOTS to stay aware

of industry knowledge and best practices (see also 4.2b[2]).

Individual training and development goals are addressed

through the ongoing PEP. As described in P.1a(2), the LOTS

culture encourages an environment where employees continuously seek opportunities for innovation and improvement in

order to save and improve more lives. LT members leverage

the Baldrige Excellence Framework, relationships with suppliers and partners, and changes in the OPO environment to

cultivate organizational agility and intelligent risk taking and

create opportunities for innovation. During an annual SD with

the BOD, senior leaders review stakeholder feedback collected

and analyzed during the SPP, conduct risk analysis on potential

strategic initiatives, and determine intelligent risks worth taking

for innovation and organizational improvement. As part of the

SPP, the LT determined that there was a gap in the performance

of managing innovation and intelligent risk. As a result, a

process and management structure were established, which is

described in 2.1a(2) and 6.1d.

Senior leaders create an environment for agility and the achievement of the mission by setting clear expectations of accountability for achieving strategies, tactics, and actions as part of

systematically deploying performance reviews, which are linked

to the values of the organization, and to the mission and vision.

Organizational agility comes from the SPP and performance

reviews, where periodic review of outcomes and strategic tactics

allows for changes to address gaps or opportunities identified

for improvement (such as those identified from the VOC (see

Figure 3.1-1). Gaps or opportunities can be addressed through

a variety of tactics including PDSA or next generation growth

(see 5.2c[4]).

The LT creates an environment that encourages and supports

accountability, organizational learning, innovation, and intelligent risk taking. One of the ways that the LT does this is

through monitoring the key metrics on the Topline Scorecard

(Figure 4.1-2). If a metric is “in the red” for three months, the

responsible leader must analyze and understand why, and if

the metric continues below the target, a new or modified AP

must be developed to address the shortfall. Gaps identified are

assessed for impact on organizational agility, intelligent risk

taking, and/or innovation. Gaps with organizational impact are

analyzed, and any that would improve agility and innovation

within appropriate risks may become improvement actions or

process changes.

The LT develops succession plans for leadership positions

(including CEO) to ensure that there are opportunities for future

leaders to grow within the organization and that appropriate

leadership is available should a vacancy occur. Succession

plans are aligned with the annual performance evaluations to

ensure that current and future leaders are receiving the needed

leadership training to support their individual growth and

development. A 360-degree feedback review is used to identify

specific improvement opportunities for current and future

leaders. LT development has included training through the

Learning Development Institute, attendance at state and national

industry conferences, and attendance at nation-wide nonindustry

conferences. In alignment with the III program, senior leaders

systematically use PDSA to review and improve the effectiveness of their involvement in succession planning, the development of future leaders, and other processes that create an

environment for organizational success. Each member of the LT

works with potential successors to mentor their development.

LT involvement in the development of future organizational

leaders includes opportunities for shadowing, special assignments, participation in the learning development curriculum,

and rewards and recognition for outstanding workforce members. The approach to succession planning has been evaluated

and improved several times; the latest refinement was in 2019,

based in part on Baldrige feedback. In its latest evaluation, the

LT recognized that growing organ and tissue donation required

greater organizational agility. In addition to formal leadership

training through the Learning Development Institute, greater

emphasis is being placed on creating opportunities for learning

within the organization. On-the-job training offers a costeffective way to cross-train and to link training more closely to

LOTS’s capacity needs and priorities, resulting in future leaders

with a broader understanding of organizational needs.

1.1c(2) Through the LS (Figure 1.1-1), the LTcreates a focus

on accomplishing the organization’s objectives, improving performance, and achieving the V/M/V. Step 1 of the LS is creating

the environment, a key part of the organization’s success. This

includes using the customer-focused and mission-driven culture

to identify opportunities for innovation and continuous improvement. Step 2 of the LS (Operationalize the Strategy) establishes

a focus on actions, which are monitored in step 3 (Monitor the

Performance). Cascading scorecards—integrated into work

systems, departments, and many individual metric levels and

incorporated into the web-based PMS—are a key piece of the

PMS and are reviewed at each work system meeting (Figures 

4.1-1 and 4.1-2). Senior leader accountability for the organization’s actions is accomplished through annual goal plans

reflected in the PEP (Figure 5.1-2). Review of the work system

scorecards occurs at the work system meetings and ensures the

ability to recognize the need to modify or implement APs as

priorities change. AP progress for all departments is reviewed

at LT meetings. Systematic reviews of the APs, via one-on-one

meetings with managers, provide workforce accountability

and opportunities to ensure that organizational performance

is progressing to plan and that LOTS is ultimately attaining

its vision. For example, the Tissue Procurement Department

and the PI staff worked collaboratively in 2018 to address “red

boxes” for documentation compliance. Several initiatives were

created and implemented, resulting in process and procedure

improvements that resulted in improved documentation metrics

that did achieve target.

Step 1 of the annual SPP helps the organization focus on

balancing the needs of customers, partners, and stakeholders.

Expectations are validated by periodic surveys and focus

groups. Performance metrics in the PMS represent key performance measures of the organization and ensure balance for key

customers and stakeholders.

The LT uses LOTS’s PDSA improvement methodology

(Figure P.2-2) to continually take the LS to the next level in

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pursuit of the vision. For example, the Corporate Compliance

Program has been through three cycles of evaluation and

improvement in the last four years. This has resulted in greater

engagement with employees and stakeholders, and has led to

changes in annual compliance policy training.

1.2 Governance and Societal Contributions 

1.2a Organizational Governance 

1.2a(1) Governance of the organization is provided by a

15-member BOD that strategically reviews organizational

results to achieve fiscal and management accountability.

Transparency in operations ensures that LOTS addresses its

responsibility to the community, exhibits ethical behavior,

practices good citizenship, and protects stakeholder interests.

LOTS’s diverse board reflects key customers, stakeholders,

and partners and is balanced to promote a diversity of insights

and perspectives. Practices of the LOTS’s BOD to review and

achieve key aspects and accountability of governance include

the following:

■ Hold management accountable for operational results

through evaluation of the monthly Status Report/Topline

Scorecard, which shows SO target progress.

■ Review and approve the strategic plan, budget, Quality

Assessment and Performance Improvement (QAPI), and

topline metrics annually.

■ Achieve fiscal accountability by in-detail review of financial

reports at board meetings.

■ Ensure transparency of the board and committee operations

through the availability of minutes, presentations, and

reports that include quality/regulatory outcomes. Transparent

selection of governance board members is accomplished by

actively soliciting nominations from sources including key

members of the community and members of the NT and ST

Medical Advisory Boards, in addition to nominations from

existing BOD members and senior leaders. COI, corporate

compliance training, and disclosure statements are signed

annually by all board members.

■ Maintain independence and effectiveness in audits through

an annual external audit. The audit firm is engaged by the

board Audit Committee, which comprises independent board

members. Audit results are reported to the committee along

with any recommendations.

■ Develop and approve a formal succession plan for the CEO.

Authority has been delegated by the BOD to the CEO

to oversee succession plan development for other senior

leaders.

■ Systematically review and improve the governance

processes using LOTS’s PDSA process. The overall

governance process has been through multiple cycles of

improvement since the BOD began its systematic reviews

in 2014. Examples of improvements include improving the

succession plan for the CEO position, improving follow-ups

to the Audit Committee’s recommendations, and creation of

the monthly Status Report.

1.2a(2) A systematic review process is utilized by the BOD’s

Compensation Committee to conduct an annual review of

the CEO’s performance. The process inputs include a selfevaluation by the CEO, a review of organizational performance

metrics, and an online evaluation of the CEO by the BOD.

These inputs are used by the Compensation Committee to

develop the CEO’s performance review and, in collaboration

with the CEO, to set new goals for the upcoming year. The

Compensation Committee engages an external consulting firm

to conduct a salary survey. In conjunction with the salary survey

information, a compensation philosophy and salary range for

the CEO are established by the Compensation Committee.

Feedback from the BOD and assessment of the committee are

utilized to adjust salary based on performance.

The CEO conducts annual performance evaluations for the ELT

using the same PEP as is used for evaluations of the LT and

the workforce. As part of the PEP process, the CEO provides

these leaders with ongoing feedback, including leadership

effectiveness and progress towards goal completion in order

to drive improvements in performance. The BOD completes

self-evaluation surveys biennially to determine the level of

performance of board members, as well as to identify opportunities to improve the effectiveness of the governance system. The

survey includes a self-assessment of the members’ knowledge

and comfort levels with key areas of LOTS’s operations; this

feedback is used to develop an educational agenda targeting

their identified development needs (Figure 7.4-3). These survey

results help guide BOD meetings and communication.

All governance processes are evaluated for effectiveness in the

third quarter BOD off-site, which is used as a key input to the SPP.

1.2b Legal and Ethical Behavior 

1.2b(1) Historically, national industry concerns have focused

on the safety of the organs and tissues, coupled with fairness

in the allocation of organs to recipients. LOTS proactively

approaches these potential threats through strict adherence to

policies and procedures put in place to provide the safest and

most equitable system for allocation, distribution, and transplantation of donated organs. Continuing scientific and technological advances in organ transplantation requires ongoing policy

refinements. Policies evolve to ensure that patients benefit from

the best possible solutions. LOTS leverages the Organizational

Structure (Figure 1.2-2) and utilizes the SPP (Figure 2.1-1,

step 2) to gather information from a variety of sources to anticipate legal, regulatory, and community concerns. As an example,

the organization engages the greater community through board

representation of stakeholder communities on both the governing and advisory boards. As part of its work, the BOD, through

its Compliance Committee, also monitors industry proposals in

an effort to anticipate new legislation or regulatory requirements

and to ensure that LOTS is prepared to address them.

A Crisis Communication Plan has been developed to ensure

an appropriate response to public concerns, if needed. As part

of the plan, media alerts and position statements created by

industry organizations are used in response to national news

stories and are distributed to the workforce, the BOD, and the

community as appropriate.

Due to LOTS’s life-saving mission, all voluntary industry

accreditations are sought to help ensure regulatory and legal

compliance (Figure P.1-5), as well as ethical behavior. These

voluntary accreditations help LOTS ensure that processes meet

4 
	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	

	 	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	 	

	 	 	

or exceed current standards and assist the organization with

proactively identifying any potential opportunities for improving processes. Feedback from these accreditations is incorporated into the organization’s PI processes. LOTS has received

full accreditation from AOPO and AATB. In addition, LOTS has

internal and external audits scheduled across the organization to

address regulatory requirements and to identify potential risks

associated with its operations, ensuring that the organization

remains in a state of readiness.

A series of internal and external audits ensure compliance

with key regulatory and legal requirements, as shown in

Figure 1.2-1. Certain audit findings include a deviation form

as part of a formal feedback loop; the form assist LOTS

with proactively addressing issues related to key compliance

processes, measures, and goals. Additionally, the auditspush

the organization to exceed regulatory and legal requirements

by serving as methods used for addressing risks associated with

key services and operations (Figure 7.4-5).

Audit feedback reports are reviewed by the appropriate work

group and summarized for the LT and BOD. Should improvements be identified, a response plan is developed and deployed

via the OMP (Figure 6.1-1).

1.2b(2) The BOD and LTpromote an environment that fosters

and requires legal and ethical behaviors through the CCP

(Figure 1.1-2). Furthermore, the organization’s ethical behavior

standards are reflected in its core value of honesty.To promote

and ensure ethical behavior across the organization, all employees adhere to a Code of Professional Conduct. During the past

year, LOTS has further developed and deployed procedures

for ensuring compliance with its Code of Conduct to its supply

network and partners.

Figure 1.2-2: Organizational Structure 

 

LOTS’s CCP is consistent with industry standards, which provide education, monitoring, and investigation of breaches. The

program provides an anonymous mechanism for the workforce

and other customers, partners, suppliers, and stakeholders to

report any noncompliance events or occurrences. The CCP

officer is responsible for investigating complaints and reporting

them to the CEO or BOD’s Executive Committee, if appropriate. All the elements of the CCP are reviewed annually by the

Corporate Governance/Nominating Committee.

Figure 1.2-1: Key Regulatory and Legal Requirements 

Key Regulatory and 

Legal Requirements 

Key Risk 

Reduction Processes 

Measures and 

Indicators Goals Figures 

Compliance with organ allocation UNOS/OPTN audits

Internal audits

UNOS organ placement policies Member in good

standing

7.4-4

Compliance with FDA requirements FDA audits FDA approval No adverse findings 7.4-4

Voluntary compliance to meet organ

donation industry standards

Internal audits

QA/Training

AOPO accreditation Full accreditation 7.4-4

Voluntary compliance to meet tissue

donation industry standards

Internal audits

QA/Training

AATB Full accreditation 7.4-4

Compliance with CMS regulations

impacting reimbursement

CMS audit

Internal audit

CMS certification Full certification 7.4-4

Compliance with IRS regulations

impacting not-for-profit organizations

External Financial audits Minimal audit adjustments Unqualified opinion AOS

AOS

7.4-5

Corporate Compliance

Process (CCP)

Annual training acknowledgement

Reported hotline issues

100% Completion

No Events

Compliance with regulations

impacting Human Resources

EEOC guidelines Policy Compliance No events or

occurrences

7.4-5

FLSA posted Posting

Safe work place Safety officer

Safety committee

Employee training

OSHA site audits

Reportable events

Full compliance

No reportable events

7.4-4

7.3-7

Compliance with DOR requirements DOR audit DOR approval No adverse findings 7.4-4

5 
	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	

	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

1.2c Societal Contributions 

1.2c(1) Accomplishment of the mission—we save and improve 

lives—is LOTS’s greatest gift and contribution to society.

This can be measured by the increase in the number of organs

transplanted and the reduction of deaths on the local transplant

waiting list, as well as the increasing number of tissue transplants (Figures 7.1-3 through 7.1-14). Step 1 of the annual SPP

session includes a discussion of key communities to ensure that

the organization is responsive to their needs and requirements

(Figure 2.1-1).

Through the design of its facility, which includes the Energy

Management System, LOTS contributes to environmental

well-being. The organization continues to explore “green”

opportunities suggested by the workforce; previous staff suggestions resulted in a formalized recycling program for paper,

plastic, and aluminum, as well as a reduction in hand-outs

for stakeholders by providing data electronically. During the

systematic review of societal contribution process in step 1 of

the SPP, LOTS completes risk analysis and determines return on

investment (ROI) for strategic decisions about societal wellbeing and community selection and support.

Through facility design, which includes the Energy Management System, LOTS contributes to environmental well-being.

Conservation of natural resources is considered through green

building practices, temperature and light conservation, recycling

programs, and assurance that the environment is protected

through effective biohazardous waste disposal. Energy conservation strategies include glazing, day lighting, lighting controls,

lighting design, and the use of air-cooled chillers. Multiple

efforts are being made across the organization to reduce paper

usage, including the use of a board portal and screen projection

of all meeting data, the transition of several support departments to paperless systems, and a reduction in paper hand-outs

for stakeholders by providing data electronically. In addition,

LOTS has recently begun formalized recycling programs for

plastic and aluminum. LOTS uses the EPA’s ENERGY STAR® 

Portfolio Manager as an online tool to measure and track energy

consumption. In addition, LOTS has recently joined EPA’s

WasteWise program, and has set a goal to reduce waste by

5 percent (through a combination of waste prevention and recycling) from its 2018 baseline (Figure 7.1-27). To accomplish

this, the organization continues to explore “green” opportunities

suggested by the workforce, partners, and customers. LOTS

prepares for impacts and concerns proactively through effective

supply-network management processes, which include a secure

electronic database and established par levels.

1.2c(2) The BOD uses a systematic approach involving

collection and analysis of feedback from community representatives to identify LOTS’s key communities to support. The

foundation of the Community Support Determination Process

(Figure 1.2-3) is LOTS’s mission and vision, core competency,

and values. Steps include identifying opportunities that may be

based on feedback from donor families, transplant recipients,

workforce members, and/or community partners; discussing

involvement using a SD and considering alignment with the

MVV; allocating resources of time, treasure, and talent; and

considering partnership involvement. The review and assess

step is used to evaluate results and gather feedback from key

communities, the workforce, and partners to determine future

participation.

Columbia University Hospital, one of LOTS’s key customers,

has created a three-year Community Health Needs Assessment

(CHNA) to determine areas of support needed for the county

and surrounding areas; through a partnership in 2019, the

hospital has shared the results from this assessment. LOTS uses

this information to help understand the residents in its DSA

and integrates this information into the SPP to create specific

strategies, tactics, and actions for organizational involvement.

Also, during the SPP, a systematic review is conducted of the

geographic and socioeconomic areas of LOTS’s involvement

(i.e., the DSA). The review has consistently shown that LOTS’s

key communities are donor families, transplant recipients, and

their families within the DSA. The LT validates the key communities annually as part of the SPP (Figure 2.1-1).

LOTS is now focusing on creating other partnerships with

regional nonprofits, businesses, physicians, and others to serve

the community by leveraging LOTS’s core competency. There

is an agile daily process of identifying unanticipated requests.

This process is evaluated for improvement two months before

the beginning of the SPP cycle (2.1a[1]), and any changes to

ensure agility of effectiveness are incorporated into the SPP.

Part of these partnerships includes an educational component on

the benefits of donor registration.

Recent examples of community support include construction of

a Donor Memorial Monument and park for donor and recipient

families to gather, remember, and honor their loved ones. In

addition, staff members actively participate in memorial events

hosted across the organization’s DSA.

Based on a cycle of learning, LOTS noted a gap in community

support for the local Air Force base. This resulted in a tie-in

with the base hospital, which now provides donor education for

the military and their families. LOTS also has become part of

a support group addressing employment opportunities for the

mobile military spouses and families.

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Category 2: Strategy
 

2.1 Strategy Development 

2.1a Strategy Development Process 

2.1a(1) The OPO business ecosystem is one that requires

LOTS to be agile to ensure its ability to meet customer and, ultimately, recipient needs. Therefore, through cycles of learning,

the focus of strategic planning has evolved from a process based

on defining and approving actions to support the budget, to the

systematic SPP occurring throughout the year, supported by APs

and goal achievement. The SPP involves strategic development,

implementation, and discussions—each of which consists of

multiple steps (Figure 2.1-1). Currently, participants in the

SPP include the LT, BOD members, customers, front-line staff,

key partners, and key suppliers. Additional input into LOTS’s

planning process comes from the national Organ Procurement

and Transplantation Network (OPTN). For example, LOTS’s

COO has been active on OPTN’s OPO Committee to develop

requirements that will expedite the organ placement process.

The recommendations have been incorporated into LOTS’s SPP.

Both the BOD and LT focus on a strategic time frame; shortterm targets and objectives are to be met in one year, and

long-term targets and objectives are set for two years. In step 9

of the SPP, focused SDs address the performance projections for

the one- and two-year time horizons established for key metrics.

Any changes and/or prioritization of change or improvement

initiatives are identified and evaluated within the SPP (Figure 

2.1-1). LOTS capitalizes on its agility achieved through the

Organizational Structure (Figure 1.2-2) to utilize a continuous

SPP (Figure 2.1-1), which has seen learning and improvements.

The LTparticipates in SDs that take place during leadership and

work system meetings, creating consistency across the SPP.

During these SDs, APs may be created, modified, and deployed

as needed, and the progress-to-plan is monitored and evaluated,

ensuring agility and operational flexibility. This ongoing cycle

of strategy development and deployment has created a strategic

LTthat fosters an environment for action, innovation, and

continuous improvement to support LOTS’s life-saving mission.

In alignment with the III program, the SPP undergoes an annual

review to ensure that all elements are addressed and that the

methods utilized remain agile, flexible, and effective in responding to changes in the donation environment.

In step 8 of the SPP,

an annual cycle of

evaluation and learning

is formally conducted

to improve the SPP

each year. This step

includes inputs from the

BOD, senior leaders,

and virtually all SPP

participants. Since 2019,

proposed changes have

been systematically vetted against 11 quantitative and 4 qualitative

criteria (AOS).

2.1a(2) The commitment to the mission of

saving and improving 

lives, along with the

value of innovation,

drives LOTS to stay

on the top of industry

knowledge and best

innovative practices.

The SWOT (Strengths,

Weaknesses, Opportunities, and Threats) list

is reviewed during

the SPP (step 2) and

validated through

ongoing SDs (step 9).

Strategic opportunities

are identified in step 3

7 

Figure 2.1-1: Strategic Planning Process (SPP) 
	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	

	 	 	 	

	 	 	 	 	

	 	

	 	 	

	 	 	 	

	 	 	

	 	 	

	 	 	

	 	 	

	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	

	 	

	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

of the SPP and during ongoing SDs that promote “out-of-thebox” thinking. These strategic opportunities are systematically

reviewed and prioritized. For the 2019 planning cycle, the key

strategic opportunities identified were to continue a focus on

registry enrollment and improving customer satisfaction.

Cycles of improvement for the process to identify, review, and

prioritize opportunities have included the utilization of Innovation Management Teams that comprise multidisciplinary and

diverse departments, workforce members, and partners (see the

Innovation Management Process (IMP; 4.1c[2]). Teams perform

data review and use PI tools, including PDSA, to complete

brainstorming and prioritization sessions. The improvement

system itself is used to ensure that appropriate and informed

opportunities are assessed and due diligence conducted before

pursuing an identified strategic opportunity.

Established this past year, an Innovation and Risk Board is

used to vet and approve large system-wide innovations (some

of which are identified through industry efforts) following the

process outlined in 6.1d. The board is staffed by the PI Team

and key members of the LT, with the goal to systematically

explore the enterprise for scalable innovations. The PI Team

focuses about 80% of its time on large process improvement

and innovation projects, and 20% supporting smaller projects

across the system. The Innovation and Risk Board oversees the

Innovation Management Teams.

2.1a(3) During step 2 (Analyze) of the SPP, LOTS evaluates

its strategic position. This step also includes review of key

performance measurement results and an environmental scan of

the donation and transplantation industry, as well as the overall

health care climate of the community. The review includes

■ Key performance measurement results (Figure 4.1-1)

■ SWOT, SCs and SAs (Figure P.2-1)

■ BOD input (Figure 1.2-2)

■ Customer, donor family (collaborator), and other key

stakeholder feedback and preferences (Figure 4.2-1)

■ Current and proposed changes to regulatory requirements

(Figure 1.2-1)

■ CHNA (1.2c[2])

An example of learning and improvement is that LOTS added

the expansion of formal input from key partners to include

additional relevant industry data gathered from customer and

partner organizations and provided in presentations to the LT.

Relationship Management 

These data may be collected from industry or nonindustry

organizational conferences (AATB, AOPO, etc.).

During step 3 (Identify), using the information gleaned from

step 2, LOTS identifies and validates its SCs, SAs, core

competencies, etc. This process also validates the SOs and

establishes the appropriate goals critical to the future success of

the organization. Potential blind spots that limit goal achievement or the accomplishment of the organization’s SOs are

identified in step 2 of the SPP during the environmental scan

with key customers.

Following analysis of the present situation, which includes a

review of historical data, step 6 involves the completion of a

performance projection exercise to effectively forecast activity

levels for key organizational metrics for the next two years.

During step 6 (Develop), LOTS cascades organizational goals

into APs to accomplish the SOs, address the SCs, and make a

final determination about the feasibility of accomplishing the

SOs during the desired time frame. Throughout the year, SDs

include a review of relevant changes impacting the organization’s ability to execute the strategic plan. The LOTS strategic

plan is fluid and provides review at many levels, thereby

providing the organization the agility necessary to be able to

modify previous strategies as needed. This constant evaluation,

monitored by the PMS (Figure 4.1-1) and facilitated by the

Communication Process (Figure 1.1-3), keeps the organization

focused on executing the strategic plan with suitable flexibility.

Organizational results are linked to the SPP (Figure 2.1-1,

step 2), and if AP results are not on target per the PMS, action is

taken to address the gap.

2.1a(4) LOTS keywork systems are theOWSand theTWS

(Figure 2.1-2). Within step 3 of the SPP, LOTS defines and

validates its SAs, SCs, SOs, current and future potential core

competencies, and organizational goals based on current performance and the environmental scanning analysis (completed

in step 2). Incorporation of organizational knowledge, new

technology, product excellence, and agility are accomplished

through the OMP (Figure 6.1-1). In alignment with the III program, work systems and the core competency are systematically

evaluated in step 8 of the SPP, which was added in 2014, as are

all aspects of the SPP itself.

LOTS understands that external suppliers and partners may

provide additional capabilities or capacity that LOTS does not

possess, so outsourcing is always an option. The decision to

outsource a process or

to manage it internally

is initiated through the 

SPP(step 5, Assess and 

Review); evaluation

of each outsourcing

opportunity is then moved

to the systematic Make/

Buy Process. Evaluation

includes annual

assessment of LOTS’s

core competency, current

and potential key supplier 

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and partner expertise/skills (using supply network surveys and

interviews), changes in the industry ecosystem and regulations,

an analysis of LOTS’s workforce capabilities and capacity, and

associated costs. Suppliers and partners must align with the

MVV and possess the skills needed to augment LOTS’s workforce capability and capacity, assessed through the Workforce

Planning Process (Figure 5.1-1). The evaluation criteria include

the following:

1. MVV Aligned: Does the supplier’s MVV align with

LOTS’s MVV?

2. Determine Risks and Opportunities: Is there an impact to

customer and stakeholder satisfaction and engagement?

3. Review Current Capabilities: Does the supplier have a core

competency that allows it to execute better than LOTS?

4. Review of Cost Impact: Internal and external cost?

5. Process Efficiencies: Is the supplier capable of executing

the system, and what training will be involved, if any?

6. Win-Win Situation: Is the partnership beneficial to all?

This approach is reviewed via SDs and the OMP every year

to enable cycles of learning and improvement. For example,

during the annual SPP, a SD was held regarding the strategic

opportunity of moving local donor transportation services

in-house. A team was formed and the question was vetted

through the OMP. Final analysis revealed higher transportation costs and additional resources required if the process was

moved in-house, which would divert focus from the organization’s mission. By leveraging the core competency of Guardian

Ambulance, cost savings were recognized. As another example,

LOTS tested a business case study to bring laboratory testing

within the organization. After reviewing the internal skill set and

financial commitment required, LOTS decided to continue to

partner with the Columbia University Hospital’s laboratory to

perform required laboratory testing.

2.1b Strategic Objectives 

2.1b(1) LOTS’s SOs, organizational goals, and timetables for

achieving them are shown in Figure 2.1-3. The first three SOs

are most critical to saving lives: maximize donations OWS,

maximize donations TWS, and maximize stakeholder relationships. The fourth SO—maximize organizational excellence—is

also critical to LOTS’s sustainability and reflects the decision to

focus on achieving cost-effectiveness and efficiencies to sustain

a strong financial position to manage future challenges.

Key changes in LOTS’s operations include the development

of new marketing partnerships. To encourage donor sign-ups,

LOTS has launched a “check-the-box” campaign in conjunction

with the DMVs in both NT and ST. In addition, LOTS has

launched a “Workplace for Life” campaign, and SDs are underway regarding plans to work with faith-based organizations on

a similar campaign to increase donor registration, tentatively

entitled “We Believe in Life.”

2.1b(2) The SOs are created in step 3 of the SPP when the

LT considers strategic opportunities and balances them against

strategic challenges, the core competency, and key stakeholders’

requirements. The resulting SOs are complementary by nature

and ensure appropriate balance for organizational needs. The

SO of maximizing stakeholder relationships helps create a focus

on driving customer and stakeholder satisfaction. The culture

also empowers the mission-driven workforce (CC) to work

towards maximizing organ and tissue donations.

To measure the balance achieved by the SOs among organizational needs, the LT administers systematic surveys and reviews

of satisfaction and engagement among the workforce, customers,

suppliers, and partners. LOTS supports its SOs with organizational goals and resulting APs that leverage its SAs and CC while

tackling its SCs (Figure 2.1-1, steps 4 and 5; Figure 2.1-3) and

strategic opportunities. During step 3 of the SPP, the CC, SAs,

SOs, and SCs are reviewed and updated to ascertain their fit with

the SOs and to ensure that key stakeholders’ needs are considered

and balanced. A recommended improvement for this process and

other SPP processes triggers a PDSA cycle.

As part of the SPP, ongoing SDs based on information from

the PMS (Figure 4.1-1) provide LOTS with an opportunity

to balance short- and long-term challenges within an evolving

industry to ensure adaptability to sudden shifts. The organization’s SOs consider and balance the needs of stakeholders by

leveraging the organizational structure, work system design, and

goal prioritization in step 6 of the SPP (Figure 2.1-1).

2.2 Strategy Implementation 

2.2a Action Plan Development and Deployment 

2.2a(1) APs and their connection to SOs are presented in

Figure 2.1-3. AP development begins in SDs through the SPP and

is a cooperative effort between the LT and employees. Through

learning and improvement, the organization has moved from a

reactive nature where the LT pushed APs to the staff following the

SPP, to a proactive nature where the LT solicits staff participation

in SDs to provide input into establishing APs, thus ensuring workforce ownership. Figure 2.1-3 outlines the SOs, organizational

goals, and key APs that are cascaded to the workforce. Some

goals are complex enough to warrant multiple APs.

2.2a(2) Strategy and AP deployment to the workforce,

suppliers, and partners occur in step 7 of the SPP and through

the Communication Process (Figure 1.1-3). LOTS sustains key

outcomes of APs through tracking and monitoring via a webbased program that aligns goals with individual performance

for all members of the workforce towards the accomplishment

of organizational goals, APs, and aligned SOs. The status of

APs is reviewed by members of the LT and staff during routine

one-to-one meetings and in-depth at the LT meetings. This

allows for strategy shifts and resource re-allocation and ensures

that the outcomes of APs can be sustained. Key outcomes of

the APs are monitored through review of the PMS. In addition,

modeling industry best practices in both the OWS and TWS,

benchmarking organizational results to industry high performers (see Baldrige Benchmark Project, P.2a[3]), and having a

mission-driven workforce (CC) further define the roadmap for

LOTS to accomplish its SOs.

To ensure full deployment of APs to the workforce, suppliers, and partners for achievement of SOs, LOTS conducts

annual surveys with these stakeholders to gather feedback on

the effectiveness of communicating the strategic plan and on

improvement opportunities. Results undergo systematic analysis

and review in the OMP.

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Figure 2.1-3: Strategic Linkages 

SOs Organizational Goals SC/SA Action Plan Samples* Measures Results 

2020 

(Short-Term) 

2022 

(Long-Term) 

(1) Maximize

Donations

OWS

Increase Organ Donors SC Implement Expedited

Referral Process

Partner with DMVs

Identify and pursue

potential partnerships

with non-hospital

referral sources (e.g.,

workplaces and faith

based organizations)

# organ donors 7.1-4 40 50 

Increase Organs

Transplanted

SC # organs

transplanted

7.1-7 125 130

Increase Bone Donors SC # bone donors 7.1-8 850 900

(2) Maximize

Donations

TWS

Increase Tissue

Authorization

SC TWS Outreach and

Communication Plan

Tissue

Authorization

7.1-18 62% 65%

(3) Maximize

Stakeholder

Relationships

Sustain Transplant Center

Satisfaction

SA Transplant Center

Communication Plan

Satisfaction

survey

7.2-1 >4 .7 >4.8

Improve Tissue Processor

and Eye Bank Satisfaction

SA TWS Outreach and

Communication Plan—

identify and address

areas of dissatisfaction

Satisfaction

survey

7.2-2 >4 .7 >4.8

Sustain Donor Family

Satisfaction

SA Donor Family Outreach

and Communication

Plan

30 day and

1 yr surveys,

enrollment

in closed

Facebook group

AOS 92 95

Improve Workforce

Retention Rate

SC Right Size Workforce

Plan (incl. cross training

and promoting within)

Workforce

retention

7.3-15 80% 85%

(4) Maximize

Organizational

Excellence

Ensure Connection

to Mission

SA Training, CDP Survey 7.3-11 100% 100%

Ensure Supply

Optimization

SA Supply Network

management plan

Supply

availability

AOS 100% 100%

Ensure Regulatory and

Legal Compliance

SA Corporate Compliance

Plan

Key Regulatory

and Legal

requirements

(Figure 1.2-1)

7.4-4 Full

Accreditation/

Compliance

Full

Accreditation/

Compliance

Increase Results

of Operations

SA Budget $$ 7.5-1 3.5M 3.6M

Accomplish Action Plans* SA — % Complete 7.5-14 100% 100%

*Complete list of Action Plans AOS 

2.2a(3) During step 5 of the SPP, APs are reviewed in detail

to ensure alignment with the organization’s SOs and resource

availability. Workforce planning (step 5) includes a summary

of capability and capacity (C&C) discussions, which prompt

the identification of adequate capacity and the key learning

and development resources needed to drive the accomplishment of APs. Through a detailed budgeting process, a monthly

departmental financial trend analysis, and a forecast of financial

risk (including an assessment of the financial impact of the APs

and organizational goals), LOTS ensures that adequate financial

resources are available to support ongoing operations and newly

developed APs. These processes are reviewed every year during

step 9 of the SPP. Members of the LT participate in the process

of budget creation and review; the budget is initially approved

by the CEO, with final approval by the BOD.

In step 9 (SDs—ongoing) of the SPP, financial risk and viability

are assessed for current operations and obligations. Financial

results are affected by allocation of costs through the CMS cost

report.Afinancial statement is prepared monthly for the LT

and BOD. Year-to-date financials are also presented at BOD

meetings. Risk assessment includes cost modeling the potential

effects of actions via financial statements, cash flow projections,

and ROI calculations. By being good financial stewards, LOTS

has more flexibility to pursue intelligent risks and innovation in

support of its mission.

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2.2a(4) Key workforce plans that support LOTS’s short- and

long-term organizational goals and APs include leadership

development, skill development, team empowerment, employee

engagement, and workforce retention. Workforce plans are

captured within step 5 (Assess) of the annual SPP and in the

Workforce Planning Process (Figure 5.1-1). As a part of these

processes, the LT performs an analysis of current and future

needs, and reviews capacity and capability information along

with onboarding and stay-and-exit interview data; this ensures

systematic learning and improvement of the workforce plan

approach. These discussions determine the staffing analysis and

consider potential impacts on the workforce, as well as workforce needs for the accomplishment of short- and long-term

organizational goals and APs.

2.2a(5) Key performance measures for tracking the achievement of APs and associated organizational goals that support

the SOs are included in the PMS outputs (Figure 4.1-1). APs

and the PMS undergo annual review and cycles of improvement

during SPP step 1 (Validate/Revalidate). The organization measures strategic and operational performance through a scorecard

system that begins with the Topline Scorecard (Figure 4.1-2)

and cascades to department scorecards and individual PEPs.

The scorecards include a series of key performance measures,

arranged to align with the Topline Scorecard. The use of these

cascading scorecards reinforces organizational alignment and

deployment of SOs and APs to the workforce. AP progress is

tracked using a web-based performance management system

and the SPP.

Tracking the effectiveness of APs is further accomplished

through AP status reviews at LT meetings. APs are updated

regularly and housed on a web-based program accessible to all

members of the workforce. The prior year’s APs areassessed for

completion and effectiveness and are summarized in a Q1 LT

meeting. Through ongoing SDs, the LTensures that the measurement system (Figure 4.1-1) covers all key areas of deployment and stakeholder requirements. The APs are ultimately

measured by topline organizational performance. Topline

measures cascade throughout departments to an individual’s

PEP via APs to reinforce alignment and the accountability

necessary to accomplish the mission of LOTS (Figure 4.1-2).

2.2a(6) Initial projections are established during step 4 of the

SPP, modified through the budgeting process, and re-validated

with end-of-the-year outcomes. Past, present, and projected

performance outcomes and benchmarks are reviewed through

the PMS. After the review, the LT establishes one-, two-, and

three-year projections through traditional trending analysis.

During this review, LOTS employs its PDSA process to evaluate and improve its performance projections.

Analysis assists in the identification of performance gaps, aids

in goal-setting, and is critical given the limited number of public

data sources. If gaps in performance are identified, SDs occur, PI

tools are utilized, APs are created or modified, and resources are

allocated to address the opportunities. Systematic gap analysis is

used as a specific method to identify performance gaps.

2.2b Action Plan Modification 

Systematic reviews occurring during work system meetings,

LTmeetings, and ongoing SDs (Figure 2.1-1, step 9) provide

the opportunity to identify performance measures that are

lagging, to modify existing APs or create new ones as needed,

and to ensure cycles of learning and improvement for AP

modification. Scorecard measures lagging over a three-month

period initiate a “red-box” discussion with the associated LT

members and a member from PI. A data analysis and subsequent

AP deployment or AP modification may beperformed, depending on the outcome of the analysis. Deployment of APs and

modified APs is accomplished through actions that cascade

from the work system or department level and may cascade

down to the individual level. Ongoing monitoring and discussion of the APs occur through LT meetings, the PEP, staff RFO,

and work system meetings. Modifications to APs are tracked

and discussed during LT meetings to ensure that the decisionmaking process is communicated. The ability to effectively

track APs and their modifications enables the organization to

allocate resources effectively.

Once actions are planned, the linkage back to the higherlevel SOs (2.1b), strategic challenges (P.2b), and strategic

advantages (P.2b) are validated (see Figure 2.2-4). Once AP

implementation begins, this linkage is checked in-process

and at the completion of the AP. If there is a gap between the

intended outcome and what is achieved, root cause analysis is

performed to understand the cause and what actions can provide

a learning cycle. This approach to strategy implementation

has been evaluated and improved several times, with the most

notable improvement being the use of a web-based performance

management system to track the achievement of APs and to

share information across the organization in a timely manner.

Category 3: Customers
 

3.1 Customer Expectations 

3.1a Customer Listening 

3.1a(1) LOTS works with four transplant centers and three

tissue processors, as well as donor hospitals, an eye bank,

medical examiners, and coroners throughout the region. LOTS

builds these relationships by offering educational programs,

working to understand each organization’s unique challenges

and recognizing its life-saving accomplishments. In addition,

LOTS has launched new initiatives aimed at increasing donor

authorizations by expanding outreach to community partners,

including DMVs and WPFLs.

LOTS uses multiple formal and informal mechanisms to collect,

transfer, and use customer information to identify opportunities for improvement and innovation. This VOC Process

(Figure 3.1-1) incorporates methods for listening, interacting,

and observing local organ transplant centers, tissue processors,

11 
	 	 	

	 	

	 	

	 	

	 	 	

	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	

and eye banks to obtain actionable information throughout

the Customer Life Cycle (Figure 3.2-1). The various listening

and learning methods used for each customer group, as well as

methods for listening for each phase in the customer life cycle,

are noted in the VOC Process; listening and learning methods

are the same for both customer groups. Learning and strategic

improvements have led to a Customer Survey Process that

incorporates surveys and feedback reports and provides results

to the survey participants on the development of any

associated APs. LOTS is able to respond to feedback from

the Customer Survey Process through immediate actions via

SDs and the SPP, as illustrated in the Communication Process

(Figure 1.1-3). The primary methodology used by LOTS to

obtain customer feedback is an online survey.

LOTS has an established website and social media presence

on Facebook, Vimeo, Twitter, and Instagram. In addition,

LOTS utilizes YouTube for media sharing because of its large

selection of tools for viewing, sharing, and embedding digital

media content that includes TV public service announcements

(PSAs) and recipient testimonials. Through the YouTube

account, LOTS staff address the VOC through monitoring

views, comments, and private messages in the same manner

as the Facebook and Instagram accounts. Through a cycle of

learning, LOTS has embraced the value of social media outlets

as a means to share information, answer questions about organ

and tissue donation, and encourage donor registration, and it has

incorporated these tools into its outreach and communication

plans. LOTS focuses social media efforts on communication

strategies that strengthen the organization’s brand, reinforce the

culture, and celebrate donors and their families.

LOTS seeks actionable feedback on the quality of services and

customer support via VOC listening and learning methods,

including surveys, formal and informal interactions, and

meetings (Figure 3.1-1). Learning is transferred via multiple

communication mechanisms through the Communication

Process (Figure 1.1-3).

Figure 3.1-1: Voice of the Customer (VOC) 

Method 

Frequency Life Cycle Phase Customers M 

 Monthly 

O 

 Ongoing 

A 

 Annual 

Q 

 Quarterly

SA = Semi-AnnualPre-Donation 

Donation Procurement Allocation 

Post-DonationLocal OrganTransplant CentersTissue Processors 

Collect

(Figure 4.1-1) 

Operational Discussions O • • • • 

Day-to-Day Work / Interactions / Department Meetings O • • • • 

Participation in SPP (Figure 2.1-1) O • • • • 

Board of Directors Q • • • • 

Medical Advisory Board SA • • 

Transplant Center Meetings SA • • • 

Surveys O • • • • 

Audits, Internal / External O • • • • 

Social and Electronic Media O • • • • 

Figure 1.1-2 Corporate Compliance Program O • • • • 

Events / Candlelight Memorial / Open House / Receptions O • • • • 

CAPA / Deviations O • • • • 

Transfer

(Figure 1.1-3) 

Best-Practice Sharing O • • • • 

Scorecards / Status Reports / Metrics On-Demand O • • • • 

Meetings, Scheduled and Ad Hoc O • • • • 

Survey / Processor Feedback O • • • • 

Social and Electronic Media (e.g., EMR, Facebook,Website,

DonorNet)

O • • • • 

Utilize 

Figure 2.1-1 SPP O • • • • 

Survey Feedback / Baldrige Feedback / Annual Report A • • • • 

CAPA / Deviations Figure 1.1-2 Corporate Compliance Program O • • • • 

Audit Findings O • • • • 

Best-Practice Sharing O • • • • 

Legend: 5 2-way communication; and 1-way communication, in and out, respectively 

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3.1a(2) As the federally designated OPO within its service

area, LOTS does not have traditional organ procurement

competitors or potential customers. Transplant centers exist

within the OPO’s DSA, and organs are allocated according to

UNOS/OPTN through two-way communication. LOTS keeps

abreast of potential changes in organ transplant center status

utilizing the Communication Process (Figure 1.1-3) and VOC

(Figure 3.1-1). The restriction of operating within a federally

designated territory eliminates competition and encourages

collaborative efforts among OPOs.

In an effort to increase the number of people in the two-state

region registered as organ donors, LOTS has established

partnerships with the DMVs in both states, and it is working to

establish partnerships with area corporations and organizations,

through its WPFL program.

Relationship management within the small, established tissue

industry allows for contact with potential, future, and competitor customers. Listening and interactions occur regularly

with potential and former customers via industry conferences

and webinars, as well as through survey data, as applicable

(Figure 3.1-1). These approaches, which undergo systematic

PDSA evaluation and improvement, allow LOTS to obtain

actionable information on its services, customer support, and

transactions. Based on survey results from 2016 to 2018 and

feedback from the 2019 Baldrige feedback report, LOTS

recognized the need to improve its relationships with tissue

processors or risk losing those who do not feel engaged by the

organization. To better understand these customers’ expectations, LOTS followed up the survey with focus groups and

one-on-one interviews. These focus groups (held in conjunction

with industry events) were also useful in gaining insights from

potential customers. These insights were critical in helping

LOTS develop its TWS outreach and communication AP. LOTS

also developed a TWS outreach and communication AP aimed

at strengthening these relationships.

Knowledge sharing and benchmarking with other OPOs for

both service lines allow for the identification of gaps among

LOTS and high-performing peers. Using feedback on the

services provided by other OPOs serves as indirect feedback

on the level of services provided by LOTS. This information

supports operational and strategic decision making and innovation (4.1a[2]) and forms the knowledge base for improvement

cycles. At least annually, the knowledge gathered is evaluated

to understand whether the customer expectations have changed,

and if they have, what actions should be taken.

For example, the idea for a faith-based outreach program and

the recognition that donor registration is low in the AfricanAmerican community came from knowledge sharing with other

OPOs.

3.1b Customer Segmentation and Product Offerings 

3.1b(1) As noted earlier, LOTS’s customers and markets

are mandated as part of its federally designated service area,

meaning LOTS does not determine customers and markets itself;

however, the SPP (Figure 2.1-1) and the Community Support

Determination Process (Figure 1.2-3) help LOTS determine

and validate customer group and market segments, as well as

community support opportunities. Additional information gathered from the VOC (Figure 3.1-1) can also be used to identify

and anticipate market segments and their needs.

Every year, during step 9 (Strategic Discussions) of the SPP, the

LT and work system leaders review learnings, and the information on customers, markets, and service offerings gathered

from the VOC is entered into the PMS for analysis to anticipate

future customer groups within the DSA. This approach undergoes systematic PDSA-based evaluation for improvement in

customer segment and product offering determination.

Information gathered through the PMS, including the VOC data,

is integrated within the SPP. Knowledge sharing and benchmarking for both service lines aid in the identification of gaps

(Figure 4.1-4). This actionable information supports operational

and strategic decision making for both work systems. Beginning in 2014, learning from this information has resulted in the

identification of key areas for improvement that are referred to

the appropriate level (e.g., LT, front-line staff).

Information collected in the VOC, along with the analysis

completed in the PMS, is used to assess potential business

growth opportunities. The OMPis used every year to determine

which customer groups to emphasize for business growth.

Customer groups and market segments are systematically

determined during the SPPbased on the customers’requirements. Similar requirements are grouped into common customer

segments and markets. As part of the internal and external

scans, as well as SWOT analysis, LOTS integrates and analyzes

data from a Customer Listening and Response System, along

with process performance reviews, to identify current and

anticipate future customer requirements. Additional analysis is

conducted using market data and demographics to determine

potential changes in market segmentation. For future requirements or where new requirements emerge, those requirements

are assessed to determine if they fit (match) within the existing

segments or if a new segment is needed.

3.1b(2) LOTS relies upon its VOC (Figure 3.1-1) to determine

customer needs and requirements for organ and tissue donation

services (Figure P.1-6). Customer requirements are solicited

through LOTS’s formal Customer Survey Process, and results

are validated during the SPP(Figure 2.1-1). The OMP is used

to systematically analyze the determined customer

and market needs and requirements to identify and adapt

tissue product offerings and new organ transplant services in

order to meet and exceed those requirements (6.1a[3]). These

requirements serve as critical inputs for the design of work

processes and identification of opportunities for innovation and

improvement to consistently meet and exceed customer needs

and expectations. For example, based on analysis of customer

survey results and feedback from the 2019 Baldrige feedback

report, LOTS recognized that there were opportunities for

improvement in meeting the needs of tissue processors. LOTS

followed up the surveys with focus groups and one-on-one

interviews and used the information gathered to develop an AP

to improve TWS engagement.

LOTS focuses on Finding the Heroes (Figure P.1-3) and

maximizing each donation opportunity to its fullest potential

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to meet the needs of its customers. Formal and informal VOC

mechanisms ensure that revised regulations and opportunities

are captured in ODs and SDs, providing organizational agility

to incorporate applicable changes in meeting and exceeding

customer needs and expectations.

Leveraging the robust Communication Process (Figure 1.1-3)

and working with its customers to identify service improvements and refinements, LOTS uses the VOC, PMS, and SPP

as inputs into the OMP(Figure 6.1-1). An example of service

improvements and refinements are new donor education and

other community services at a local Air Force base. Also being

looked at are 3D organ printing and new processing partners.

For the OWS, service offerings in new markets are not possible

due to the assigned DSA. TWS new-customer opportunities,

expansion of relationships with current customers, or new

service offerings are identified via the SPP or the VOC Process.

LOTS’s commitment to innovation and improvement differentiates its services and creates opportunities to expand and deepen

relationships with current customers.

LOTS is always alert to potential opportunities for new organ or

tissue offerings. While it is true that LOTS is highly regulated

and controlled, the regulatory agencies truly wish to provide the

best services for a reasonable cost. In this vein, LOTS provides

input to them about possible changes. This sequence is typically

followed: (1) LOTS listening, (2) analysis, (3) determination of

an opportunity, (4) initial discussion with the regulators to determine receptivity, (5) formal proposal developed, (6) proposal

submitted, (7) proposal analyzed by regulators, (8) trial approval

and test, (9) full approval, (10) live prototype and test, and (11)

full implementation.

3.2 Customer Engagement 

3.2a Customer Relationships and Support 

3.2a(1) LOTS’s mission-driven workforce (CC) develops

and manages customer relationships as outlined in the VOC

(Figure 3.1-1). Information is collected from customers and

transferred into the SPPand ongoing SDs, where trending,

analysis, and validation take place. Validated information is

utilized to improve the level of service provided to current

customers. LOTS leverages its brand, reputation, and performance to acquire tissue processor customers and build market

share. This information is also used for systematic evaluation

of opportunities and the creation of improvements. Surveys

assessing customer satisfaction show that LOTS is working to

perform at levels to ensure that processor satisfaction is met or

exceeded. For example, Advantage Life, a former tissue processor, contacted LOTS in 2018 to resume providing tissue donors

based on LOTS’s prior performance and effective relationship

management.

As another example, in the past year, as part of LOTS Donor

Family Outreach and Communication Plan, LOTS has completely transformed its support materials to provide a consistent

message to the donor families, including “thank you” cards,

donor family packets, “navigating grief” support books, email

follow-ups, and one-year anniversary cards. LOTS has also

created a closed Facebook group for donor families. Online

surveys show donor families with 90 percent overall satisfaction; 74 percent indicated that their satisfaction was because of

the efforts, care, and compassion of the LOTS staff.

The provision of exceptional service allows LOTS to retain

customers while meeting their requirements, exceeding their

expectations, and increasing their engagement in every stage of

the customer life cycle. The Customer Survey Process includes

assessments to drive improvements in both satisfaction and

engagement.

LOTS uses several systematic approaches to build and manage

customer relationships. It utilizes the various methods included

in the VOC Process (Figure 3.1-1) to listen to and interact with

local organ transplant centers, tissue processors, and an eye

bank to obtain actionable information throughout the Customer

Life Cycle (Figure 3.2-1). Through the VOC, it collects

and reviews customer information. The information is then

transferred into the SPPand SDs where trending, risk, and other

analyses and validation take place resulting in annual focused

strategies and APs to meet/exceed customer requirements,

improve service level and satisfaction, and enhance customer

engagement. The LT monitors these goals and outcomes

through review and analysis of results from annual customer

surveys to ensure cycles of continuous improvement.

LOTS conducts a multipronged public awareness program to

increase the number of donor registrations in the region and

ultimately organs available for transplantation. The program

consists of the development and dissemination of materials

such as downloadable brochures; radio, print, and TV PSAs;

web materials; videos and outreach through social media; and

partnerships with DMVs in NT and ST.

LOTS uses data and information gathered through social media

to help enhance the organization’s brand by raising awareness of

donation and transplantation and, ultimately, driving its vision

of organs and tissues are always available.As a supplement to

the environmental scanning analysis performed during step 2

of the SPP(Figure 2.1-1), LOTS follows the social media

postings of its customers and key stakeholders to ensure access

to the latest developments and to celebrate customer and partner

successes. In response to donor family requests, a private,

closed Facebook group was created to allow families to engage

with one another and LOTS donor family advocates. Moreover,

the organization follows appropriate industry news sources to

identify trending stories or ones gaining in media exposure,

to generate talking points, and to create prepared responses,

as necessary. This includes social media alerts for several

key words such as organ/tissue donation and transplant. This

additional insight may assist in the identification of new service

lines and market segments, including 3D organ printing and

new processing partners.

Customer support, information resources, media campaigns,

branding strategies, and partnerships contribute to build market

share. In addition to environmental scanning and crisis communication, LOTS supplements organizational strategies to

increase share rates and followers to its own social media outlets

through the identification and sharing of value-added content.

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Another way that LOTS builds and manages relationships with

customers, partners, stakeholders, and potential donors is by

using a systematic Customer Relationship System, a six-stage

process that covers the lifecycle of the relationship. Customer

Relationship System levels are designed to move those who are

“unaware of LOTS” through “support LOTS and donation” to

becoming “advocates” for LOTS and registering to become an

organ or tissue donor. Upon becoming advocates, LOTS has the

potential to leverage experiences by connect-ing advocates with

those who have not heard of LOTS or the benefits of registering

as an organ or tissue donor, thereby increasing engagement.

Physician referrals to transplant centers and tissue processor are

a key focal point for acquiring patients and building market

share since a physician referral is a typical driver of where the

patient seeks health care. Where physi-cians choose to practice

impacts the services that LOTS is able to offer and the quality

of the outcomes LOTS can achieve; therefore, LOTS has

developed a Physician Partnership System that targets

physicians with specific specialties to practice at LOTS. The

Physician Partnership System integrates with the strategic

challenge of the changing physician culture and further

demonstrates LOTS’s core competency. For each stage, LOTS

has specific tools, actions, and methods to track progress.

The WPFL is a new initiative that unites LOTS and the organ

donor community with workplaces throughout the region

to spread the word about the importance of organ donation.

Partners include local and regional companies, associations,

unions, and community organizations. Their shared goal is to

promote organ donation by fostering education and creating

opportunities for individuals to sign up to save lives. More than

100 businesses in the two-state area have joined as workplace

partners. They have helped register more than 1,000 people.

SDs are underway to create a similar marketing effort aimed at

faith-based institutions, using the tagline “We believe in life.”

3.2a(2) LOTS offers many opportunities for customers to

seek information and support throughout the Customer Life

Cycle (Figure 3.2-1), as illustrated in the VOC Process (Figure 

3.1-1). Customers are able to conduct business with LOTS via

inputs as listed in the VOC and by leveraging the Communication Process (Figure 1.1-3).

The key means of customer support in both work systems is

the fulfillment of customer requirements (Figure P.1-6). Key

communication mechanisms, including email, 24/7 phone

contact, and website accessibility, enable customers to seek

information, receive support, and conduct business. Information

is also shared through printed materials, educational programs,

and community outreach. Methods of customer support do not

vary between customers, customer groups, or market segments.

Key customer support requirements are determined through the

VOC and validated through the Customer Survey Process, focus

group meetings, and informal data gathering that occurs through

conversation; requirements are deployed to the workforce via

the Communication Process. The Customer Survey Process has

undergone learning and cycles of improve-ment and has been

supplemented by the use of focus groups and informal data

gathering.

3.2a(3) Customer complaints are obtained via leader rounding, surveys, focus groups, phone, mail, and social media. The

LOTS mission-driven workforce (CC) is dedicated to complaint

resolution, resulting in high levels of customer satisfaction

(Figures 7.2-1 A–C; 7.2-2; and 7.2-2A–D). As the initial

step in the Customer Complaint Process (Figure 3.2-2), all

staff members are trained in service recovery. Front-line staff

members are empowered to implement immediate corrective

action at the point of service and use additional resources if

needed to quickly resolve customer complaints. This process

allows the LOTS workforce to follow up and provide real-time

feedback to successfully resolve the complaint. Complaint

trends continue to be low (Figures 7.2-4 and 7.2-4A). If

front-line staff members or managers are not able to resolve the

complaint to satisfy the customer, the complaint is elevated to

the ELT for resolution.

Local organ transplant center, tissue processor, or eye bank

complaints or policy/procedure deviations are routed through

the corrective action preventive action (CAPA) system for tracking and identifying root causes of the deviations. Trend analysis

of customer complaints is presented at OWS/TWS meetings

and quarterly at LT meetings, and it is incorporated into the

SPP for process improvements. This allows the organization to

avoid similar complaints in the future. The Customer Complaint

Process is reviewed and improved every year using PDSA

methodology. This information is also used as a key driver for

the evaluation and improvement of processes where dissatisfaction events are occurring.

Figure 3.2-2: Customer Complaint Process 

Receive Customer Complaint 

Resolve and Provide Feedback to Customer 

Track and Trend Complaints 

Identify and Implement Improvement 

Log Customer Complaint in CAPA System 

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3.2b Determination of Customer Satisfaction 

and Engagement 

3.2b(1) Local organ transplant center, tissue processor, and

eye bank satisfaction is determined through formal survey

results (Figures 7.2-1A–C; 7.2-2; and 7.2-2A–D) and personal

communication and interaction with members of the LOTS

workforce (Figure 3.1-1). The methods to determine customer

satisfaction are the same for all service lines. Survey data are

segmented by multiple dimensions, including by customer

group or market segment, the level of service quality received,

and customer requirements. Customer satisfaction data are

analyzed and shared via the Communication Process (Figure 

1.1-3) through SDs at TWS/OWS meetings, and the findings are

incorporated into the SPP (Figure 2.1-1, steps 2 and 8).

LOTS measures customer engagement based on the theory

that relationship strength is correlated with customer loyalty,

and that loyalty is obtained via those customers who are highly

satisfied. Customer satisfaction—or “engagement”—at the

highest level is determined via “top-box” scores—or scores of

5 on a survey measuring satisfaction on a scale from 1 to 5.

LOTS uses multiple methods, including surveys, to capture

customer dissatisfaction as shown in the VOC (Figure 3.1-1).

Local organ transplant center, tissue processor, and eye bank

feedback is shared via the Communication Process with LOTS

staff and other stakeholders and customers. It is also reviewed as

part of the SPP (Figure 2.1-1) and SDs occurring at work system

meetings to ensure actionable feedback and process improvements. A Deviation and Complaint Process is part of the CAPA

system. Dissatisfaction data are trended through the CAPA

system using collected deviation and/or complaint reports. This

results in the identification of root causes and actionable items.

In addition to complaints, LOTS utilizes customer survey data

to measure dissatisfaction by determining the percentage of

poor and very poor responses (scores of 1 or 2). Results for both

service lines – organ and tissue (including eye)–remain at or near

0% since 2013 (Figure 7.2-4A).

The PMS (Figure 4.1-1) is used to define and collect key

performance indicators from both work systems. These data are

transferred back into these processes in the form of actionable

information via the Communication Process, where the data can

be used to deliver improvements to meet and exceed customers’

expectations, thereby securing customer engagement for the

long term. For example, processor satisfaction with the Donor

Screening Process was identified as a low-scoring metric on a

2016 survey. Discussions in the OMP led to the development

and implementation of APs in 2017 and 2018 to address the gap,

resulting in changes in the way information was provided at

screening. Scores for processor overall satisfaction with donor

screening, and with the information provided at screening,

were higher in 2018 and 2019. The multiple approaches to

gather customer feedback on satisfaction, dissatisfaction, and

engagement undergo annual review to improve their design and

effectiveness.

3.2b(2) LOTS relies on collaboration with other OPOs

(P.2a[3]) to systematically obtain comparative data, including

their customers’satisfaction data and information available

from AOPO, OPTN/SRTR, and tissue processors. This is part

of its systematic comparative data process (Figure 4.1-4) that

considers additional sources of comparative customer satisfaction data, including data from past Baldrige applications. Due

to designation of its service area by CMS, LOTS does not have

customer competitors in the OWS, but it uses customer satisfaction comparative data. As a member of AOPO’s Data and

Information Management Council, LOTS’s Director of Quality,

Bart Wilson, is seeking to obtain information about customer

satisfaction with other OPOs and to share best practices for both

the OWS and benchmark setting, improvement, and innovation

(see Baldrige Benchmark Project, P.2a[3]). In the TWS, through

direct contact with regional OPOs and tissue processors, and

from the national OPO database for national level comparisons,

processors may provide their metrics using industry comparisons. To obtain customer satisfaction relative to other OPOs,

LOTS currently uses data from (1) local health care organizations, (2) industry comparisons of customer satisfaction (TWS;

described above), and (3) CMS benchmark/comparison data

from OPOs who have a similar size, market area, and demographic breakdown.

3.2c Use of Voice-of-the-Customer and Market Data 

LOTS selects and collects VOC data through multiple listening,

interaction, and observation methods, as indicated in VOC

(Figure 3.1-1). VOC data are integrated into the PMS, which

drives operational and strategic decision making through the

OMPand SPP, ensuring that a customer-focused culture exists

in the organization. This process undergoes systematic review to

ensure cycles of improvement and learning and a more effective

use of VOC and market data. Data are segmented by multiple

dimensions, including customer group or market segment, the

level of service quality received, customer requirements, and

the phase of the customer life cycle. VOC data are analyzed and

shared via the Communication Process (Figure 1.1-3) through

SDs and at work system meetings. This includes aggregated

data on complaints and data and information from social media.

APs to bridgegaps in performance and minimize complaints are

deployed to appropriate members of the workforce (3.1b[1]).

All customer relationship processes (3.1a)—including satisfaction and engagement processes (3.2b) and use of VOC and market data (3.2c) processes—go through systematic assessment

and improvement cycles, including the PDSA. The frequency is

determined by a significant event in the life-cycle of the process

or (at a minimum) annually. Process owners are responsible

for reporting on their progress using a documented Process

Improvement Log, which documents the improvement cycle, as

well as the results achieved before and after the improvement.

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Category 4: Measurement, Analysis, and Knowledge Management
 

4.1 Measurement, Analysis, and 

Improvement of Organizational Performance 

4.1a Performance Measurement 

4.1a(1) Key performance measures are selected, collected,

aligned, and integrated in the SPP (Figure 2.1-1). The SPP is

also the mechanism that the organization uses to select its SOs

and to develop goals supported by aligned APs. To accomplish

its mission, LOTS uses the data and information collected from

the PMS as inputs into the SPP, as well as into key decisionmaking processes and the OMP (Figure 6.1-1).

LOTS uses the PMS (Figure 4.1-1), which is reviewed at least

annually by OWS, TWS, and support service leaders, to support

its agility and continuous improvement. Last year, the process

underwent a cycle of learning to monitor more efficiently all

key business and daily operational processes. Central to the

PMS is an electronic system of cascading scorecards (Figure 

5.1-4) starting with the Topline Scorecard (Figure 4.1-2), which

has the capability to drill down through work system- and

department-level scorecards to individual performance plans.

LOTS tracks progress on achieving SOs and APs by documenting and reviewing scorecard measures, process measures, and

personal goals in the PMS that is available to the workforce

24/7 through the LOTS intranet.

Performance measures are used to support organizational

decision making through their aggregation and integration into

the cascading scorecard system and the PEP (Figure 5.1-2).

AP progress is tracked using the web-based performance

measurement system, and APs are reviewed at LTmeetings

and individually during RFO. Scorecards use a series of targets

(defined as goals) to measure organizational performance

and projections, which are defined as annualized calculations

based on year-to-date and/or actual performance in achieving

the SOs. Targets facilitate the determination of the appropriate

color-coding for all metrics, allowing real-time evaluation and

tracking of progress of the organization’s performance.

The Communication Process (Figure 1.1-3) is used to deploy

and integrate this information across the organization. The LT

and workforce are able to navigate the color-coded scorecard to

enhance decision-making effectiveness and support continuous

improvement. Once PI staff members populate and validate

the organization’s scorecards, they may notify the appropriate

manager to set up a meeting to analyze the data and develop

anAP or modifiedAP if metrics falling short of the target have

been identified. The key organizational performance measures

are tracked monthly and found in the Topline Scorecard

(Figure 4.1-2). Key Financial Measures (Figure 4.1-3) are

both short- and long-term.

Collect 

• VOC (Figure 3.1-1) 

• Comparative Data Process 

(Figure 4.1-4) 

• Deviations 

Transfer 

• Cascading Scorecards 

• AP Tracking 

• Financial Performance 

• Key Customer Reports 

Utilize 

• LS (Figure 1.1-1) 

• SPP (Figure 2.1-1) 

• OMP (Figure 6.1-1) 

• PEP (Figure 5.1-2) 

• LDS (Figure 5.2-2) 

Define Measures 

• SPP (Figure 2.1-1) 

• Comparative Data Process 

(Figure 4.1-4) 

Figure 4.1-2: Topline Scorecard 

Key Metrics* 

2020 Year-to-Date End-of-Year Projection Last Year 

Actual Target % Gap Annualized Year-End Target 2019

SO#1—OWS

Organ Donors (7.1-4) 40 50 20% 40 90% 36 

Organs Transplanted (7.1-7) 120 130 8% 130 96% 125

Bone Donors (7.1-8) 550 850 35% 1,040 122% 775 

SO#2—TWS

Tissue Authorization Rate (7.1-18) 60% 62% 3% 55% 62% 60%

SO#3—Stakeholders

Workforce Retention Rate (7.3-15) 80% 85% 6% 80% 85% 80%

SO#4—Org Excellence*

Supply Availability (AOS) 99% 100% 1% 100% 100% 99%

*Key financial measures reported in Figure 4.1-3 

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Figure 4.1-3: Key Financial Measures 

Key Financial Measures 

Short Term

Consolidated Results of Operations 7.5-1

Days Cash on Hand 7.5-9

Days in Accounts Receivable 7.5-5

Long Term

Operating Reserves 7.5-8

Total Assets 7.5-10

Average OAC Comparison 7.5-12

4.1a(2) LOTS uses the systematic Comparative Data Process

(Figure 4.1-4) to select and effectively use key comparative

data and information for target and benchmark setting, improvement, innovation, and operational decision making. This Comparative Data Process starts with the output of the SPP and the

selection of key performance measures. LOTS determines if the

comparison is valid based on validation of the process and the

method used to capture the data. LOTS ensures organizationwide effectiveness by selecting and using comparisons at every

step and at every level of the organization.

In the Comparative Data Process, which relies on data-sharing

collaborations, LOTS gathers comparative data in the organ, tissue, and support process fields from other OPOs, tissue processors, eye banks, Baldrige Award recipients, and related organizations during the Benchmark Scorecard step (Figure 4.1-4).

Once collected, the comparative data are evaluated, prioritized,

selected, and incorporated into the PMS (Figures 4.1-2, 4.1-3, 

4.1-4) and periodically reviewed by the OWS, TWS, and

support service leaders.

Data become part of the feedback to define, measure, and

compare results. Performance is then monitored, feeding back

to planning. The gap between what is and what could be drives

improvement strategies. Then updated plans connect to the

Comparative Data Process to close the loop.

In the OWS, national regulatory agencies select key performance indicators and establish performance threshold levels

Evaluation 

Criteria 

Monitor 

Performance 

PMS 

(Figure 4.1-1) 

Define Measures & 

Comparisons 

SPP (Figure 2.1-1) 

PMS (Figure 4.1-1) 

Benchmark Scorecard 

• AOPO 

• OPTN/SRTR 

• AOPO 

• Tissue Processors 

• AOPO 

• Board info 

• DHHS 

• US DoL 

Key Support 

Processes 

TWS 

OWS 

that must be met by all OPOs in order to maintain designation.

Published quarterly, this information is used to identify gaps

in performance between LOTS and high-performing peers.

The OPO calculator is a gage of organizational performance.

Provided by the Scientific Registry of Transplant Recipients

(SRTR), this tool allows for the monitoring of local organ donor

yield by comparing observed (actual) results versus what would

be expected based on the national experience (Figure 7.1-20).

This information is used in post-case reviews, SDs, and ODs,

and gaps in performance are addressed accordingly.

Due to the lack of a standard national process or availability

of comparative tissue data, the selection of key performance

indicators and the determination of performance thresholds are

established by tissue processors; LOTS reviews and selects the

key indicators that best align with its strategic plan and objectives to target, as well as support decision making and enable

opportunities for performance improvement and innovation.

Processors track OPO performance regularly on scorecards.

These data support operational decision making as they

allow LOTS to assess its success in meeting tissue processor

requirements and permit the identification of best practices.

For example, while LOTS’s procurement efforts met the Tissue

Transformations requirement for average usable skin yield

per donor, an operational decision was made to exceed the

processor requirement by increasing skin yield results. LOTS

contacted the Tissue Transformations liaison, discussed best

practices, and implemented a new process for recovering skin

that has led to sizeable improvements (Figure 7.1-23).

LOTS’s organization-wide long-term goals are set at the top

decile nationally (or higher if currently at top decile), and shortterm/annual goals build to the top decile. The BOD has ultimate

approval of all goals as part of the SPP.

Comparative data must be valid and drive performance excellence. When an improvement or innovation is needed, a review

of the available sources is performed to support PDSA with

appropriate tools. In addition to the process above, LOTS also

uses a Benchmarking Hierarchy to determine what types of

comparisons can be used if national top-decile comparisons are

not available (e.g., top quartile, national average) to ensure that

the best available comparison is used. The hierarchy is part of

the Baldrige Benchmark Project (P.2a[3]).

4.1a(3) LOTS uses PDSA for annual reviews of the PMS

(Figure 4.1-1), which is modified as appropriate during the SPP

and OMP, ensuring that the organization’s PMS is current and

constantly adapting to evolving accreditation, regulatory, operational, and financial needs and requirements. Each year during

the SPP, the LT evaluates the scorecard measures and goals and

makes necessary changes to support the SOs and to address

the competitive and regulatory landscape. Frequent, scheduled

performance reviews during work system meetings help to alert

the LT when a key process or system is not performing to goal;

this approach enables timely corrective analysis and action,

and also allows for the addition of new measures throughout

the year if a new process is implemented or significant process

redesign occurs. Annual evaluation of the PMS and frequent,

scheduled reviews of organizational performance ensure that

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The BOD reviews the organization’s performance by reviewing

the Topline Scorecard and key financial measures at regularly

scheduled meetings. The CEO reports on gaps in performance

and progress on achieving strategic SOs and APs.

the organization and its PMS are able to respond to rapid or

unexpected organizational or external changes. In addition,

monthly environmental updates, conclusions, and improvement

recommendations arising from ODs and SDs and within the

work system meetings are reviewed for impact (Figure 6.1-1).

The formal, PDSAimprovement methodology, in conjunction

with the organizational structure (Figure 1.2-2) and ongoing

SDs, ensure that the organization remains agile and able to

respond quickly to PMS-related issues that may arise in order to

provide timely data.

Reviews address all timeframes, including real-time, hourly,

daily, weekly, and up to annually. Every review assesses

whether LOTS has the data needed to make decisions in a

timely manner. If new changes are in a timeframe that is not

addressed with the current measures, staff members at every

level of review have the authority (and the responsibility) to

add or change measures to ensure the needed agility. This

is in accordance with the process described in 4.1a(1) and

is documented in our training material of “How to Review

Performance at LOTS."

4.1b Performance Analysis and Review 

The LTreviews the key organizational performance measures

and capabilities during work system meetings as part of ODs

and during quarterly C&C meetings. Individual LTmembers

are also responsible for conducting monthly reviews of work

system and department scorecardswithin their scope of

responsibilities, as appropriate, within the OMP(Figure 6.1-1).

Comparative and customer data are inputs into the PMS and

are used to review performance metrics. LOTS compares

performance, progress, and success to BaldrigeAward recipients

andAOPO benchmarks, when benchmarks are available. These

reviews help to identify gaps to goals and comparisons to provide a mechanism to generate steps to bring performance back

on track, as needed. PI staff members are responsible for data

validation and analysis using a variety of robust analyses and

analytics, including comparative, quantitative, root cause, trend,

variance, and correlation analyses. Scorecards and data reports

are stored in a Data Mall on the intranet that is accessible 24/7.

LOTS reviews progress relative to the SOs, key process

outcome measures, andAPs during SDs as part of the OMP

to ensure that the organization is on target to meet or exceed

the defined goals and is progressing towards best in class in

all areas. Organizational performance, competitive standing,

financial health, and completion of SOs and APs begin with

the Topline Scorecard and cascade todepartment scorecards.

Scorecard reviews provide a mechanism to rapidly respond to

changes identified through the SPP or OMP, as well as to ensure

changes toAPs as appropriate, which might include a response

to a transformational change in structure or work system. The

approach helps ensure that (1) performance is assessed using

a balanced set of measures, (2) measures are aligned with

strategy, (3) performance results are analyzed, and (4) opportunities for improvement are identified. The workforce is provided

with updates on key organizational metrics andAPs at various

meetings, and they have the opportunity to ask the LTquestions

regarding organizational performance and direction.

4.1c Performance Improvement 

4.1c(1) The organization’s future performance is projected

through the analysis of three-year, historical, organizational

trend data and industry trends to identify gaps and areas of

opportunity. This analysis creates short- and long-term projections that are utilized in the PMS (Figure 4.1-1) and PEP

(Figure 5.1-2). Identifying top-decile performance from comparative organizations for key measures creates a benchmark

and a course of action for improvement efforts, as applicable.

If indicated, APs are created to replicate the top-decile performance of comparative organizations. The collegial nature of the

industry creates an environment for open dialogue for sharing

the necessary steps to replicate benchmark results demonstrated

by other organizations. Reconciliation of differences between

projections of future performance (4.1[b]) and performance

projections (2.2[b]) occurs through the PMS.

4.1c(2) LOTS utilizes the systematic review of performance

data and SDs in the OMP (Figure 6.1-1) to identify opportunities for improvement and innovation, focusing on areas where

significant gaps have been identified or major changes are

anticipated. Findings drive the development of priorities for

continuous improvement and innovation. Priorities and opportunities are shared with the workforce and, when appropriate, with

LOTS’s suppliers, partners, and collaborators through the OMP

and the Communications Process because LOTS recognizes

that innovative ideas may come from any of these groups. If

indicated, a multidisciplinary team may be identified to look at

possible opportunities (see 2.1[2]). (Suppliers and collaborators

are included on teams, as appropriate, to ensure organizational

alignment.) The teams develop ideas that are vetted through

the LT for prioritization and disposition as part of the IMP

(Figure 6.1-3). The Innovation and Risk Board (2.1a[2]) is

used to vet and approve large system-wide innovations.

The SPP and findings from performance data in the OMP

(Figure 6.1-1) are used to develop priorities for continuous

improvement and opportunities for innovation. Input received

from stakeholders and environmental scanning is also used to

identify opportunities for improvement and innovation in areas

related to in-process and outcome measures. Goals for LOTS’s

key measures address the need for (1) improvement (using

PDSA), (2) design/redesign of processes (using PDSA for design),

and/or (3) innovation. Where projections of future performance

through performance reviews show an inability to achieve goals,

a 90-day AP is put in place using PDSA for improvement. If

projections of future improvement show that rapid cycles of

improvement may not achieve the goal, PDSA for innovation is

used. Performance review findings can also trigger a 90-day AP.

Performance reviews may include participation by key suppliers, partners, and collaborators. Contractual relationships with

key suppliers, partners, and collaborators include quality and

operational discussions, which are aligned in the OMP with SDs

among leadership and units. Selected approaches supporting

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SOs and goals are subjected to risk analysis to identify intelligent risks worth pursuing in support of innovation. When

determined by the LT, a team is identified to pursue via APs

the new innovation opportunities or look at other opportunities

(see 2.1a[2] and 4.1c[2]). Approved plans are deployed via the

Communication Process.

Directors and managers deploy the priorities and opportunities

to members of their respective departments and work groups.

Incorporation of a project report at staff meetings, using the

Communication Process, reinforces the departmental and work

group discussions. When appropriate, priorities and opportunities are identified, and organizational APs are deployed to

LOTS’s suppliers and partners through the OMP. The processes

to analyze/review organizational performance and utilize the

findingsto prioritize continuousimprovement and opportunitiesfor

innovation undergo annual review viaPDSAby work groups with

input from suppliers and partnersto ensure cycles of learning and

improvement. 

4.2 Information and Knowledge Management 

4.2a Data and Information 

4.2a(1) LOTS’s policies and procedures address accuracy

from the initial referral, through the organization’s work

systems,

to the allocation of organs and tissues. Clinical information

is entered into Transplant Technology, an electronic software

system that now has several built-in accuracy and error-proofing

checkpoints. For key nonelectronic data, LOTS ensures

accuracy and integrity through manual validation of reports

and audits of critical information. For example, upon case

completion, both electronic and nonelectronic data are validated

through chart review by the Quality Systems (QS) Department

to ensure accuracy. QS staff members conduct monthly audits,

ensuring a systematic approach for existing process evaluation and feedback. Validity, integrity, reliability, currency, and

confidentiality (Figure 1.1-2) of electronic data and information

are ensured through the methods listed in 6.2b.

4.1a(2) Data and information availability is critical to the

ability of the workforce to carry out the mission to save lives.

Because many employees work off-site, electronic systems are

used to ensure that staff members have access to critical data

and information. To ensure user-friendly access while keeping

all confidential data secure, the corporate intranet may only be

accessed remotely via a direct access software. Because the

staff access and input data from a remote location, the EMR is

accessible wherever web access is available. Laptops are issued

with password-protected, encrypted, disk partitions to protect

data from compromise in the event of theft and/or loss. The

timeliness of data is crucial to the processes for donation and

transplantation. The Transplant Technology system creates realtime access to donation activity for the workforce and partners.

To gain needed access, data not stored in Transplant Technology

can be obtained through multiple methods including telephone,

fax, email, and the Data Mall.

LOTS provides information to the workforce, partners, suppliers, customers, and collaborators using the Communication

Process (Figure 1.1-3). In addition, LOTS provides information

to customers through real-time access to the Transplant Technology system for read-only information. Transplant Technology

clinical data are uploaded into a national database, DonorNet.

These data are used by regulatory bodies and organizations

within the industry for collaboration. Access to such critical

data has improved turn-around and decision-making time for

LOTS’s partners. Tissue processors can access critical data

through a dedicated SharePoint portal and can receive realtime data via XML transfer from Transplant Technology. The

requirements for key suppliers are captured annually through

the SPP and ongoing SDs. Currently, there are no operational

requirements for suppliers to be linked with LOTS’s data information systems (IS). Information and data are made available to

suppliers via electronic means, conference calls, and in-person

meetings, as appropriate.

Through cycles of learning and improvement, before implementation of new software and/or hardware, a user committee

is formed to ensure that the software and/or hardware is

user-friendly, accessible, and functional. The efficiency and

effectiveness of LOTS’s processes used to ensure the quality

and availability of organizational data and information are

assessed by the QS department using the PDSA methodology to

ensure yearly cycles of learning and improvement.

4.2b Organizational Knowledge 

LOTS relies on electronic means, as well as personal communication, to manage and improve information and organizational

knowledge. The organization is able to capitalize on the

accessible Organizational Structure (Figure 1.2-2) through

the SPP (Figure 2.1-1) and the OMP (Figure 6.1-1). These

systems work together to synthesize information and turn it

into knowledge that can be used to innovate and manage work

systems and processes.

4.2b(1) LOTS collects information from people, processes,

and the environment through electronic and nonelectronic

methods via the PMS (Figure 4.1-1), which feeds into the

OMP where SDs or ODs occur and information is analyzed and

translated into actions. The LDS (Figure 5.2-2) and the Communication Process (Figure 1.1-3) demonstrate how job-related

knowledge is disseminated. Transfer of workforce knowledge

readily occurs due to the alignment of the workforce with work

systems. Multidisciplinary meetings within the work systems

ensure that consistent messages and information are shared.

One-on-one RFO conversations among staff members and

their direct managers ensure that the organization benefits from

the knowledge assets of the workforce. Ideas and information

gathered through the systematic deployment of RFO are shared

with the workforce at staff meetings via a Stoplight Report. The

intranet serves as a 24/7 vehicle to disseminate information to a

decentralized workforce. LOTS reports organizational information through the PMS and analyzes it to create knowledge using

the SPP, SDs, and the OMP (Figure 6.1-1).

As evidenced in the second step of the PMS, a variety of data

types are collected from customers via the VOC (Figure 3.1-1)

and remaining stakeholder groups (Figure 4.2-1), in addition to

clinical information captured through the organization’s EMR

(Transplant Technology). For example, combining the SRTR

data with the Transplant Technology data to analyze 2018

20 
	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	

	 	 	

	 	 	

	 	

	 	

	 	 	

	 	

	 	

Figure 4.2-1: Voice of the Stakeholder (VOS) 

Method 

Frequency Collaborators Partners Suppliers Internal A 

 Annual 

M 

 Monthly 

O 

 Ongoing 

Q 

 Quarterly 

W 

 Weekly

Donor FamiliesFuneral HomesDonor HospitalsNon-HospitalReferral SourcesGuardianWright BrothersTTTransplant Tech.ColumbiaCremationBoard ofDirectorsWorkforce 

Collect

(Figure 4.1-1) 

Operational Discussions O • • • • • • • • • 

Supplier Meetings Q, W • • • • • • 

Strategic Discussions O • • • • • • • • 

Participation in SPP (Figure 2.1-1) O • • • • • • • • 

Rounding / PEP (Figure 5.1-2)/

LDS (Figure 5.2-2) 

O • 

Surveys O • • • • • • • 

Audits, Internal/External O • • • • • • • • • 

Social and Electronic Media O • • • • • • • 

Corporate Compliance Process (Figure 1.1-2) O • • • • • • • • • 

Contracts O • • • • • • • • • 

CAPA / Deviations O • • • • • • • • • 

Transfer

(Figure 1.1-3)Best Practice Sharing O • • • • • • 

Scorecards / Status Reports / Metrics On-Demand O • • • • • • • • • 

Survey Feedback Reports A, O • • • • • • • • 

SOPs / SharePoint / Intranet / Email O • • • 

Utilize 

Strategic Planning Process (Figure 2.1-1) O • • • • • • • • • • • 

Survey Feedback / Baldrige Feedback /

Annual Report

A • • • • • • • • • • 

CAPA / Deviations / Corporate Compliance

Process (Figure 1.1-2) 

O • • • • • • • • • • • 

Best Practice Sharing O • • • • • • • • • • 

OMP (Figure 6.1-1) O • • • • • • • • • • • 

organ yield data provided information about the quality of 2018

donors that was used to validate future performance projections.

A variety of mechanisms found in the OMP are used to transfer

relevant knowledge to customers, suppliers, partners, and

collaborators. The PMS serves as the basis for the knowledge

assembly to integrate into the OMP and SPP. These processes

involve detailed data analysis developed in collaboration with

the PI staff. Improvement initiatives are presented at LTmeetings to ensure transfer of knowledge and help drive improvement and innovation throughout the organization. Step 3 of

the PMS ensures the transfer of organizational awareness and

knowledge.

4.2b(2) LOTS systematically strives to move toward bestpractice performance in all areas. When an internal goal is

met or exceeded (where LOTS can identify organizational

units or operations that are high performing), a re-evaluation

is conducted on how to reach the mission and stretch toward

a goal or benchmark. High-performing units are responsible

for documenting how they exceeded performance in a manner that can be scalable to other units. Best-practice sharing

is a combination of the knowledge management techniques

for sharing best practices across the organization and a wide

range of systematic sharing techniques within each discipline.

For example, LOTS identified a process to address family

needs prior to approval for a donation. This process was shared

not only across LOTS but across the industry and resulted in

refinements that led to higher levels of satisfaction for

families. Examples of best-practice sharing tools include an

internal shared drive, a Wiki of best practices, and an intranet

with functional team rooms. In addition, during reviews of

performance, best practices are identified and shared through

integration teams, management councils, shared governance

facility councils, senior leader meetings, quality councils, and

system improvement teams. For the various functional areas

(both clinical and nonclinical), more than 100 sharing councils

or forums are used. These forums are a normal part of how

each function operates and integrates.

21 
	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

The systematic scorecards, Comparative Data Process within

the PMS (Figure 4.1-1), and the Voice of the Stakeholder

(Figure 4.2-1) provide the tools used by the organization’s

workforce to monitor organizational performance and identify

best practices for sharing and incorporation into SOPs by the

OWS and TWS team leaders. LOTS uses the OPO performance

data regularly tracked by tissue processors on scorecards to support operational decision making, the meeting of requirements,

and the identification of best practices. As a result, for example,

LOTS has met and exceeded the Tissue Transformations

requirement for average usable skin yield per donor, which has

been identified as a best practice leading to sizeable day-to-day

improvements (Figure 7.1-23). Another identified best practice

is the modified donor prep procedure to minimize the bone

contamination rate.

In addition, LOTS identifies best practices after monitoring

monthly gaps in performance for remedial action at the individual level. Identified best practices are then shared at OWS/

TWS meetings. LOTS voluntarily participates in accreditation

councils in order to exceed standards. Accreditation inspections

assist the organization with identifying performance gaps in

practices. Participation on the councils allows for the identifying

and sharing of information and best practices to proactively

evaluate and improve operations. Approaches to systematic

knowledge management and identification of best practices

based on the above processes for sharing undergo annual review

and improvement using the PDSA methodology. Performance

review data, which include evidence of high performance within

organizational units and best practices, are shared across the

organization in SDs via the SPP, OMP, and Communication

Process. Implementation of best practices is accomplished in

both daily operations and strategically through the development of APs and ongoing monitoring of the PMS for success.

For example, the Communication Center department’s organ

authorization rate for 2018 (Figure 7.1-5) exceeded all previous records. Best-practice identification included monitoring

monthly gaps in performance at the individual level and the use

of a department manager to support and retrain struggling individuals, as well as identification of best practices. Information on

the best practices was shared at the OWS/TWS meetings, which

contributed to the hiring of a combined TWS/OWS trainer.

4.2b(3) Demonstrating a focus on the values of quality and

innovation, LOTS ensures that new learnings are continuously

embedded in day-to-day operations and strategic direction.

Organizational learning is systematically embedded in LOTS’s

operations through the LDS (Figure 5.2-2), which is aligned

and integrated with multiple organizational work processes.

Organizational learning is also embedded in the organization

through adoption of best practices and changing policies and

procedures as a result of continuous improvement. Through the

various sharing forums, LOTS captures changes for additional

improvements. Furthermore, each process owner has the

responsibility to improve his/her processes contributing to

organizational and personal learning and innovation.

Once the workforce learning and developing needs are captured

in RFO, new knowledge, required skills, and knowledge sharing

are reinforced through well-established competency testing,

work system discussions, training sessions, the Communication

Process (Figure 1.1-3), and the PDSA methodology for process

improvement.

Organizational learning is linked to expected outcomes in

employee goal plans, data-driven decisions ensure that key

processes are systematically measured, and performance results

are evaluated and used to drive improvement. Both outcome and

in-process measures are defined for each process, and progress

is evaluated through performance reviews and further enhanced

through best-practice sharing.

Regular training offerings are selected and deployed throughout

LOTS after analysis of staff feedback and organizational gaps,

and in response to personal learning goals identified by staff

members. To facilitate the transfer of knowledge among the

workforce, staff members assist in training where appropriate

and feasible. Knowledge sharing is a standing agenda item in

work system meetings. For example, an improvement team

was used to increase satisfaction with staff meetings, resulting

in the addition of manager report-outs and a Q/A session with

the CEO at each meeting. The effectiveness of the LDS in

contributing to embed learning to help solve problems locally

and bring about meaningful change is PDSA-assessed and

improved every year, and key learnings and critical knowledge

are captured and housed within the electronic PMS system for

easy access to information and tracking of approaches that have

been adopted in other areas. In addition, knowledge transfer is

supported by expanding work instructions, SOPs, forms, and

processes, which are especially critical in clinical areas.

Strategic opportunities are identified by comparing the gaps

and the strategic challenges. Analysis and decisions during the

SPP and the actions to address the gaps support intelligent risk

taking through a validation of goals (including their priority)

and strategies from internal and external stakeholders designed

to close those gaps or meet those strategic opportunities. Based

on this validation, senior leaders make the determination of

which strategic opportunities they will pursue based on cost,

risk, and benefit.

Category 5: Workforce
 

5.1 Workforce Environment are defined in terms of knowledge, skills, abilities, and specific

5.1a Workforce Capability and Capacity 

5.1a(1) Workforce C&C is assessed through the Workforce

Planning Process (Figure 5.1-1). Workforce capability needs

competencies, and capacity needs are determined by assessing

the amount of work and the number of people required for each

role. LOTS has identified the skills and competencies that are

22 
 

 

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	

Data analysis 

Determine appropriate action 

Improve/modify process 

Prioritize & select needs to address 

Communicate the action (Figure 1.1-3) 

PMS │ SDs 

Right-size workforce: Hire/Reduce/Realign or train 

VMV 

(4) 

Intelligent Risk 

Considerations 

(3) 

Annual 

Evaluations 

with LT & Staff 

(1) 

Goal Setting 

During SPP 

Figure 2.1-1 

(2) 

Goal & 

AP Updates 

(5) 

Improvement / 

Modifications 

to Process 

needed to perform each role within the organization successfully. To better define capability, LOTS identifies necessary

skills in job descriptions, and job competencies, which are

supported by job descriptions, are monitored through the PEP

(Figure 5.1-2). In addition, job descriptions are periodically

updated based on emerging technologies and strategies. LOTS

continually evaluates the need for new competencies through

multiple input mechanisms, including the SPP(Figure 2.1-1),

RFO, LDS (Figure 5.2-2), and C&C meetings. In addition,

the need for various certifications is discussed during the

Hiring Process (Figure 5.1-3) as a condition of employment,

if applicable, and is included in the job description for the role.

After hiring, the certification requirements, if applicable, are

discussed through the communication cycle and documented in

the employee’s trainingfile.

LOTSsystematically assesses staffing levels by soliciting

feedback through RFO, ongoing SDs at work system meetings,

LTmeetings, ELT meetings, and C&C discussions. Using the

PMS, LOTS forecasts staffing needs in the SPP (Figure 2.1-1).

The SPPassists with projecting potential staffing needs one year

out, ensuring a right-sized workforce for the organization.

Changing technology has also resulted in the need for changing

in-house capabilities. For example, the growing importance of

social media resulted in the hiring of a public relations communication professional to lead LOTS’S social media outreach

efforts. In addition, the LT determined that additional cybersecurity IT expertise was needed to implement the National

Institute of Standards and Technology’s (NIST’s) Framework 

for Improving Critical Infrastructure Cybersecurity (CSF).

5.1a(2) LOTS uses the Hiring Process (Figure 5.1-3) to recruit,

hire, place, and retain new workforce members. Validated in the

workforce survey, LOTS’s mission is the highest scoring key

factor for workforce engagement and satisfaction

(Figures 7.3-12 and 7.3-12A). Therefore, hiring right-fit talent

begins prior to employment by ensuring that the organizational

culture is clear to all applicants (Figure 5.1-3, Phase 1). Through

systematic C&C meetings, LOTS identifies workforce needs

during the initial stage of the Hiring Process. To ensure that the

workforce represents the diverse cultures of the community,

LOTS uses diverse recruiting methods, including local community colleges and universities, behavioral interviewing,

social media sites, and after-hiring shadowing and mentoring

to ensure a strong cultural fit. Donor families and recipients are

also considered for appropriate positions within the organization. These individuals reflect the thinking ofthe organization’s

key communities by already possessing a strong connection to

the mission. Such hiring systematically ensures that LOTS is

recruiting across a wide base and hiring the best person who fits

the culture and the culture of the organization’s customers.

LOTS’s recruitment strategies use behavioral and team interviewing to ensure that the cultural mix is appropriate. Referrals

by workforce members also contribute to the pool of applicants.

Last year, 20% of all new hires were referred by a workforce

member, an indicator of high engagement. As part of the Hiring

Process, OWS and TWS managers and Human Resources (HR)

personnel review the gathered information from behavioralbased interviews, values assessments, and other approaches,

and they evaluate the final job candidates for diversity reflecting

the hiring community and for cultural fit regarding customers’

and LOTS’s values, ideas, and needs. To enhance the cultural

fit of new recruits, LOTS gives special consideration to job

applicants who are currently working with local hospitals,

tissue processors, and eye banks and who are familiar with and

match the needs of LOTS’s customers. The Hiring Process is

PDSA-reviewed annually by HR to ensure cycles of learning

and improvement.

As part of supporting the community (1.2c[2]), a gap in serving

the local Air Force base was noted. LOTS has become part of a

community program serving the employment needs of military

spouses, who often have a problem in gaining area employment.

Hiring from this source had the effect of providing a more

diverse workforce for LOTS.

23 

SPP (Figure 2.1-1) │ RFO │ C&C │ LDS (Figure 5.2-2)
	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	

The fit of organizational culture with new workforce members is

ensured in the hiring and onboarding processes through several

recent changes, including shadowing and behavioral-based

interviewing practices. Improvements also include incorporating a conversation about values into the in-person interview

to help ensure the fit of new workforce members with the

organizational culture. As part of the on-boarding process, new

workforce members receive information online prior to starting

the job. In addition, a peer-mentor is selected from a work

team similar to the one that the new workforce member will

be joining. The peer-mentor serves as a resource for policies,

procedures, and paperwork and is encouraged to meet regularly

with the new workforce member. Shadowing assignments create

bonds between LT members and new employees, and they help

provide the new employees with a broader understanding of

the MVV. In redesigning its process for recruiting and hiring

new workforce members, LOTS gave particular attention to

survey results suggesting that members of GenZ are looking for

employers who have a purpose, and that they value face-to-face

time at work with mentors and with a network of peers and

other individuals who share a common purpose and passion.

5.1a(3) LOTS prepares the workforce for changes in C&C

needs through the Workforce Planning Process (Figure5.1-1).

Information about changing C&C requirements and needs,

including workforce growth, is gathered through several

methods including C&C meetings and RFO. Every year, the

LT analyzes current and future workforce and organizational

needs and reviews C&C information along with onboarding and

stay and exit interview data. Then workforce plans are captured

within step 5 (Assess) of the annual SPP. This is followed by

C&C meetings and RFO to gather information about changing

C&C requirements and needs, including workforce growth,

and the preparation of the workforce for changes in C&C

needs through the Workforce Planning Process (Figure 5.1-1).

In this process, data from the SPP, workforce plans, C&C

meetings, RFO, and LDS are analyzed, and the appropriate

workforce-related needs and actions to address C&C changes

are determined in order to right-size or train the workforce. This

process helps LOTS manage the needs of the workforce and the

organization, ensures continuity, prevents workforce reductions,

and adjusts for periods of growth (2.2a[4]).

Should a workforce reduction, period of growth, or change in

organizational structure or work system be required, qualitative

or quantitative information from the PMS (Figure 4.1-1) would

be used to conduct a series of SDs to determine appropriate

action. Such action might include recruitment, contingency

planning for remaining staff, or potential reassignment or exit

strategy for affected staff. Where possible, staffing levels are

benchmarked, and adjustments are made to enable operational

efficiencies across the Workforce Planning Process and other

processes. For example, strategies to achieve desired levels

of organizational C&C to address recent growth in organ and

tissue donation include a greater emphasis on cross-training

and promoting from within. The workforce environment is

systematically reviewed by HR using the PDSA methodology

to maintain cycles of learning and improvement. This approach

helps ensure continuity of operations and retention of outstanding workforce members (Figure 7.3-15).

To prevent workforce reductions, LOTS forecasts workforce

capacity needs (Figure 5.1-1) in both the short- and long-terms

and hires to those needs. As a cycle of improvement, LOTS

has created and launched a resource pool to address staffing

during growth periods. LOTS hires staff members who are

permanently necessary using the standard recruit, hire, place,

and retain processes (5.1a[2]). To prepare the workforce for

changes in organizational structure and work systems, LOTS

communicates strategic direction through the communication

methods, department meetings, and one-on-one meetings.

These techniques systematically translate the LOTS’s SOs to

each employee’s responsibilities. Changing needs are identified during the SPP and incorporated into workforce plans.

Changes in organizational structure that change work needs are

addressed through the SPP and the resulting workforce plans.

These processes are updated annually, and the primary focus is

to ensure that LOTS is meeting workforce needs, as identified in

Figure P.1-6 . 

LOTS’s leaders prepare the workforce for changing capacity

needs by (1) cross-training, (2) ensuring that all key positions

have a succession plan, (3) using a resource pool, (4) using

agency personnel in periods of significant demand, and (5) not

hiring unless the long-term need is validated. Changes in workforce capability are addressed through identification of workforce strengths/gaps related to documented job requirements and

competencies, as well as changes identified through the SPP.

These are addressed formally during the PEP (Figure 5.1-2).

To ensure that LOTS understands and manages workforce

needs, the organization has numerous workforce listening posts

(see Figure 1.1-1), and LOTS ensures continuity through the

PEP Performance Conversations Process. The PEP Performance

Conversation Process is where leaders identify and re-recruit

high performers to raise the bar for those meeting expectations,

and leaders provide coaching and performance improvement

plans for those who are not meeting expectations. This is an

opportunity to recognize/reward and re-recruit those who meet

expectations or create a training and development plan. Where

the individual or organizational need exists, LOTS effectively

trains, rewards, and re-recruits high performers and trains them

to expand the skills of solid performers.

5.1a(4) The LTprovides work system oversight and strategic

direction through the LS (Figure 1.1-1), which serves as the

foundation for key decision making. Continuity of processes

is ensured for both new and long-term workforce members

through training, education, frequent communication, SOPs,

and cross-training.

LOTS organizes and manages its workforce at the individual, key

process, and work system levels through systematic cascading

of goals/scorecards (Figure 5.1-4), which reinforces a customer

and business focus. The reinforcement of customer and business

needs is a priority and is managed by the LS, which incorporates approaches for creating the environment, operationalizing

the strategy, and monitoring the organization’s performance.

This approach begins with the Hiring Process (Figure 5.1-3),

which ensures that the best candidates are hired and fit with the

LOTS culture of a mission-driven workforce (CC).

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The integration of the LDS (Figure 5.2-2) with the LS reinforces the V/M/V and ensures that training for performing daily

tasks meets customer needs. In alignment with that training,

workforce members are empowered to make decisions for the

prompt resolution of customer concerns. These efforts lead

to competence in the delivery of service, which allows the

organization to meet and exceed customer satisfaction and to

strengthen loyalty (Figure 7.2-5).

The SPP(Figure 2.1-1) is used to create focus, establish

priorities, and set expectations for the work of the organization,

while ongoing performance is monitored through the PMS

(Figure 4.1-1) and PEP(Figure 5.1-2). Performance expectations are reinforced through SDs, RFO, and PEP. Organizational

goal ranges are established to define how employees can exceed

expectations. Ongoing discussions are supported through a

web-based PEPsystem that uses targets for APs to create an

awareness of how each member of the workforce can meet and

exceed expectations and subsequently be rewarded through

multiple mechanisms. Organizational transparency and accountability are ensured through the web-based system, allowing

each member of the workforce to monitor all staff progress

towards goals.

5.1b Workforce Climate 

5.1b(1) LOTS systematically assesses workplace environmental

factors to ensure and improve workforce health by using a comprehensive wellness program. Components of this comprehensive

wellness program include exceptional health insurance packages,

$20/month reimbursement towards wellness-related expenses,

no-cost wellness screenings (Figure 7.3-7) and flu shots, 24/7

access to an employee assistance program, and other health

opportunities. Workplace environmental differences are not

pertinent for these benefits; these programs encourage employees

to become more proactive in improving their overall health.

To ensure and improve workforce security (Figure 7.1-29),

LOTS maintains a safe facility complete with automatic locking

doors and 24/7 video surveillance. Badges are required for entry

into all the work areas of the facility, with levels of restriction

based on job function. To ensure a secure workplace environment, policy requires all visitors to sign in and be escorted by

an employee through the building.

In a cycle of learning, it was recognized that these efforts to

ensure workplace security did not include off-site workforce

members. To ensure workplace security for employees who work

in different workplace environments, including at area hospitals,

employees are required to adhere to that site’s unique security

measures. LOTS has taken additional measures to ensure the

security of the workforce by offering personal alarms to all workforce members. Training in CPR, workplace violence response,

and defensive driving classes are also provided.

LOTS ensures workplace accessibility by maintaining an

Americans with Disabilities Act (ADA)-compliant facility with

handicap entrance options. Moreover, LOTS is an equal opportunity employer and maintains realistic and flexible expectations

regarding the importance of reasonable accommodations. To

guarantee technological workplace accessibility, LOTS provides

all employees with IT training to ensure their understanding of

the IT systems.

A sample listing of performance measures for workforce health,

security, and workplace accessibility can be found in Workplace

Environment (Figure 5.1-5) and Workforce Preparedness

(Figure 7.1-28). These performance measures are designed to

25 
	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	

	 	

	 	

	 	

	 	

Figure 5.1-5: Workplace Environment 

Factors Measures Results 

Health EAP 

OSHA Compliance

Wellness Program Participation

AOS

7.3-9

7.3-7

Security Training

Safety Drills

ERP

Safety Measures

Security Measures

7.1-29, 7.1-30

7.1-31

AOS

7.1-32

7.1-29

Accessibility ADA compliant

EEOC compliant

IT resources

AOS

AOS

AOS

provide a work environment conducive to supporting the LOTS

workforce to accomplish the mission.

5.1b(2) Focusing on the CC of a mission-driven workforce,

LOTS maintains a workforce philosophy of “We take care of

‘Our People’so they can take care of others.” To meet the needs

of a diverse workforce, multiple benefits plan options are available with distinctions within the services, benefits, and policies

dependent on workforce demographics, including tenure and

performance.

The supportive work environment includes multifaceted health,

financial, and scheduling options and benefits. The workforce

services, benefits, and policies are assessed in the workforce

survey. LOTS has many services as a part of its wellness

initiative that are available to all employees, including health

screenings, flu shots, a health coach, voluntary smoking cessation programs, optional flexible scheduling, and an employee

assistance program (EAP), which is available to staff members

as well as their family members.

LOTS supports its workforce by providing a comprehensive

insurance benefits package to all full-time employees; the package includes three medical plan options, as well as dental and

vision plans, on a tiered-cost platform. Employees can select

the best plan to meet their medical, financial, and family needs.

The organizational policies that support the workforce include a

generous paid time-off plan, Extended Medical Bank plan, paid

holidays, and tuition assistance.

Benefits with financial impacts may vary based on staff type,

length of service, and performance. A generous 401k plan,

which includes a discretionary contribution, is provided to all

eligible staff members.

The range of benefits and services offered by LOTS was developed in response to workforce surveys and focus groups, which

identified benefits as a key workforce requirement. Employees

who choose the workforce engagement driver of benefits in the

2019 workforce survey scored their satisfaction at 89%, exceeding the industry comparative (Figure 7.3-17). These workforce

benefits and policies enable LOTS to strengthen its CC of fully

engaged workforce members who are motivated to fulfill its

mission to save and improve more lives.

5.2 Workforce Engagement 

5.2a Assessment of Workforce Engagement 

5.2a(1) The key drivers of workforce engagement are

determined through customized workforce surveys developed

by Survey System Success. From 2008 through 2014, the

engagement elements included in the workforce survey were

determined by a staff focus group. The survey included openended questions to assess each employee’s drivers of workforce

engagement and satisfaction. All workforce segments indicated

that the overarching reasons for working at LOTS were the mission, relationships with coworkers, and benefits. Survey results

during this time period were exceptional, with the organization

scoring in the 90th percentile in the vendor’s database for

the 2014 survey. A different vendor was chosen for the 2017

workforce survey. The goal for changing providers was to gain

a deeper understanding of employee engagement, validation

of the key drivers of employee satisfaction and engagement,

and actionable feedback. Beginning with the 2017 survey, the

new vendor, Excel Employee Engagement, allowed the staff

individual selection of satisfier and engagement drivers. Excel

Employee Engagement also provides benchmark data from

a variety of sources, including a benchmark from a cohort of

400 health care organizations and an OPO/blood donation facility benchmark. Across all workforce groups and segments, key

drivers of workforce engagement continued to be the commitment to the mission, coworkers, and benefits.

5.2a(2) LOTS assesses workforce engagement through the

workforce survey. Through learning and improvement, the

survey has gone from an internally tabulated questionnaire

regarding culture and benefits, to an externally developed

process that includes national benchmarks and provides input

into the SPP(Figure 2.1-1). The 2019 workforce survey

validated LOTS’s CC of a mission-driven workforce (Figures 

7.3-11, 7.3-12, and 7.3-12A). The workforce survey allows

measurement of engagement across workforce groups and segments, including work system, tenure, and department, so that

each workforce segment can review its results in detail. Other

engagement indicators include retention rates and clinical

staffing levels.

Workforce retention is measured on the Topline Scorecard and

has remained a priority (Figure 7.3-15). Departmental retention

is assessed, and APs may be developed for areas that are falling

below target. Absenteeism is not monitored as an organizational

metric but is monitored on a case-by-case basis. Productivity is

monitored through the accomplishment of APs through the PEP

and PMS and is measured via gross revenue per full-time

employee (FTE). Productivity of the workforce is

acknowledged through the Rewards and Recognition Program

(Figure 5.2-1).

5.2b Organizational Culture 

TheLS(Figure 1.1-1),PMS(Figure 4.1-1),SPP(Figure 2.1-1),

and V/M/V foster and reinforce an organizational culture

characterized by open communication, high performance,

and an engaged workforce that provides excellent service

to its customers. As a component of the Communication

26 
	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	

Figure 5.2-1: Rewards and Recognition 

 

 

 

 

 

Process (Figure 1.1-3), RFO fosters open communication.

The workforce survey noted satisfaction with clear, effective

communication at 75%, exceeding the health care median by

15%. The RFO questions have varied based on SDs and staff

feedback and currently include questions like “What do you

need to accomplish your goals?” and “Is there anyone you

would like to recognize?” A Stoplight Report was designed

to communicate progress to the organization as part of a staff

meeting; this serves as a feedback loop and possible input into

organizational improvements. An engagement tool was added

in 2018 and offered the staff the option to attend a group lunch

hosted by the CEO. This setting allows employees to have

access and conversations with the CEO in small-group settings.

These “Cafe CEO” lunches have provided an additional forum

for open communication.

The SPP and PMS provide the foundation for a culture of high

performance. The PMS engages both leaders and employees in

defining high-performance work, which is documented through

the PEP. Employee performance and success are evaluated based

on completion of APs and achievement of specific goals that

align with the SOs. The LT regularly acknowledges success to

drive a high-performance workforce through the Rewards and

Recognition Program (Figure 5.2-1), which includes rewards/

recognition for intelligent risk/innovation as part of III recognition. RFO also encourages high performance and achievement of

goals through regular goal review.

LOTS fosters an engaged workforce through the V/M/V

(Figure P.1-1). To reinforce LOTS’s cultural message, donor

families and recipients periodically attend staff meetings and

share their heartfelt stories. These stories allow LOTS to put

a face to the mission, while motivating, inspiring, and engaging the staff. These touching testimonies are why the LOTS

workforce works so hard to fulfill its mission. In 2019, staff

members scored their connection to the mission at 95%, the

highest of all 22 engagement drivers, exceeding the health care

median benchmark (Figure 7.3-11). In addition, values are part

of the PEP (Figure 5.1-2) and are highlighted at various staff

meetings to demonstrate how that value may be applicable in

day-to-day work. For example, a recent staff meeting presentation was made around the value of honesty and the applicability

of that value when dealing with donor families.

The Communication Process engages the LOTS workforce in

sharing ideas and ensures that the organization benefits from

the diverse ideas, culture, and thinking of the workforce to

support the organizational culture. The workforce is empowered

to make decisions and acts to achieve individual and organizational success through transparent communication—specifically

through the PMS and PEP. Leveraging its mission-driven

workforce (CC), LOTS ensures that the right staff member

is placed in the right job with the right training, empowering

the workforce to provide superior customer service (including

resolution of complaints), resulting in customer loyalty and

engagement (Figure 7.2-5).

The key drivers of employee engagement and satisfaction have

been determined using the workforce survey and the Communication Process (Figure 1.1-3). In the 2018 workforce survey, the

overall engagement score was 75%, exceeding the health care

median as well as the OPO benchmark group. Workforce survey

segmentation based on demographics, including work system,

tenure, and length of service, isAOS.

5.2c Performance Management and Development 

5.2c(1) The Workforce Performance Management System

(WPMS) and the PMS (Figure 4.1-1) support high

performance, engagement, and intelligent risk-taking in the

workforce and LT. In addition, the fully deployed PEP(Figure 

5.1-2) consists of several layers that are structured and systematic, complements the above systems in supporting high workforce performance. Through the WPMS and utilizing the SPPas

the foundation, APs are created using staff input to support high

performance in the accomplishment of organizational goals,

which ultimately drives the achievement of SOs. These goals

are aligned with the V/M/V of the organization and are

cascaded to the workforce. Part of the PEPalso includes

individual personal development goals for each staff member

that help ensure personal development and growth and,

ultimately, ensure that the needs of the organization are met.

Managers analyze performance review scores and track goals

and APprogress in real-time. The PEPis designed to ensure

transparency across the organization; in turn, each evaluation

tool includes results on organizational and individual goals,

demonstration of core values, and personal development plans.

The WPMS includes a process to incentivize, support, reinforce,

and reward intel-ligent risk-taking among the LT and OWS/

TWS leaders when considering strategic opportunities for

innovation.

While staff members name the mission, coworkers, and benefits

as the highest-scoring engagement drivers, LOTS recognizes

the importance of compensation and rewards and recognition

(Figure 5.2-1). The organization’s compensation system establishes competitive salary ranges and a merit-based pay increase

system to reward staff members for achievement of their goals

and demonstration of the core values. LOTS has a strong

commitment to maintaining market-based salaries and works

triennially with an external consultantto determine necessary

market adjustments. The organization’s Rewards and Recognition Program includes a program that allows employees to

recognize one another, accomplishment of organizational goals,

and other personalized recognition opportunities (Figure 5.2-1).

27 
	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	

	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	

	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

Personal growth and learning are also strong values for many

workforce members. The PEP, via the LDS (Figure 5.2-2), is

used to evaluate program effectiveness, identify learning and

development needs, and serve as a direct input to the PMS

(Figure 4.1-1). The information from the PEP is used throughout the year in ongoing SDs. LOTS’s customer and business

focus, as well as the achievement of APs, is guided by the

PMS and reinforced by the PEP. This allows the organization

to ensure that all goals and targets are closely monitored, and

accountability is achieved.

5.2c(2) LOTS’s LDS (Figure 5.2-2) begins with the orientation of mission-driven workforce members, alignment with

the organizational culture to support the organization’s needs,

and the personal development of the workforce. To achieve

the V/M/V, LOTS focuses on the continual development of its

staff and LT, beginning with new-employee orientation. Newemployee orientation is now offered in two phases: Introduction

and LOTS Learning. During the Introduction Phase, new hires

are introduced to the culture and complete onboarding activities

during their first week of employment to create an understanding

of the organization’s needs. The LOTS Learning Phase is offered

as an extension of new-employee orientation. This comprehensive, eight-hour program highlights key organizational elements.

Staff members participate in LOTS Learning after they have

completed several weeks of employment. The utilization of a

training and development goal allows staff members and leaders

to identify training and development needs collaboratively,

based on strengths and opportunities for the individual. This also

enhances the organization’s capability for goal accomplishment.

The priorities of the workforce LDS (Figure 5.2-2) are evaluated annually and aligned with the SOs, SCs, APs (short- and

long-term), and goals to ensure support of organizational needs.

As an example, an AP was initiated to implement a web-based

performance management system. The complexity of the

software required a two-year AP, including implementation and

incorporation of future models of the software and a training

component. The successful completion of this AP resulted in the

workforce having 24/7 access to monitor the status of organizational and individual goals, while promoting transparency

across the organization.

Organizational and performance improvement, organizational

change, the determination of strategic opportunities that are

intelligent risks worth taking for innovation, and risk taking

are driven from the SPP through the LS (Figure 1.1-1) and the

Organizational Structure (Figure 1.2-2), to the employee level

where they are reinforced by the PMS (Figure 4.1-1) and the

LDS. The LDS supports organizational performance improvement and intelligent risk taking through its Learning phase,

specifically the On-the-Job Training, Industry Conferences, and

Industry Networking components. Decisions and transfer of

intelligent risks and innovations occur during the Knowledge

Sharing phase.

The IMP (6.1-3) and the Innovation and Risk Board (2.1a[2])

are used to ensure that LOTS is taking appropriate (intelligent)

risks to significantly improve the PEP and learning development. The results of these risks are measured and reported to the

BOD annually.

For all LTmembers, LOTS deploys a systematic leadership

curriculum, which is reviewed annually. New LT members are

provided with internal training to assist with cultural integration and to share organizational knowledge. Additionally, new

leaders complete a leadership training session that includes

coaching, performance management, behavioral interviewing,

development of decision-making skills, and the development of

intelligent risk taking.

LOTS’s approach to leadership development was modified in

2019 in recognition of the need to retain outstanding workforce

members and promote from within to address the growth in

organ and tissue donations. Additional emphasis is being placed

on cross-training to ensure that workforce members have

opportunities to learn and the organization has a more agile

workforce. On-the-job-training offers a cost-effective way to

cross-train and to link training more closely to LOTS’s capacity

needs and priorities, resulting in future leaders with a broader

understanding of organizational needs.

To support ethics and ethical business practices, annual policy

training includes review of the COI policy, Code of Professional Conduct, Corporate Compliance Training, and ongoing

procedural compliance. The LOTS workforce is educated on

the organization’s legal and regulatory requirements through

mandatory training. The CCP(Figure 1.1-2) training is

conducted during new-employee orientation, and the CCP

policy competency is assessed annually thereafter; CCPtraining

encourages the reporting of suspected breaches of policy violations or unethical practices.

To perpetuate and improve the customer focus of the organization, LOTS trains all new employees during orientation on

the organization’s customer complaint philosophy to ensure

superior customer service. Customer focus is also achieved

through a variety of APs targeting customer satisfaction and an

extensive Customer Survey Process to assess performance.

With the recent addition of the Innovation and Risk Board

and process, a course was established and conducted with all

employees on innovation and intelligent risk taking.

The learning and development needs of workforce members

are captured in RFO and are also part of the LDS(Figure 5.2-2).

As a component of the LDS, LOTS reinforces new knowledge

and on-the-job skills through ongoing competency testing, work

system dialogue, bringing in subject-matter experts for training,

and the Communication Process (Figure 1.1-3). Knowledge

sharing is also a component of the LDS.

5.2c(3) Learning and development are critical components of

workforce success, which in turn drives organizational sustainability and supports the CC of a mission-driven workforce.

To increase its effectiveness, the LDS system (Figure 5.2-2)

is systematically validated as part of the SPPand improved

through root-cause analysis and the PDSA methodology. Past

improvements have included the addition of skills days and a

formal exit interview process. In the 2018 workforce sur-vey,

on the engagement driver of continuous learning, training, and

development, results showed an 82.6% satisfaction level with

training and development, exceeding the health care mean

28 
	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

Figure 5.2-2: Learning and Development System (LDS) 

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	

(Figure 7.3-18). This is one of the approaches LOTS uses to

evaluate the efficiency and effectiveness of the LDS.

HR staff members evaluate the effectiveness of training, including by looking at quality goals (evidence-based measures) and

service goals (experience outcomes). The courses that directly

impact goals are carefully evaluated, and some include “proof

of learning” through the appropriate licenses or certifications.

The use of rubrics also allows LOTS to evaluate the effectiveness of training by correlating the learning and development

outcomes with results of customer satisfaction and the findings

of workforce satisfaction and engagement. In addition, HR

systematically applies use of the Kirkpatrick Model’s four levels

of learning evaluation where results are evaluated regarding satisfaction, knowledge/skills increase, adoption level, and impact

on the business model (levels 1–3). Where these correlations are

not strong, LOTS identifies opportunities for improvement in

learning approaches used, development approaches used, and/or

approaches needed to strengthen workforce engagement.

Depending on the nature of the training, learning efficiency is

linked to an outcome measured in the performance plan for each

employee. Staff members who attend training off-site complete

formal evaluations of the training attended and the outcomes

that resulted. They also are asked to share the information they

learned at department, work system, or LT meetings to help other

team members gain insight from the training. Information from

these evaluations is used to determine which external training

vendors to continue using, which to delete, and what topics to

obtain from other vendors. This step has resulted in improvements in measurable outcomes from external training. Further,

an analysis was added this year that correlates staff members’

completion of courses in the LDS and performance in identified

areas in the PMS.

In addition, LOTS evaluates the efficiency of the LDS by conducting evaluations of internal and external opportunities, and

comparing the results to affording employees’the opportunity to

provide feedback about the training they expected and received;

this process is also used to identify any industry training needs

of interest that will support the mission (Figure 5.2-2, step 4).

5.2c(4) LOTS uses the LDS to manage career development

planning (CDP) for the workforce and future leaders. A BOD

policy stipulates that professional and personal development

opportunities and

cross-training must be

provided for all staff and

leaders every year in

alignment with the strategic plan and workforce

plans. At LOTS, most

job- and career-related

development involves

job enhancement

opportunities within the

organization. Both the

internal and external

learning components

of the staff knowledge

step of the LDS include leadership development and career

support for leaders and staff members who are identified by the

PEP (through annual HR capability reviews, key system leader

surveys, and LT recommendations) as high performers so that

they can utilize their skills, knowledge, and abilities in various

ways at their same or higher career levels. and mentoring and

formal development through CDP.

Due to the organization’s size and structure, CDP is often

supported in horizontal transitions to different roles, managed

through biannual discussions by a committee composed of

representatives of the LT, OWS, TWS, and support systems.

Over half of the workforce is in a different position today than

originally hired for, and many of those employees have transitioned multiple times. The PEP helps identify high performers

who can utilize their skills, knowledge, and abilities in various

ways. CDP is further used to help employees develop specific

skills and knowledge to enable progression to other career

opportunities.

The LDS is also used to prepare the workforce for replacement and succession planning. Succession plans are reviewed

annually through the SPP (Figure 2.1-1, step 5) andmodified as

needed by the CHRO, CEO, COO, CMO, and each LTmember;

the plan provides strategy for short- and long-term coverage

for each LTposition. The LTsuccession plans focus on the

development of current leaders positioned to take on additional

responsibilities and emerging leaders who could serve as the

next generation of leadership. Development needs of identified

emerging leaders are now incorporated within the training and

development plan as part of the employee’s PEP.As an example,

targeted training is being provided quarterly to team leads

across the organization to ensure foundational understanding,

including understanding of team dynamics, handling difficult

conversations, and team motivation.

Emerging leaders are identified through the PEP, and if they are

on succession plans, they have an individually developed plan

for their leadership development and growth. All employees

understand: (1) their job requirements; (2) their current performance; (3) the gap between #1 and #2, above; (4) what needs to

be done to improve; (5) the access they have to the development

they need; (6) the requirements of a desired job; and (7) the

access they have to develop toward the desired job.

29 
	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	

	 	 	 	

	 	 	 	

	 	 	

	 	 	

	 	 	

	 	 	

	 	

	 	 	 	

	 	 	 	

	 	 	

	 	 	

	 	 	

	 	 	

	 	 	 	 	

	 	 	 

Category 6: Operations
 

6.1 Work Processes 

6.1a Product and Process Design 

6.1a(1) Key work product and process requirements are

determined by analyzing customer and stakeholder inputs and

requirements, regulatory and compliance requirements, and

organizational requirements like the MVV and SOs. Customer

and stakeholder input is obtained through a variety of listening

and learning methods via the VOC (Figure 3.1-1), including

formal and informal surveys, feedback reports, and informal

interactions. The product and process requirement analysis and

discussion start in the SPP(Figure 2.1-1, step 8) and continue

during the year in ongoing SDs and throughout the OMP

(Figure 6.1-1). For example, it was determined through survey

data feedback that referring physicians from donor hospital

partners did not feel prepared for their involvement in Donation

after Cardiac Death (DCD) organ donor cases. This requirement

for information was taken to the Critical Care Taskforce, and a

tool was developed using the input. An information card is now

distributed to physicians and nurses caring for potential organ

donors to help prepare them for involvement. In 2018, there

were a record number of DCD donors, and the hospital partner

satisfaction exceeded prior years (Figure 7.1-2)

6.1a(2) LOTS’s key service is the facilitation of organ and

tissue donation (Figure 2.1-2), a service provided to customers in collaboration with key partners (Figure P.1-6). Key

work processes of referral management, authorization, and

procurement are designed to drive organizationalsustainability

by fulfilling the needs and requirements of key customers

(Figure P.1-6). Through these key processes, the workforce

advances the organization’s SOs and ultimately provides organs

and tissues for transplant.

In the ODs of the OMP, process owners meet with the process

customers. This is for both key work processes that have external

customers and support process that have internal customers. A

Customer Agreement

Process is used

to ensure that owners

Figure 6.1-1: Operational Management Process (OMP)

and the customer

systematically evalu- SPP PMS 

ate relevant factors (Figure 2.1-1) (Figure 4.1-1) 

for cost, efficiency,

and effectiveness, Staf

(RFO) 

f Knowledge 

including cycle time,

productivity, rework, VOC 

and the other factors (Figure 3.1-1) 

shown in 6.2a. The VOS 

form and process (Figure 4.2-1) 

ensure that the

owner and customer Technology

Environmental, 

, Risk, systematically Agility Information 

address these issues

and both sign off that

they understand the

requirements.

30 

6.1a(3) The OMP (Figure 6.1-1) demonstrates the methods

used to design, refine, and construct key work processes to meet

requirements. Through the OMP’s use of RFO; the VOC; the

VOS; and environmental, technology, risk, and agility information, internal and external factors are considered to ensure that

new and appropriate technology, agility, customer value, and

key requirements drive work processes that are systematically

analyzed, reviewed, and translated into priorities. In addition,

the need to incorporate organizational and workforce knowledge

to make newly designed work processes successful is assessed

during the OMP; work process effectiveness is evaluated post

implementation during step 4 of the LDS (Figure 5.2-2). These

considerations are evaluated for improvement during the SPP

and continued throughout the year during ongoing SDs and ODs.

Incorporation of organizational knowledge, new technology, service excellence, customer value, risk, and agility is also accomplished through the OMP and step 4 of the LDS (Figure 5.2-2).

Both the OMP and LDS are integral inputs into the SPP, which

drives ODs, data analysis, real-time decision making, and

improvement to ensure customer value. LOTS’s workforce

members drive organizational improvements and innovation

using the SPP, OMP, and PMS (Figures 2.1-1, 6.1-1, and 4.1-1),

as well as the PDSA methodology (P.2c) to assess performance,

look for opportunities for improvement and innovation, and

deploy appropriate solutions to meet customer needs.

6.1b Process Management and Improvement 

6.1b(1) The OMP drives work processes through multiple

inputs, including the SPP, PMS, workforce knowledge, and

stakeholder and environmental information, to ensure that key

N

requirements are met. Within the OMP, the PMS (Figure 4.1-1)

is used to ensure that key metric requirements are measured,

analyzed, and benchmarked. ODs also include analysis of

metrics, evaluation of current APs and process steps, and validation that current performance is meeting or trending to meet
	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	

	 	

	 	

	 	

	 	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	

	 	 	 	

targets. As an example, during Organ Operations meetings, a

systematic review of selected organ cases is performed. During

these multidisciplinary reviews, workforce members assess

achievement of the Hospital Referral Process, Authorization

Process, and the Clinical Procurement Process steps, along with

stakeholder feedback. This systematic review helps determine

if process changes are indicated and provides an opportunity

to share learning across the work system to improve OWS

processes.

Key performance and in-process measures used for the

control and improvement of work processes are outlined in

Figure 6.1-2A. These in-process measures drive increased

performance and strict adherence to processes to ensure

maximized outcomes and service. An extensive set of policies

and procedures, incorporating key stakeholder input, defines the

work required to accomplish the key work processes. Deviations to these processes are captured in the CAPAdeviation

system, analyzed for trend identification, and resolved. APs

are deployed and work processes are modified, as indicated.

Capitalizing on LOTS’s CC is critical to the accomplishment

of the key work processes. Ongoing evaluation of these key

work process measures occurs through the PMS; alignment

and integration of performance measures begin in the SPP and

continue through the OMP to ensure that all data and information needs are met to effectively manage performance outcomes.

Key in-process and outcome measure selection is used to drive

and assess service quality and performance.

6.1b(2) LOTS’s key support processes and in-process

measures used for the control and improvement are outlined

in Figure 6.1-2B. The OMP (Figure 6.1-1) demonstrates the

process used to determine the key work system requirements

to select and construct the key support processes, based on the

PMS, staff knowledge, the VOC, and other information. Key

support processes are Laboratory Testing, Donor Chart Review

and Release Process, Supply and Equipment Management,

Financial Management, HR Management, IT Management, PI,

and Quality Compliance Management, which are determined by

the need to maintain the successful operation of the key work

processes involved in the OWS and TWS. This need aligns to

the requirements and design of support processes (determined

during ODs and feedback analyses). Day-to-day operation of

the support processes and the ability to meet key business support requirements is ensured by the OMP (Figure 6.1-1). This

approach is annually reviewed for improvement.

Figure 6.1-2A: Key Work Processes 

PHASE PRE-DONATION DONATION POST-DONATION 

Key Work 

Process Referral Management Authorization Procurement/Allocation Post-Donation 

Work System 

Alignment OWS TWS OWS TWS OWS TWS OWS TWS 

Key 

Requirement 

Hospital

Partner

Satisfaction

OWS

(7.1-2) 

Hospital

Partner

Satisfaction

TWS

(7.1-2A) 

Referrals Referrals Organ

Donors

(7.1-4) 

Tissue

Donors

(7.1-3) 

Consistent

message to the

donor families

(Donor Family

Outreach and

Communication

Plan. 3.2a[1])

(AOS)

Consistent

message to the

donor families

(Donor Family

Outreach and

Communication

Plan. 3.2a[1])

Results (7.1-1) (7.1-2) (AOS)

Key 

In-Process 

Measure 

Missed

Organ

Referrals

(7.1-16) 

LOTS

Tissue

Approach

Rate

(7.1-17) 

Organ

Authorization

(7.1-5) 

Collaborative

Approach

Tissue

Authorization

(7.1-18) 

Re-approach

Rate

Donor

Management

Protocol

Compliance

(7.1-20) 

Organ

Donor Cases

In-house

(7.1-21) 

Bone

No Growth

Rates

(7.1-22) 

Skin Yield

(7.1-23) 

Follow-ups,

memorial

service

attendance

(AOS)

Follow-ups,

memorial

service

attendance

(AOS)

Key Outcome 

Measure 

Organ

Referrals

(7.1-1) 

Tissue

Referrals

(7.1-3) 

Local

Organ

Donors

(7.1-4) 

Organ

Conversion

(7.1-20) 

Total

Tissue Donors

(7.1-6) 

Local

Organs

Transplanted

(7.1-7) 

Skin

Donors

Released

(7.1-9) 

Donor family

satisfaction

(AOS)

Donor family

satisfaction

(AOS)

Continued. 

31 
	 	 	

	 	

	 	 	 	

	 	

	 	

	 	

	 	

	 	

	 	 	 	 	

	 	

	 	

	 	

	 	

	 	 	 	 	 	 	

	 	 	 	

	 	

	 	 	 	 	

	 	

	 	 	

	 	 	

	 	

	 	 	 	

	 	

	 	

	 	

	 	 	

	 	 	

	 	 	

	 	

	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

Figure 6.1-2A: Key Work Processes (continued) 

PHASE PRE-DONATION DONATION POST-DONATION 

How 

Determined 

• Regulatory

CMS FDA CMS UNOS/

OPTN

UAGA

AOPO 

UAGA

AATB

VOC (3.1-1) 

UNOS/

OPTN

AOPO 

VOC

(3.1-1) 

AATB

VOC (3.1-1) VOC (3.1-1) 

Recent 

Improvement 

Added family communication

requirement through LOTS

Donor Family Outreach

and Communication Plan

(3.2a[1])

Added organ rejection rate

to scorecard (AOS)

Through marketing,

outreach, and

communications

programs, created new

partnerships with state

DMVs and WPFL

(2.1b[1])

Added family communication

requirement through LOTS

Donor Family Outreach and

Communication Plan

Figure 6.1-2B: Key Support Processes 

PHASE PRE-DONATION DONATION POST-DONATION 

Key Support 

Process 

Laboratory

Testing

Donor Chart

Review and

Release

Supply and

Equipment

Management

Financial

Management

HR

Management

IT

Management

PI Quality

Compliance

Management

Key 

Requirement 

Customer,

Partner

Satisfaction:

Customer

Satisfaction:

Customer,

Partner

Satisfaction:

Strong

Board

Ratings:

Workforce

Engagement

24/7

Uptime/

Security

Service

Quality

100%

Compliance

Results (7.1-2, 7.1-2A, 

7.2-1–7.2-2) 

Laboratory

Requisition

Error Rate

(AOS)

(7.2-1–7.2-2) 

Donor Chart

Error Rate

(AOS)

(7.1-2, 

7.1-2A, 

7.2-1–7.2-2) 

(7.4-6) (7.3-12) 

Connection

to Mission

(7.3-11) 

(7.3-12) 

Server

Uptime

(AOS)

(7.3-12) 

Energy

Efficiency

(7.1-27) 

(7.3-12) 

Observed vs.

Expected

by Organ

(7.1-20) 

Key InProcess 

Measure 

Sterilizer

Accuracy

(AOS)

Current Ratio

of Assets vs.

Liabilities

(7.5-7) 

Key Outcome 

Measure 

Laboratory

Turnaround

Time by

Work System

(7.1-24) 

Chart

Release

Cycle Time

(7.1-25) 

Radiation

Exposure

(AOS)

Net Margin

(7.5-4) 

PEP Ratings

(7.3-1) 

Security

Measures

(7.1-29) 

PI Help

Desk Tickets

(7.1-26) 

Regulatory

and Legal

Compliance

Key Measures

(7.4-4) 

How 

Determined 

• Regulatory

CAP CMS, FDA CAP, FDA,

OSHA

CMS, IRS EEOC, DoL,

OSHA

CMS CMS All (P.1-5)

Within the OMP,the PMS (Figure 4.1-1) is used to ensure that

key support metric requirements are measured, analyzed, and

benchmarked to drive associated APs. ODs also include analysis

of metrics and evaluation of current APs and process steps. Key

support metrics are reviewed at the department level to assess

performance for meeting key business requirements on an ongoing basis. For example, the laboratory requisition error rate was

tracked as a key laboratory metric and was one of the highest

sources of errors. Requisition errors were the source of rework

and had the potential to slow the testing and/or release of critical

laboratory infectious disease testing. PI, Laboratory, Organ, and

Tissue Procurement Departments met and developed an online

laboratory requisition module that reduced the number of errors

dramatically.

6.1b(3) Improvement of work processes, products (services),

the CC, and performance is initiated through the OMP

(Figure 6.1-1) by using the PMS (Figure 4.1-1) and SPP

(Figure 2.1-1) to identify opportunities for improvement and

innovation. The overarching approach to support work process

and product improvements is PDSA, with the foundation of III

program components. As an example, the TWS staff developed

a PDSA to test a modified donor prep procedure to minimize the

bone contamination rate, a critical metric to ensure maximizing

donation and customer satisfaction (Figures 7.2-1 through 

7.2-2, 7.2-2C, and 7.2-2D). Initial results showed improved

outcomes, and the rigorous prep practice was incorporated into

LOTS’s policies and procedures. LOTS has had the lowest

contamination rate of all Tissue Transformations partners, and

the prep procedure was identified as a best practice. LOTS has

trained other OPOs on the procedure. Improvements in work

processes to enhance the mission-driven workforce (CC) are

also part of the OMP, ensuring a multifaceted and systematic

analysis and discussion of product and process improvements.

32 
	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

6.1c Supply-Network Management 

In a nontraditional sense, supply-network management includes

the receipt of the donor referral from LOTS’s hospital partners

and is the most critical supply-network event for the organization (Figure 2.1-2). The selection of these nontraditional suppliers is predetermined by the DSA. The “donor” supply-network

management entails creating and communicating performance

standards and expectations during regularly scheduled meetings.

In addition, there is a Standardized Identification and Referral

Process at partner hospitals of all potential donors, ensuring that

operational needs are met (Figures 7.1-1 and 7.1-2). After the

initiation of the referral process, potential donor suitability is

established, and the potential donor’s family is approached for

donation. The donor referral system is developed collaboratively

with hospital and nonhospital partners, and the Procurement

Process begins with the donor entering the OWS or TWS. Hospital partners initiate the referral; their supplier performance is

regularly tracked via metrics noted on the Quarterly Dashboard

report and in the Hospital Services scorecard. Poorly performing

hospitals are identified via these metrics, and subsequent APs

are established with workforce buy-in to ensure improvement

in outcomes. For example, one partner hospital referral compliance for 2017 was 68%. The Hospital Services staff worked

with the hospital to PDSA several improvements, including

training, additional approaches to communication (including

daily emails), new workforce orientation, and follow-up with

hospital administration. As a result of this focused PDSA, the

hospital’s 2018 compliance improved to 85%.

LOTS recognizes that collaborative relationships with more

traditional suppliers play an important role in enhancing

organizational performance and customer satisfaction. LOTS

manages its traditional supply-network with an online inventory

management system. This system enables the organization

to manage ordering, purchase orders, purchasing history, and

supply expiration monitoring, which allows LOTS to establish

minimum inventory levels that consider lead times and expiration dates. Additionally, a Quarantine and Release Process for

critical supplies ensures that sterility certificates and inventory

qualifications meet or exceed industry requirements. Suppliers’

performance is measured and evaluated on a variety of levels,

including metrics on damaged and returned supplies and

delivery times. Poorly performing suppliers are contacted to

resolve recurring issues, and if issues persist, they are replaced

by another available supplier/supply.

Key non-referral-supplier performance (Guardian Ambulance,

Transplant Technologies, and Wright Brothers Charters) is

monitored, tracked, and trended to ensure they meet LOTS’s

operational needs for transporting organs and related activity

around the key requirements of accurate information, service

quality, and timely communication. These results are included in

regular feedback with the key suppliers (Figures 7.1-27, 7.1-28, 

7.1-29, and 7.1-30). These key suppliers are also vetted based

on their abilities to align, communicate, and collaborate with

LOTS. To ensure this, LOTS has implemented annual supplynetwork meetings where donor referral hospitals, medical

examiners, and hospices, as well as non-referral key suppliers

and partners, gather to review and analyze performance metrics

and dashboard reports, discuss procurement and improvement

issues, and update customer and regulatory requirements. The

resulting annual Supply-Network Improvement Recommendations report contributes to increase two-way communication,

strategic alignment, process improvement, and innovation to

meet customer requirements and increase the effectiveness of

LOTS’s Partnership Model (Figure P.1-2) to save lives. For

instance, Wright Brothers Charters recently expanded its ability

to transport donors by adding planes and pilots to additional

sites in the DSA to ensure that it could meet time requirements,

a key requirement for LOTS.

A report card was put in place this year for tracking all other

suppliers, with information shared with them. Performance

thresholds were set in order to take action with nonperforming

suppliers. Selection criteria includes five factors: organizational

alignment, VMV, fit with LOTS’s core competency, affordability, and impact on customers. The selection process is a

systematic review of capabilities against these factors.

6.1d Innovation Management 

Innovation and improvement are embedded in the culture

from the governance level with the BOD, down through the

mission-driven workforce. To encourage workforce members to

bring innovative ideas forward, LOTS has published guidance

in a booklet entitled “What Do You Do with an Idea?” and has

recently compiled a collection of success stories entitled “What

You Do Matters.”

LOTS’s six-step IMP (Figure 6.1-3) provides a practical

approach to decisions related to identifying which innovations

are worth pursuing. As innovation is brought forward, ideas

are matched to LOTS’s SOs and goals to determine if they will

address the challenges or opportunities that are prioritized every

year during the SPP and LT strategic meetings (2.1a[(2]); ideas

are subjected to risk analysis and PDSA steps under the OMP

(Figure 6.1-1). Idea assessment includes the scope of a potential

33 
	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	

	 	 	

	 	 	 	

	 	 	 	

	 	 	

	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	

	 	 	 	 	 	

project, schedule, and needed resources, including financial

resources. The final step in the IMP links back to III recognition

(Figure 5.2-1).

An evaluation is used to determine which opportunities are

intelligent risks worth taking for innovation and corresponding prioritization. After SDs, a multidisciplinary Innovation

Management Team may be formed to further consider a new

process or implement new ideas/processes. In 2019, LOTS

introduced III and has built in reviews of every process every

time. This includes an evaluation of every meeting in order to

improve the quality of meetings. Results of these reviews can be

found in category 7.

Idea assessment includes the scope of a potential project,

schedule, and needed resources, including financial resources

and potential benefits. These are reviewed at the LT meetings. If

approved, an APis put in place for the project, and financial and

other resources are made available.

Decisionsto discontinue or modify large innovation projects

are made by the Innovation and Risk Board; for example, a

project or AP may be discontinued or modified with changes to

resources if its scope is not being met, cost or schedule is over

10% of the AP, or benefits are not being achieved by less than

90%. There are currently three innovation projects underway

with none canceled. Similar innovation teams are used to create

breakthrough processes to achieve LOTS’s vision of “organs

always available.”

The SA of financial stability positions the organization to

actively pursue innovative ideas and improvements. Financial

and other resources are made available through a robust budgeting process and multiple financial analysis tools, including

financial projections.

The OMPallows for a systematic review of potential and

current projects, and it ensures the agility to enhance support for

higher-priority opportunities. As an example, organ biopsies had

been performed in-house for many years. A discussion during

a C&C meeting, along with continued discussion in the OWS

meeting, resulted in the evaluation of whether biopsies should

be performed in-house or outsourced. Robust discussions and

analysis addressed financial, capability, and customer satisfaction. Ultimately, the Organ Biopsy Process was outsourced,

resulting in decreased cost and higher customer satisfaction.

6.2 Operational Effectiveness 

6.2a Process Efficiency and Effectiveness Systematic

evaluation to ensure that all aspects of operation effectiveness

are built into each process is accomplished

through ongoing use of PDSA, the identification of key opportunities, and the development of new approaches, resulting in

learning and cycles of improvement.

Overall costs of operations, cycle time, productivity, and efficiency and effectiveness factors are assessed through the OMP,

which includes inputs from the PMS. LOTS controls the overall

cost of operations through efficiency and improvement gained

by quarterly C&C meetings, group purchasing organizations,

inventory control, and Lean tools, including process mapping.

These strategies include financial analysis, such as an evaluation

of budget, cost modeling, and ROI, along with ongoing SDs

(Figure 2.1-1, step 8). Efficiency and effectiveness factors are part

of the in-process metrics included in Figures 6.1-2Aand 6.1-2B . 

Many factors lead to inefficiencies in the Organ Allocation

Process. Some of these, such as logistical issues, are difficult

to control; others come down to communication. LOTS has

recently undertaken a number of efforts to improve communications and reduce the time limits for responding to organ

offers, while using DonorNet to electronically notify transplant

hospitals about organ offers and to provide donor information.

The expedited process that LOTS is pioneering is shown in

Figure 6.2-1. The enhanced use of electronic communications

effectively addresses delays in the donation process, which can

result in the loss of an organ for transplant.

An example of cost control is the development of LOTS’s

inhouse OR, which incorporated customer feedback and has

resulted in process efficiencies and substantial costs savings; the

development resulted from a PDSA and the process has been

through three cycles of improvement. These cost savings have

impacted the charge structure, allowing LOTS’s organ acquisition

charges (OACs) to be below the median for all OPOs (Figure 

7.5-12). TWS efficiencies have allowed increases in donor volume that have not required additional workforce (Figure 7.3-3).

Another example that illustrates the reduction and cost of rework

is the utilization of the CMO in real-time tissue donor suitability

assessments, which has led to reductions in on-site deferrals and

impacted overall tissue donor numbers.

Originating from the annual SPPsession and its evaluation, a

well-defined audit calendar, developed in 2014, is established

each year. Audits are conducted systematically, and outcomes

drive frequency and sample size, ensuring maximum effectiveness with minimal audit costs. LOTS uses an internal quality

report to communicate audit findings at the LT meetings. At

every LT meeting at which audit findings are discussed, the LT

recommends an improvement to a process under discussion. LT

members are also evaluated by their subsequent contribution

to improvements discussed at these meetings. LOTS exceeds

industry standards by proactively

seeking all voluntary accreditations

(Figure P.1-5) and participating in

accreditation councils.

Accreditation inspections assist the

organization with identifying possible gaps in practices that result in

minimizing service errors, rework,

and defects. Participation on the

councils allows for the sharing of

34 
	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

information and best practices to proactively evaluate and

improve operations. Input from mission-driven workforce

members (CC) during audit preparation meetings ensures that

the organization’s workforce contributes to opportunities for

process improvement and innovation while meeting regulatory

and compliance requirements.

To further maximize efficiency and cost control, LOTS uses

preventative measures to minimize maintenance costs, and

contracts are established to ensure that capital equipment is

properly maintained to prevent unplanned, costly repairs. Group

purchasing agreements are utilized to leverage economies of

scale in order to negotiate reasonable prices for supplies and

maintenance contracts.

New supply requests are evaluated and approved/denied at

the director level via the Supply Requisition Process. LOTS

employs comprehensive measures to maximize efficiency and

ensure cost control, which are balanced with customer needs.

The work within the OMPdrives the organization to perform

as efficiently as possible. Cost savings allow for continued and

increased funding of projects to ensure high levels of customer

satisfaction.

6.2b Security and Cybersecurity 

LOTS uses an Information Protection Program (IPP) to protect

the security and cybersecurity of sensitive and privileged data

and information about its customers, partners, collaborators,

stakeholders, and suppliers. LOTS manages electronic and

physical data and information to ensure confidentiality and

appropriate access through protected applications and secured

access based on the role in the organization at time of hire or

role change. LOTS has a Technology Refresh Process to provide

replacement based on hardware lifecycles, technology changes,

etc.; this ensures that leading-edge technology and security are

in place.

Software technology changes and review of current needs occur

at least annually in the Information Management Plan, which

includes input from the Information Technology Leadership

Council, senior leaders, and medical staff leader-ship. The IPP

consists of four leadership areas: (1) information security, (2)

privacy, (3) information lifecycle management, and (4) physical

security. Identification and prioritization of infor-mation

technology systems to secure from cybersecurity threats are

based on program audit assessments and BOD discussions. They

include the requirements to (1) prevent harm to donors and

donor families, (2) prevent a “mega breach,” (3) prevent

disruption of operations, and (4) drive compliance.

LOTS maintains its awareness of emerging security and

cybersecurity threats through a dedicated cybersecurity team

with access to industry knowledge and expertise as a guiding

source. The team’s strategy aligns with the NIST CSF to protect

systems from cybersecurity attacks, including methods to detect,

respond, and recover from cybersecurity attacks. In alignment

with the NIST CSF, LOTS uses the Baldrige Cybersecurity

Excellence Builder to evaluate and assess its cybersecurity processes. LOTS has adopted the seven-step Cybersecurity Process

from the NIST CSF. These steps are repeated to continuously

improve cybersecurity.

The IS used includes software, data, network infrastructure,

computer hardware, and key assets. An overview of IS and a

systematic PDSA review of the process for data and information security and cybersecurity are components of the annual

SPP to ensure cycles of continuous improvement and learning;

evaluation, and improvement of IS is a component of the annual

SPP. LOTS uses cloud software for server hardware and data;

the software provides redundancy, reliability, and monitoring

tools to ensure speed, security, uptime, and overall reliability.

In-house servers contain redundant components, including dual

power supplies, network interface cards, and disks, and they are

stored in a secure location with access granted only to approved

staff. All hardware is under vendor support and monitored 24/7

using various tools. Vendor contracts include requirements for

responsibilities and roles regarding cybersecurity. In addition,

vendor contracts include requirements to overnight hardware

components that may fail; this ensures that full internal redundancy remains intact, and uptime and reliability meet organizational requirements.

LOTS utilizes Software as a Service (SaaS) as applicable. SaaS

decreases risk and increases overall reliability by using various

vendors that host from different servers and data centers. LOTS

also uses the LinkingSmart ticketing system to track IT needs,

problems, and/or issues. LinkingSmart allows trend analysis

and detection of applications and components’reliability;

unreliable components can then be repaired or replaced before

reliability becomes an issue (Figure 7.1-30). Communication

Center data reliability is ensured through a process that includes

nightly backups, with one copy sent to a secure off-site location

in Columbia, NT, and the other copy sent to Washington, DC

(ensuring protection fromlocal/regional disasters; 4.2a[1]).

LOTS has established multiple policies and procedures to ensure

the security and cybersecurity of all sensitive or privileged data

and information, particularly of the sensitive and privileged type.

These policies and procedures outline the physical and technical

safeguards for all computers that access electronic, protected,

health information to restrict access to authorized users. Those

allowed access are required to receive training in security and

confidentiality policies annually. The organization’s password

policy outlines the appropriate parameters for selecting and

securing system- and user-level passwords. Forced password

changes occur every 90 days to ensure security and integrity.

Workforce members with EMR access are required to sign confidentiality agreements, and IT audits performed by QS verify

appropriate access and current users. There is also a generation

and destruction schedule for backup paper documents. These are

kept in secure combination-lock file cabinets with access granted

to staff with required access to the documents

In 2019, LOTS hired a cybersecurity contracting agency that

follows the NIST CSF. This firm “BOT BUSTERS” was used

by prior Baldrige Award winners and so was selected by LOTS

because of its desire to benchmark against Baldrige winners.

LOTS is going through an assessment phase and will have

results to report in early 2020.

LOTS’s cybersecurity strategy includes a layered approach

that includes encryption and authentication. LOTS has a mail

encryption policy, which requires encryption of all emails that

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contain personally identifiable information (PII) or personal

health information (PHI). Through LOTS’s policy and the LDS,

all users with access to PII and PHI are informed and trained on

how to understand and fulfill their security and cybersecurity

roles and responsibilities, followed by learning effectiveness

testing every month.

Monthly vulnerability testing on all devices helps to identify

and prioritize technology system protection from internal and

external risks. IT locations include badge entry for authorized

personnel only. Continual education in cybersecurity is provided

through ongoing phishing exercises that train end-users on how

to detect suspicious items (see Figure 7.1-39). Improvements

have resulted in automated patch deployments, encryption of

information, investment in data-loss-prevention software, and

regularly updating of antispyware on all computers.

As a result of feedback from its 2019 Baldrige report, LOTS

has taken steps to ensure that customers and key stakeholders

understand and fulfill their security and cybersecurity roles and

responsibilities. Suppliers are required by contract to implement

appropriate measures designed to meet the objectives in the new

Cyber Supply-Network Risk Management Plan. Suppliers are

monitored to confirm that they have satisfied their obligations,

as required. Response and recovery planning and testing are

conducted with suppliers/providers. In addition, customers and

partners are provided cybersecurity awareness education and

are adequately trained to perform their IS-related duties and

responsibilities, consistent with related policies, procedures,

and agreements

6.2c Safety and Emergency Preparedness 

6.2c(1) In 2014, based on the PDSA of emergency preparedness, LOTS established a new Safety Program, managed by

the Safety officer, that utilizes systematic processes, including

the LDS and PDSA for ensuring a safe operating environment.

Identification of workforce safety concerns and a timely Injury

Reporting Process allow for a systematic review to identify

areas for prevention and improvement. Injuries are reported,

and these data are monitored to identify potential trends and

opportunities for training on accident prevention (Figure 7.3-9).

In addition, the 2019 workforce satisfaction survey noted an

increase in overall satisfaction with safety to 4.25 out of 4.5

(Figure 7.3-8).

Accident prevention, embedded inthe culture of the organization, starts with new hires in orientation and continues with

annual training. Prevention examples include OSHA training,

blood-borne pathogens training,the provision of personal

protection equipment, and workforce members being provided

the hepatitis B vaccine. In addition, workforce safety concerns

are identified in ODs, department meetings, RFO, workforce

surveys, focus groups, regular quality audits, and investigation

of injuries. The Safety Program, utilizing the Safety Committee,

recommends needed training sessions, policy change recommendations, and/or other needed safety enhancements. These

learnings may result in training sessions for staff members or

changes to policy, if required.

The Safety Calendar includes monthly safety programs

encompassing personal safety, CPR, automated external

defibrillators, fire extinguisher training, defensive driving and

driver safety, and malicious intruder training. The Injury Reporting Process ensures that all injuries are investigated, root cause

is determined, and a change in process or environment is taken

if indicated to ensure recovery. For example, in 2018, there was

a 25% decrease in tissue needle sticks/injuriesin the Tissue

Procurement Department, which was a result of improved training in orientation and the requiring of protective gloves.

LOTS’s safety programs and accident reporting approach are

fully deployed to all workforce members and sites, including

personnel stationed at, visiting, or in transit to hospitals and

other remote sites. Results from biannual surveys of operatingenvironment safety and of safety and security perception among

the workforce at headquarters and each remote site provide

actionable information for the LT and work system leaders to

identify safety issues, conduct root-cause analysis, apply PDSA,

and formulate required APs for remedial action. Safety knowledge is shared via the Communication Process; regular safety

updates are communicated to the workforce at department and

staff meetings. Fire and tornado drills, along with other safety

drills, are regularly conducted. Personal safety classes now

include providing personal safety alarms to workforce members.

Badges are required for entry into work areas, with levels of

restriction based on necessity as determined by job description. Moreover, a local security company is used to provide

continuous perimeter and campus security during nonbusiness

hours, including weekends and holidays. Security cameras are

managed in the Communication Center area and allow for 24/7

monitoring of perimeter door and access points, along with a

fenced parking area for staff workforce members.

LOTS’s leased aircraft meets FAA’s general aviation aircraft

certification standards, and pilots and crew are well trained in

safety and emergency preparedness. All passengers are briefed

using the AOPAAir Safety Institute’s Passenger Briefing

Checklist, which covers emergency procedures.

6.2c(2) LOTS has a well-documented, executable disaster

preparedness plan that is evaluated and improved each year

and allows the work systems to continue to achieve a high level

of customer satisfaction. Emergency preparedness is ensured

through regular testing and analysis of the Emergency Response

Plan (ERP). The plan prepares the workforce to respond to

operational disruptions in the event of an emergency. The plan

has been updated as a result of testing and analysis, and

expanded to address additional scenarios, such as an activeshooter scenario. Multiple measures are also in place to ensure

continuity of operations.

The design of LOTS’s facility ensures that all critical services,

including the Communication Center, IS network, and clinical

operations, are continuously online and supported by an emergency generator. Routine testing and preventative maintenance

of all critical equipment optimize the organization’s ability to

respond to any event. Additionally, remote access capabilities

allow work to continue uninterrupted in case of a disaster,

emergency, or weather interruption. Remote access to phone

systems ensures 24/7 remote access for external services.

36 
	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

In the event of a disaster, an extreme volume of cases, or critical

workforce needs, LOTS has reciprocal agreements with other

OPOs to provide support on a short-term basis. In the event

of a long-term, off-site option, LOTS is prepared to complete

organ and tissue clinical processes at local hospitals, and the

Communication Center would be operational via remote access.

Recovery following an event would be dependent on the

incident or event, but LOTS’s facility would be re-established

at another location if necessary. The organization maintains

business interruption insurance to ensure adequate financial

resources to support continued operations. In the event that

LOTS’s continuity contingency plans, including suppliers and

partners, are deemed ineffective or not available due to catastrophic circumstances, the highest-ranking leadership member

available may make the decision to cease operations until

alternative options are identified by the ELT. Led by all OWS and

TWS leaders, the ERPand related safety and emergency preparedness

work processes undergo review forimprovement and learning using

the PDSAmethodology every year during the SPP.

Category 7: Results
 

7.1 Product and Process Results 

7.1a Customer-Focused Product and Service Results 

LOTS has four key work processes within the work systems:

Referral Management, Authorization, Procurement/Allocation,

and Post-Donation (Figure 6.1-2). (Results for Post-Donation

are AOS.) Referral Management, the first key process in both

work systems, is measured by organ and tissue referrals. Organ

referrals (Figure 7.1-1) experienced organizational best levels

in 2019. Referral is the start of collaboration; hospital satisfaction with the donation is reflected in Figures 7.1-2 and 7.1-2A . 

(GPR is a national organization providing comparative satisfaction and engagement data.) Tissue referrals have increased,

allowing LOTS to achieve “tenth in the nation” status in 2019

(Figure 7.1-3); LOTS is one of 58 OPOs in the United States.

The key outcome measurement for authorization in the

OWS is organ donors (Figure 7.1-4) and organ authorization

(Figure 7.1-5), and the authorization outcome measure in the

TWS is tissue donors by population (Figure 7.1-6). Organ

donor numbers remain high. Tissue donor numbers have

37 
	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

and tissue processors/eye bank (Figure P.1-6). The organs 

transplanted can be segmented by organ type: heart, lung,

 liver, kidney, and pancreas, and results are shown by organs


 

remained steady over the last three years, meeting the industry
 

transplanted per million (Figures 7.1-10, 7.1-11, 7.1-12, 7.1-13, 

and 7.1-14). In 2018, there was an increase in Hepatitis C+

donors and Public Health Services (PHS)-increased risk donors,

which limited growth in results. To help increase the number of

hearts transplanted, LOTS is involved in a heart research project

to improve heart function. Local lungs transplanted per million

places LOTS in the top quartile in 2019. Livers transplanted per

million remains steady, nearing the top quartile. Kidneys transcomparative. planted per million remains steady, with steady improvement
 
 

since 2017. Pancreata transplanted per million remains near
 

top-quartile performance. Tissue donors can be segmented by
 

bone donors and skin donors (Figure 7.1-15). (Eye donor data

are AOS.) Bone and skin donor numbers have been impacted
 

by the opioid epidemic, resulting in decreased suitability, and
 

Procurement is measured by local organs transplanted in the
 

OWS (Figure 7.1-7). Local organs transplanted are a topline

measure directly responsible for increasing lives saved.
 

Local organs transplanted positions LOTS at the national top
 

quartile. In the TWS, the measures are Age-Targeted Bone
 

Donors Released (Figure 7.1-8) and Skin Donors Released

(Figure 7.1-9). An AP has been established for age-targeted

bone donors; skin donors released, a more recently added metric,

exceeds the internal target for 2019 and shows a beneficial trend.

The two work systems include two service lines that are segmented into two customer groups: local organ transplant centers

processor limits have also resulted in decreases.
 

 

38 
	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 Good

7.1b Work Process Effectiveness Results 

7.1b(1) LOTS’s key in-process measures are noted in Figures 

6.1-2A and 6.1-2B. The relationship management efficiency

and effectiveness results for OWS are missed organ referrals

(Figure 7.1-16). Missed referrals have remained at or under

2% since 2016. For TWS, the relationship management

in-process measure is the percentage of approaches by LOTS

(Figure 7.1-17). Hospital Services staff have worked closely

with hospital partners to transition the Tissue Authorization

Process to the LOTS Communication Center department. In 2019,

0% 

2% 

4% 

2016 2017 2018 2019 2020 ytd 

Missed Referrals 

Missed Organ Referrals 

LOTS Hospital Partners 

Tissue Transformations Best in Class 

Good

Relationship Management Results 

0% 

50% 

100% 

2016 2017 2018 2019 2020 ytd 

Approach Rate 

LOTS Tissue Approach Rate 

LOTS Hospital Partners 

Converting Hospital Partners to LOTS Approach 

Good 

LOTS performed the approach for tissue authorization at 100% of

the hospitals, an increase of nearly 10% in the last four years.

The authorization in-process measure for OWS is the organ authorization rate (Figure 7.1-5), which shows steady performance.

The TWS in-process authorization measure is the tissue authorization rate (Figure 7.1-18). Breakthrough process changes implemented, combined with new job requirements, hiring practices,

and workforce development and training, have resulted in tissue

authorization outcomes exceeding the industry top quartile.

The in-process measures for procurement are listed in

Figure 6.1-2A. Optimizing the gift (yield; Figure 7.1-19) is

demonstrated in the OWS by the ability of the clinical staff

to manage the donor’s clinical status to ensure the highest

number of transplantable organs. Yield was impacted in 2018

by an organizational record of DCD donors and an increase in

Hepatitis C+ donors and PHS-increased risk donors. Despite

those challenges, LOTS’s observed performance exceeds

national results with lungs (Figure 7.1-20). Donor management

protocol compliance continues to show 100% compliance

and represents the ability of the clinical organ staff to manage

donors effectively. Organ Donor Cases In-House (Figure 7.1-21)

is the practice responsible for creating significant cost savings

and customer satisfaction. This is a partner/customer satisfier

39 
	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	

Figure 7.1-20: Observed vs Expected by Organ 

Figure 7.1-21: Organ Donor Cases In-House 

   Figure 7.1-23: Skin Yie

Figure 7.1-24: Laboratory Turnaround Time by Work System 

for the donor hospitals, transplant centers, and eye bank. The

TWS procurement in-process measures include bone no-growth

and skin yield. LOTS met the Tissue Transformations partner

benchmark for Bone No-Growth Rates (Figure 7.1-22). Skin

Yield (Figure 7.1-23) shows favorable trends.

Laboratory testing turnaround time (Figure 7.1-24) has seen

steady performance. Chart Release Cycle Time—Organ and

Tissue (Figure 7.1-25) has seen 100% performance in the

number of days needed for organ charts to be reviewed and

uploaded to meet regulatory requirements. Chart Release Cycle

Time—Tissue reflects a critical step in the TWS Process during

which charts are completed, quality checked, and released to

the processors, fulfilling a tissue processor requirement and

triggering reimbursement to LOTS. The tissue chart cycle

time is meeting or exceeding the Tissue Transformations

partner requirement. Sterilizer accuracy is the documentation

compliance that impacts clinical equipment availability, which

has been at 100% since 2016. Similarly, to support business

operations, server uptime has been at 100% since 2016. As seen

in Figure 7.1-26, process improvement is consistent.

Figure 7.1-22: Bone No-Growth Rates 

Figure 7.1-26: PI Help Desk Tickets 

Figure 7.1-27: Environmental Concerns 

FY 2017 2018 2019 Goal 

Recycling % of Waste 75% 79% 85% 90%

Energy Efficiency 72% 75% 82% 90%

7.1b(2) Workplace Preparedness (Figure 7.1-28) demonstrates

multiple efforts deployed to ensure the safety of the workforce.

Emergency preparedness actions are taken to minimize

40 

LOTS Organ

Figure 7.1-25: Chart Release Cycle Time—Tissue and Organ 

 
	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	

	 	

	 	

	 	

	 	

	 	

	 	 	

	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

interruptions in the delivery of LOTS’s services. Figures 7.1-29 

through 7.1-32 show security measures, safe workplace training,

safety drills, and safety measures.

Figure 7.1-28: Workplace Preparedness 

Preparations Goal 2016 2017 2018 2019 

2020 

YTD 

Safety Training All 

Employees

100% 100% 100% 100% 100%

Fire Alarm

Testing

Quarterly 4 4 4 5 3 

Aero Charter

Safety Training

All 

Applicable

Employees

100% 100% 100% 100% 100%

Generators and

System Availability Testing

Weekly 100% 100% 100% 100% 100%

Injury

Investigation

All Injuries 100% 100% 100% 100% 100%

Data/VOIP

(Communication) Testing

Real Time 100% 100% 100% 100% 100%

Figure 7.1-32: Safety Measures 

2016 2017 2018 2019 

OHSA Violations 0 0 0 0 

State and Local

Safety Citations

0 0 0 0 

Worker Comp Claims 2 0 0 0 

7.1c Supply-Network Management Results 

Supply optimization via an electronic inventory system has

resulted in 98% availability for supplies for all in-house

cases. Wright Brothers provides 24/7 access to aircraft with a

90-minute launch requirement, and as demonstrated in Figure

7.1-33, delays due to provider issues occurred in less than 5% of

the 260-plus launches annually. Guardian Ambulance exceeds

requirements 100% of the time (Figure 7.1-34). Columbia

Cremation, a key collaborator in serving as a referral for organ

donors and coordinating activities to match a donor’s wishes,

has seen improvements since 2016, exceeding delivery time

requirements in 2019 (Figure 7.1-35). Transplant Technologies,

a key supplier, has seen increasing numbers of major releases

with complex features in 2018 that exposed more opportunities

for defects (Figure 7.1-36). TT has managed to reduce the

number of open IT Help Desk Tickets in Queue (Figure 7.1-37).

LOTS also tracks the satisfaction of key suppliers (Figure P.1-6)

on how they fulfill LOTS’s expectations of accurate information, service quality, and timely communication.

In regards to cybersecurity, LOTS performs monthly vulnerability

testing on all devices and continual education through ongoing

phishing exercises that train end-users on how to detect suspicious

items. Phishing Prone Percentage by Month (Figure 7.1-38) is an

example of data tracked.

Figure 7.1-29: Security Measures 

Preparations Goal 2016 2017 2018 2019 

Security Alarm

Surveillance

24/7 24/7 24/7 24/7 24/7

Motion-Sensored Lighting 24/7 24/7 24/7 24/7 24/7

DVR-Monitored Security

Cameras

24/7 24/7 24/7 24/7 24/7

Monitored Panic Buttons

(Vendor)

24/7 24/7 24/7 24/7 24/7

Badge Access Required     

Secure Parking 24/7 NA 24/7 24/7 24/7

 In Compliance 

Figure 7.1-31: Safety Drills 

2016 2017 2018 2019 

Safety Drills Held 3 4 4 4 

Met Population and

Time Requirement

2 3 4 4 

Figure 7.1-30: Safe Workplace Training 

Figure 7.1-33: Wright Brothers Delays 

Figure 7.1-34: Guardian Cycle Time 

 

41 
	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	

	 	 	 	

 

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	

	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	

Figure 7.1-35: Columbia Cremation Cycle Time 

Figure 7.1-36: Transplant Technologies Change Requests 

Figure 7.1-37: IT Help Desk Tickets in Queue 

Figure 7.1-38: Phishing Prone Percentage by Month 

7.2 Customer Results 

7.2a Customer-Focused Results 

7.2a(1) Customer satisfaction data are gathered through the

VOC methods as listed in Figure 3.1-1, including the Customer

Survey Process, which has undergone multiple cycles of

learning and strategic improvement.

Overall satisfaction levels with LOTS’s organ transplant

centers (Figure 7.2-1) demonstrate performance that is equal to

or exceeds the benchmark for the last four years. Local organ

transplant center satisfaction, segmented by key requirement,

shows strong performance in “competence” (Figure 7.2-1A)

and “information” (Figure 7.2-1B). Customer satisfaction in

meeting the third requirement, “maximize donation,” is not

measured through surveys. Instead, operational results are

utilized to gauge effectiveness in achieving this key customer

requirement and SO (Figure 7.1-7). Organ transplant center

satisfaction (Figure 7.2-1C) shows strong results for 2019 for

all three segments.

Satisfaction levels among LOTS’s tissue processors

(Figure 7.2-2) are critical to ensuring organizational success. Customer satisfaction meeting the first key requirement

Figure 7.2-1A: Transplant Center Satisfaction—Organ 

Figure 7.2-1: Transplant Center Satisfaction—Organ 

Figure 7.2-1B: Transplant Center Satisfaction—Organ 

Figure 7.2-1C: Transplant Center Satisfaction—Organ 

42 
	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

Figure 7.2-2: Tissue Processor Satisfaction 

“accountability,” defined as error rate minimization, is measured

utilizing operational metrics reported via tissue processor

scorecards (Figures 7.2-2A and 7.2-2B). When segmented by

the key customer requirement of “information” (Figure 7.2-2C),

results are consistently high. The third processor requirement

is “maximize donation,” which is tied to LOTS’s tissue donation rates (Figure 7.1-6). Tissue processor satisfaction can be

segmented by individual processor (Figure 7.2-2D). Satisfaction

by processor has remained strong.

LOTS also has recently begun partnering with an eye bank,

VisionMax, to ensure eye donation opportunities for families in

the DSA (Figure 7.2-3).

To determine dissatisfaction levels with local organ transplant

centers, tissue processors, and the eye bank, LOTS analyzes data

obtained through the Customer Complaint Process (Figure 3.2-2).

Despite an increase in the number of organ and tissue donors, the

percentage of customer complaints for the two customer groups

has demonstrated favorable trends (Figure 7.2-4). The implementation of a formalized CAPA system provides standardization

Figure 7.2-2A: Vein Accuracy Rates 

Figure 7.2-2B: Heart Valve Accuracy Rates 

Figure 7.2-2D: Tissue Processor Satisfaction 

Figure 7.2-2C: Tissue Processor Satisfaction 

Figure 7.2-4: Customer Complaints 

Figure 7.2-3: Eye Bank Partner Satisfaction 

and allows for systematic evaluation of complaints regardless of

where they occur within the customer life cycle.

In addition to complaints, LOTS utilizes customer survey data

to measure dissatisfaction by determining the percentage of

poor and very poor responses (scores of 1 or 2) on customer

surveys. Results for organ, tissue, and eye are at or near 0%,

with organ and tissue maintaining low trends since 2016

(Figure 7.2-4A).

43 
	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	

Figure 7.2-4A: Customer Dissatisfaction 

Figure 7.2-7: Social Media Engagements 

Social Media Engagements 2019 

YouTube Views 33,000

Instagram Followers 750 

Facebook Followers 6,200

Twitter Followers 300 

7.2a(2) To identify levels and trends in customer engagement,

LOTS calculates the percentage of very satisfied or top-box

scores (perfect 5 out of 5) on its customer satisfaction scores.

LOTS has maintained consistent levels of engagement with its

local organ transplant centers (Figure 7.2-1). Tissue processor

engagement results have demonstrated favorable trends since

2016 (Figures 7.2-2).

To assess its performance in building customer relationships,

LOTS analyzes its number of active customers (Figure 7.2-5).

The organ service line operates in a noncompetitive service area

designated by the federal government, so the number of local

organ transplant centers has not changed in 15 years. In the

tissue service line, LOTS maintains contractual agreements with

its tissue customers and expanded its customer base at the end

of 2017 and into 2018. LOTS tracks customers as they move

through the cycles of relationship/stages.

Social media are used for campaigns and messaging to increase

the number of registered donors within the DSA. In addition,

social media are used to communicate and highlight donor family

and recipient stories via Facebook, Instagram, and Twitter, reinforcing the mission. Figures 7.2-6 and 7.2-7 highlight LOTS’s

increasing Facebook followers and social media engagements.

7.3 Workforce Results 

7.3a Workforce-Focused Results 

7.3a(1) Workforce C&C key measures and results are shown

in Figures 7.3-1 through 7.3-4. The PEP ratings (Figures 7.3-1)

illustrate the average performance evaluation score for the

LOTS workforce, which is measured on a four-point scale.

Through the implementation of an outcome-based performance

evaluation tool, PEP rating results indicate that the majority

of the workforce “achieve expectations,” therefore meeting

the organization’s capability needs. LOTS maintains adequate

capacity for the OWS through evaluation of organ donors

per the OPC (Figure 7.3-2). Within the TWS, evaluation of

workforce capacity is assessed at quarterly C&C meetings

by ongoing comparison of the number of tissue donors to the

number of TOPC staff members (Figure 7.3-3).

Workforce Growth (Figure 7.3-4) demonstrates continued

staffing levels and stable New Hire Diversity (Figure 7.3-4A)

over the past four years as services have expanded. Figure 7.3-5 

shows the percentage of promotions from within the organization; promoting within is part of an AP for the SO Maximize

Stakeholder Relationships (Figure 2.1-3). Figure 7.3-6 shows

referrals as a percentage of new hires.

Where possible, workforce is segmented by job type

(Figure P.1-4); additional segmentation by gender, tenure,

department, and ethnicity AOS.

Figure 7.2-5: Customer Loyalty 

7,000 

Facebook Followers 

Figure 7.2-6: Facebook Followers 

Figure 7.3-1: PEP Ratings 

Figure 7.3-2: Organ Donors per OPC 

44 
	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

Figure 7.3-4: Workforce Growth 

 

Figure 7.3-4A: New Hire Diversity 

Figure 7.3-3: Tissue Donors per TOPC 

security, as well as employer-provided services and benefits, are

monitored continuously to ensure effectiveness.

In an effort to exhibit concern and care for employees, as well

as engage employees in the topic of personal health, a wellness

program was initiated in 2009. The wellness program participation remains strong (Figure 7.3-7). Figure 7.3-8 shows overall

perception of safety by work system and by LOTS as a whole,

with 0 being lease satisfied and 5 most satisfied.

As a result of the organization’s dedication to adherence to

safety procedures and protocols, LOTS monitors its DART rate

(Days Away/Restricted/Transferred Rate) due to workplace

injuries (Figure 7.3-9).

Radiation exposure rates are used to assess the amount of radiation organ clinical staff members are exposed to when utilizing

imaging equipment; LOTS has been at 0% for several years.

The organization has consistently shown commitment to the

health and satisfaction of its employees by continuing to offer

rich benefits plans in medical, dental, vision, and life coverage,

as well as additional benefits as shown in Benefits

Expenditures (Figure 7.3-10).

Figure 7.3-7: Wellness Screening Participation 

Figure 7.3-5: Promotions from Within 

Figure 7.3-8: Workforce Satisfaction with Safety 

Figure 7.3-6: Referrals as a Percentage of New Hires 

Figure 7.3-9: DART Rate 

7.3a(2) Workforce climate measures are key to retaining a

mission-driven workforce (CC) and do not differ by diversity

of the workforce or work group. Workforce health, safety, and

45 

20 
	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	 	

	 	

Figure 7.3-10: Benefits Expenditures 

Figure 7.3 -12A: Overall Workforce Engagement by Work System 

7.3a(3) Essential to the workforce climate, and a key contributor to employee engagement, is the connection to the organization’s mission. On workforce surveys, staff members repeatedly

indicate an exceptional level of understanding of how their

individual positions contribute to the mission, exceeding health

care median performance (Figure 7.3-11).

Excel Employee Engagement results show the top quartile.

Results in the Excel Employee Engagement survey assessing the

organization’s overall engagement exceed the health top-quartile

benchmark (Figure 7.3-12). In addition, segmentation by work

system demonstrates strong engagement scores in both the tissue

and organ work systems (Figure 7.3-12A). Figures 7.3-13 and 

7.3-14 shows results from key questions on the survey.

LOTS continues to have consistent organizational retention

(Figure 7.3-15). Overall workforce satisfaction survey results

show a sustained trend and favorable comparison to the external

benchmark (Figure 7.3-16). Overall benefits satisfaction

(Figure 7.3-17) shows strong results, equal to the health care

industry top quartile.

Figure 7.3-11: Connection to Mission 

Figure 7.3-12: Overall Workforce Engagement 

Figure 7.3-13: My Opinion Seems to Count 

Figure 7.3-14: Employee Satisfaction Survey 

Figure 7.3-15: Overall Retention 

Figure 7.3-16: Overall Job Satisfaction 

46 
	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	

	 	 	 	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	

	 	 	 	 	

	 	 	 	

	 	

	 	 	

	 	

	 	 	

	 	

 

Figure 7.3-17: Overall Benefits Satisfaction 

7.3a(4) LOTS supports the training and development of the
 

entire workforce, as seen in Overall Training and Development
 

Satisfaction (Figure 7.3-18) and LOTS’s financial investment in training expenditures per full-time equivalent (FTE;
 

Figure 7.3-19). Figure 7.3-20 shows leader results indicating

satisfaction with employer-sponsored training and development

meeting the industry top quartile.

7.4 Leadership and Governance Results 

7.4a Leadership, Governance, and Societal 

Contribution Results 

7.4a(1) Perception of Leadership (Figure 7.4-1) reflects

senior leader communication with the workforce, on a scale of

0 to 100%. Figure 7.4-2 shows the percentage of workforce

members touched by leader rounding; LOTS is approaching the

AOPO best in class for this measure.

7.4a(2) LOTS’s Board Self-Assessment (Figure 7.4-3)

compares favorably to the benchmark.

LOTS engages in multiple activities to ensure fiscal

accountability, as listed in section 1.2a(1). As a nonprofit

organization, an Audit Committee is not a requirement, but one

was voluntarily estab-lished as a best practice in governance to

expand fiscal account-ability. External financial audits sanctioned

by this committee have always achieved the highest rating of

“unqualified” opinion. 

Figure 7.3-19: Training Expenditures 

Figure 7.3-20: Leader Development Satisfaction 

Figure 7.3-18: Overall Training and Development Satisfaction 

Figure 7.4-1: Perception of Leadership 

Leadership Measure 2017 2018 2019 

Deploy vision

and values

Workforce Survey 90 92 94

Customer Survey 90 91 93

Donor Family Survey

(new)

— — 95

Encourage

2-way

communication

Workforce Survey 85 90 93

Customer Survey 90 92 93

Donor Family Survey — — 90

Create a focus

on action

Workforce Survey 80 85 88

Customer Survey 85 85 86

Donor Family Survey — — 92

Figure 7.4-2: Monthly Leader Rounding with Staff 

Figure 7.4-3: LOTS Board Self-Assessment 

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7.4a(3) LOTS views accreditation and regulatory compliance

as a baseline expectation for performance. The organization has

received full accreditation from all voluntary accrediting bodies

within its industry and has maintained this trend for several

years. Additionally, LOTS maintains full compliance with

regulatory and legal mandates that have been sustained since the

organization’s inception (Figure 7.4-4).

7.4a(4) The nature of LOTS’s business requires that the

organization lives its core value of honesty and demonstrates

social responsibility as indicated by key metrics related to ethical

behavior. In addition, 100% of the BOD, LT, and workforce

complete annual conflict-of-interest documentation. Currently,

100% of the workforce and board is CCP-trained. Limited

corporate compliance issues are noted in Report of Corporate

Compliance Hotline Issues (Figure 7.4-5), which illustrates

program effectiveness. Stakeholder (BOD) requirements

show a high level of satisfaction (Figure 7.4-6) based on the

BOD evaluation of the CEO’s performance. Similarly, trust in

leadership (CEO) by the BOD consistently meets or exceeds the

organizational goal of 2.5 on a 3-point scale.

7.4a(5) A true measure of societal benefit is the reduction of

deaths on the local waiting list as LOTS increases transplanted

organs; this dynamic trend has impacted the community living

within the DSA (Figure 7.4-7). In addition, LOTS holds memorial events twice a year in the late spring and before Christmas

(Figure 7.4-8); it is not unusual for families to wait a year

before attending.

Figure 7.4-6: BOD Requirements of CEO 

Figure 7.4-7: Deaths on Local Waiting List 

Figure 7.4-8: Community Service 

7.5 Financial, Market, and Strategy Results 

7.5a Financial and Market Results 

7.5a(1) LOTS’s financial performance is benchmarked

by evaluating key measures within OPO financial surveys

conducted by AOPO. LOTS utilizes the surveys to examine its

overall financial condition. The organizational goal is to assess

whether LOTS’s financial and operating status are improving

over time and against benchmarks.

Consolidated Results of Operations (Figure 7.5-1) demonstrates

that LOTS is in a strong position with good performance

levels compared to budget, with 2019 organizational results of

Figure 7.4-4: Regulatory & Legal Compliance Key Measures 

Measures & Indicators Results 

AATB Accreditation (3 years)

AOPO Accreditation (3years)

CMS Certification (4 years)

DHHS (3 years)

DOR

EEOC 

FDAApproval

FLSA

IRS Compliance

OSHA

UNOS/OPTN (3 years)

Full Accreditation

Full Accreditation

Full Certification

Full Compliance

No Adverse Findings

0 Issues

No Adverse Findings

0 Issues

0 Issues

Full Compliance

Member in Good Standing

Unblemished Performance

Figure 7.4-5: Corporate Compliance Hotline Issues 

Reported Corporate Compliance Hotline Issues/Outcomes 

2015 0 Complaints Reported

2016 1 Complaint Reported Corrective Action Taken

2017 1 Complaint Reported No Violation Found

2018 1 Complaint Reported Corrective Action Taken

2019 4 Complaints Reported Corrective Action Taken

Figure 7.5-1: Consolidated Results of Operations 

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$3.36 million. LOTS demonstrates favorable levels in several

financial measures utilizing the AOPO top-quartile benchmark

including gross revenue (Figures 7.5-2, 7.5-2A, and 7.5-2B),

Operating Margin (Figure 7.5-3), Net Margin (Figure 7.5-4), Days

in Accounts Receivable (Figure 7.5-5), Days in Accounts Payable

(Figure 7.5-6), Current Ratio of Assets versus Liabilities (Figure 

7.5-7), and Days Cash on Hand (Figure 7.5-8). These results

reflect LOTS’s identified strategic advantage of possessing a

strong financial position and support organizational sustainability.

Operating Reserves (Figure 7.5-9) includes cash, investments,

and accounts receivable. The amount of operating reserves is set

by BOD policy and allows LOTS to ensure mission attainment

Figure 7.5-2: Total Gross Revenue 

 

Figure 7.5-2A: Gross Revenue—OWS 

 

Figure 7.5-2B: Gross Revenue—TWS 

 

Figure 7.5-3: Operating Margin 

 

and organizational sustainability. LOTS sets the standard as

Tissue Transformations best-in-class performer. Total Assets

(Figure 7.5-10) indicates LOTS’s sustainability and strong

financial position. Performance shows best-in-class results.

Figure 7.5-4: Net Margin 

Figure 7.5-5: Days in Accounts Receivable 

Figure 7.5-6: Days in Accounts Payable 

 

Figure 7.5-7: Current Ratio of Assets vs. Liabilities 

Figure 7.5-8: Days Cash on Hand 

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Figure 7.5-10: Total Assets 

Figure 7.5-9: Operating Reserves 

Figure 7.5-12: Average OAC Comparison—All Organs 

Figure 7.5-13: Market Share Growth— 

Tissue Transformations Partners 

7.5a(2) As a nonprofit organization with a DSA that is

designated by CMS, LOTS does not look to increase market

“share” in the typical way that other companies do, but it looks

to improve its own performance within its DSA and to track its

progress via the measures represented in item 7.1.

Organ Donor Cost Comparison (Figure 7.5-11) demonstrates

the difference in donor costs when donors are recovered in the

traditional hospital setting versus when transferred to the LOTS

facility for donor care and surgical recovery. Efforts to contain

costs are measured by budget spending trends and OACs. OAC

fees that have been charged to the transplant center partners

have historically been (and continue to be) in the lower quartile

of similar OPOs at the strategic direction of the LOTS BOD

(Figure 7.5-12). The comparison data for these charges are

compiled from OPOs, typically with geographic proximity,

that are most frequently involved with organ-sharing activities

impacting the local transplant centers. Cost containment is an

essential area for LOTS’s transplant partners to remain competitive in the health care payer market.

Limited by its DSA, LOTS knows that increases in tissue donations are still possible with identification of new or expanded

referral sources. Market Share Growth (Figure 7.5-13) shows

Figure 7.5-11: Organ Donor Cost Comparison 

LOTS’s contribution to the total Tissue Transformations tissue

volume.

7.5b Strategy Implementation Results 

Results for accomplishing the organizational APs are found in

Figure 7.5-14 . 

The key metrics for strategy achievement of the mission include

Deaths on Local Waiting List (Figure 7.4-7) and organ and

tissue donors by population (Figures 7.1-4 and 7.1-6). Results

for building and strengthening the CC are given in Figures 

7.3-12 and 7.3-12A . 

One of LOTS opportunities is to increase the donor registry.

Measures being tracked for new partnerships to educate the

public about organ donation and encourage people to register as

donors at state DMVs and local workplaces are AOS.

Figure 7.5-14: Focus on Action: Accomplishment of APs 

50