2019 www.nist.gov/baldrige

nonprofit

LifeBridge Organ 

and Tissue Sharing 

Case Study
Baldrige Performance Excellence Program

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

July 2019

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 is a fictitious Baldrige Award application prepared for use in the 2019 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 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. 2019. 2019 Baldrige Case Study: LifeBridge Organ and Tissue Sharing. 

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 2019

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 is a fictitious Baldrige Award application prepared for use in the 2019 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 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. 2019. 2019 Baldrige Case Study: LifeBridge Organ and Tissue Sharing. 

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

2019 Eligibility Certification Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E1

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

2019 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Category 2: Strategy

2.1	 Strategy Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2.2	 Strategy Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Category 3: Customers

3.1	 Customer Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

3.2	 Customer Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Category 4: Measurement, Analysis, and Knowledge Management

4.1	 Measurement, Analysis, and Improvement of Organizational Performance . . . . . . . 14

4.2	 Information and Knowledge Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Category 5: Workforce

5.1	 Workforce Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

5.2	 Workforce Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Category 6: Operations

6.1	 Work Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

6.2	 Operational Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Category 7: Results

7.1	 Product and Process Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

7.2	 Customer Results.....................................................37

7.3	 Workforce Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

7.4	 Leadership and Governance Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

7.5	 Financial, Market, and Strategy Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2019 ELIGIBILITY

CERTIFICATION

FORM
Eligibility package due February 13, 2019

Award package due April 23, 2019

2019 Eligibility Certification Form

Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006

Expiration Date: 06/30/2019

Page E-1 of 12 

1. Your Organization

Official name LifeBridge Organ and Tissue 

Sharing

Headquarters 

address 

444000 Georgie Blvd. Suite 100

Columbia, NT 01011

Other name 

Prior name (if changed within the past 5 years)

 

2. Highest-Ranking Official

☐Mr. ☒Mrs. ☐Ms. ☐Dr.

Name Marie Address ☒Same as above 

 Job title Jamerson

Email Chief Executive Officer

Telephone 123-555-0001

Fax 252-555-1000

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 Address ☒Same as above 

Job title Director, Quality 

Email bart.wilson@LOTS.opo

Telephone 

(office and cell, 

if possible)

252-555-0072 (office);

123-555-2715 (cell) Overnight 

mailing 

address 

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

number.)

 

Fax 123-555-1000

4. Alternate Eligibility Contact Point

☐Mr. ☐Mrs. ☒Ms. ☐Dr.

Name Lisa Renaldo Telephone 123-555-0007

Email lisa.renaldo@LOTS.opo Fax 123-555-1000
Eligibility package due February 13, 2019 

Award package due April 23, 2019

2019 Eligibility Certification Form

Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006

Expiration Date: 06/30/2019

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) 2018

Name(s) 

☐No 

☐Don’t know 

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

☐Yes. 

Did your organization receive the award in 2013 (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 2014 and 2018, 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. 

 
Eligibility package due February 13, 2019 

Award package due April 23, 2019

2019 Eligibility Certification Form

Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006

Expiration Date: 06/30/2019

Page E-3 of 12 

b. Has your organization officially or legally existed for at least one year, or since April 1, 2018? 

☒Yes ☐No 

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. 

(https://www.nist.gov/baldrige/baldrige-award/your-organization-eligible). Then 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? 
Eligibility package due February 13, 2019 

Award package due April 23, 2019

2019 Eligibility Certification Form

Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006

Expiration Date: 06/30/2019

Page E-4 of 12 

☐ 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.

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 2014).

☐

Yes

Your organization is 

eligible.

No Continue with 

statement 2.

2. Between 2014 and 2018, 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 2014 and 2018, my organization

applied for the national Baldrige Award and

received a site visit.

☐

Yes

Your organization is 

eligible. 

Year of site visit: 

No Continue with 

statement 4. 

4. Between 2014 and 2018, my organization

received the top award from an award

program that is a member of the Alliance for

Performance Excellence.

X

Yes

Your organization is 

eligible. 

Award program: 

Year of top award: 

No Continue with 

statement 5. 
Eligibility package due February 13, 2019 

Award package due April 23, 2019

2019 Eligibility Certification Form

Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006

Expiration Date: 06/30/2019

Page E-5 of 12 

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. 

7. Between 2015 and 2018, my organization

applied for the national Baldrige Award

through the alternate method (option 8

below) and the total of the process and

results bands assigned in the feedback report

was 6 or higher.

X

Yes

Your organization is 

eligible.

Year: 

No, my 

organization 

did not 

apply using 

this method. 

☐ My

organization

applied

using this

method, but

did NOT

receive a

total of 6 or

higher.

Continue with 

statement 8. Your 

organization is 

not eligible. Call

877-237-9064, 

option 3, if you 

have questions. 

8. My organization will submit additional

eligibility screening materials (i.e., a

complete Organizational Profile and two

results measures for each of the five Criteria

results items). The Baldrige Program will

use the materials to determine if my

organization is eligible to apply for the

award this year (as described in the

Eligibility FAQs).

☐

Yes

The Baldrige 

Program will review 

the materials and 

contact your ECP 

after determining 

your eligibility.

No Call 877-237-

9064, option 3, if 

you have 

questions. 

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

☐ Service

☐ Small business (≤ 500 employees)

☐ Education

☒ Nonprofit

☐ Education

☐ Health care
Eligibility package due February 13, 2019 

Award package due April 23, 2019

2019 Eligibility Certification Form

Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006

Expiration Date: 06/30/2019

Page E-6 of 12 

☐ 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.

 

8. Organizational Structure

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

☐ up to $1 million ☒ $1.1 million–$10 million 

☐ $10.1 million–$100 million ☐ $100.1 million –$500 million 

☐ $500.1 million–$1 billion ☐ more than $1 billion 

☐ sales 

☐ revenue

☒ budget 

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.

 

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. 
Eligibility package due February 13, 2019 

Award package due April 23, 2019

2019 Eligibility Certification Form

Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006

Expiration Date: 06/30/2019

Page E-7 of 12 

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. 

 

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.

Example (ABC HealthCare)

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).

Check one or 

more.

 Employees

 Faculty

 Staff

Volunteers

(no. or 

N/A)

Check one. 

% of 

 Sales

 Revenue

 Budget

Relevant Products, Services, 

and/or Technologies

ABC Medical Center, Anytown, NY 1,232 147 77% Admin. offices, inpatient care, 

ED, imaging services, lab

ABC Hospital West, West Anytown, NY 255 78 14% Inpatient services, ED, lab

ABC Medical Group, Anytown, NY

Located on same campus as ABC

Medical Center

236 N/A 6% Primary & specialty physician 

care 

ABC Imaging Center, West Anytown, 

NY 11 N/A 1% Imaging services

ABC Hospice Services, West Anytown, 

NY Different location than ABC 

Hospital West and ABC Imaging 

Center

94 89 1% On- and off-site hospice services
Eligibility package due February 13, 2019 

Award package due April 23, 2019

2019 Eligibility Certification Form

Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006

Expiration Date: 06/30/2019

Page E-8 of 12 

ABC Urgent Care, West Anytown, NY 8 N/A 1% Outpatient emergency and 

urgent care services

Total 6 1,836 314 100%

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).

Check one or 

more.

☒ Employees

☐ Faculty

☐ Staff

Volunteers

(no. or 

N/A)

Check one.

% of 

☐ Sales

☐ Revenue

☒ Budget

Relevant Products, Services, 

and/or Technologies

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.

Joint Ventures

Partner Organization # of applicant 

employees

included in joint 

venture

% Owned by 

the 

Applicant

Describe extent/level of operational and 

managerial responsibility your organization 

has for the joint venture.

Total

10. Key Business/Organization Factors
Eligibility package due February 13, 2019 

Award package due April 23, 2019

2019 Eligibility Certification Form

Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006

Expiration Date: 06/30/2019

Page E-9 of 12 

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) and tissue processors (Tissue Transformations, LifeBank, 

and Advantage Life)

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

Allograft Resources, Columbia Cremation, 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

Parent organization (if your organization is a subunit). N/A
Eligibility package due February 13, 2019 

Award package due April 23, 2019

2019 Eligibility Certification Form

Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006

Expiration Date: 06/30/2019

Page E-10 of 12 

11. Nomination to the Board of Examiners

If your organization is eligible to apply for the Baldrige Award in 2019, you may nominate one senior member from your 

organization to the 2019 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.

Bart Wilson from our organization will serve on the 2019 Board of Examiners.

bart.wilson@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 2019, this examiner nomination will not be considered for the 2019 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, 2019

Signature of highest-ranking official Printed name Date
Eligibility package due February 13, 2019 

Award package due April 23, 2019

2019 Eligibility Certification Form

Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006

Expiration Date: 06/30/2019

Page E-11 of 12 

13. Submission

To be considered for the 2019 award, your complete eligibility certification package must be postmarked no later than

February 13, 2019, 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
Eligibility package due February 13, 2019 

Award package due April 23, 2019

2019 Eligibility Certification Form

Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006

Expiration Date: 06/30/2019

Page E-12 of 12 

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: 

Checking account number: 

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

7205, or BaldrigeContractAdmin@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 13, 2019 

Award package due April 23, 2019

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 2019 Board of Examiners. 

☐ I am not nominating a senior member of my organization to the 2019 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
O1

O1

Tissue Procurement 

Supervisors 

Kris Daniels Marvin Torre

Tissue Procurement 

Elaine Hart

Coordinators 

Reed AndersonFern Barnes Wayne Johns Eva Karnes Thomas Lowe Mike Mannis Horace Miller Gail Nolen Rachel Roper Helen Sharp

Director, 

Tissue Procurement

Markus Weber

Director, 

Organ Procurement

Organ Procurement 

Supervisors 

Sam Lewis Yvette Sayer

Organ Procurement 

Coordinators 

Smitty Eads Nick Hall Cindy Hanover Kenzie Harrison Abe Jains Sunny Newkirk Calvin Schneider Julien St. James Raul Sommers Hal TeasdaleBen Uhles Kelly Zenk

Administrative Assistant

Joby Leathers

George Mateo, MD

Chief Medical Officer

Donation Coordinators 

Harold Carter Carlyn Davis Dalton Jefferson Peter Johannson Paula Martin Jenny Pettit Fran Rose Creighton Smith Felicity Stephens

Triage Coordinators

Victor Charles Grayson Edwards Leon Frank Enya Karr Hope Stanton

Receptionist/

Switchboard Operator

Connie Evers

Family Support 

Specialists

Avery AmesLea Benton Brittany Carter Andrew Chen Casen Edwards Nina Foster Wendy Jasper Everett Rousell Linda Underwood

Aftercare Coordinators

Tony Halsey Diane Jefferson Emily Strickland

Performance 

Improvement 

Specialists

Carole Frewin Lenny Keller

Quality Control 

Specialists

Jordan Kornblat Pahal Singh

Medical Records 

Reviewers

Henry Marshall Raymond Watson Katy Yates

Hospital Services 

Supervisor

Fiona George

Hospital Services 

Specialists

Efram Baker Blair Bates Wanda Coleman Anna Fish Reva Gordon Damon Owens Ruth Anne PayneAlan Quinn Pearl Renate Lucy Rippon Ivy Shelton

Abigail Newton

Manager, 

Family Services

Communications 

Coordinators

Darcy Bennett Quincy Noonan Janice Potter

Lisa Renaldo

Chief Operating Officer

Delane Oberly

Director, 

Hospital Services

Bart Wilson

Director, 

Quality

Floyd Bailey

Manager, 

Communications Center

Talia Marshfield

Director, 

Marketing

Marie Jamerson

Chief Executive Officer Jai Merrion

Executive Assistant

HR Coordinators 

Mona Joyce Lucinda Phelps

Benefits Coordinator

Kim Lewis

Bethany Orr 

Chief Human Resources Officer

Accounting Clerks 

Mary Meyers Paige Clark

Facilities Specialist

Miles Richards

IT Technicians 

Garrett Burns Roland Easton Karen Len David Wayans

Alex Wharton

Chief Financial Officer

Susan Cooke

Director, 

Information Systems
PAGE A-1

OF THE

2019 AWARD

APPLICATION FORM
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I state and attest that 

 

 

 

 

 

 

 

-

-

2019 Award Application Form

Malcolm Baldrige National Quality Award 

OMB Control No. 0693 0006 

Expiration Date: 06/30/2019 

Page A 1 

1. Your Organization 

LifeBridge Organ and Tissue Official name Sharing 

Mailing 444000 Georgie Blvd, Suite 100 

address 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 this official contact point 

changes during the application process, please inform the 

program. 

☒ Mr. ☐ Mrs. ☐ Ms. ☐ Dr. 

Name 

Title 

Mailing 

address 

Overnight 

mailing 

address 

Telephone 

(office and cell, 

if possible) 

Fax 

Email 

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 

Email 

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, my 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 at 

https://www.nist.gov/baldrige/baldrigeaward/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 

(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, 2019 

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
G1

Glossary of Terms and Abbreviations

24/7

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

C

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

CEO

Chief Executive Officer

CFO 

Chief Financial Officer

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

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

DHSS

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

EBAA

Eye Bank Association of America

EEOC

Equal Employment Opportunity Commission

EKR 

Employee Key Requirement
G2

ELT

Executive Leadership Team consisting of the CEO, CMO,

CHRO, CFO, and COO

EMB

Extended Medical Bank-employee benefit to cover extended

illnesses

EMR

Electronic Medical Record

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

HLA

Human Leukocyte Antigen

HR

Human Resources

HRSA

Health Resources and Services Administration

I

ICU

Intensive Care Unit

Individual Scorecards

Measurement system tool tracked at the individual level

IT/IS 

Information Technology/Information Systems

L

LDS

Learning and Development System

LOTS

LifeBridge Organ and Tissue Sharing

LS

Leadership System

LT

Leadership Team

M

ME

Medical Examiner

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
G3

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

PTO

Paid/Personal Time Off

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

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

TOPC

Tissue Ocular Procurement Coordinators

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
ORGANIZATIONAL

PROFILE
i

Organizational Profile

Picture Sally, who is only 16 years old, a typical teenager 

who loves her friends, family, and dog, Spot, and is a beloved 

daughter, sister, and friend. Following a critical injury 

during a car accident, she is now in the intensive care unit. 

After evaluating Sally’s injuries and performing life-saving 

measures, doctors have diagnosed conclusively that Sally is 

brain-dead. Machines keep her organs functioning, while a 

team from LifeBridge Organ and Tissue Sharing (LOTS) talks 

compassionately to Sally’s family about donating her organs 

and tissues. On the most agonizing day of this family’s life, 

family members find the courage to say “yes.” Sally saved 

multiple lives that day, including a three-year-old boy from 

North Takoma who received Sally’s left kidney and was then 

excited to go home with his family after being in the hospital 

since birth; a 56-year-old father, a factory worker from South 

Takoma, who had been waiting for a liver for four years; and 

a nine-year-old fire victim who was airlifted to a state hospital 

with burns on over 50 percent of her body who received 

Sally’s skin tissue that helped keep out infection while the 

victim’s skin regenerated. The ability to impact countless lives 

motivated Sally’s family to provide the literal “Gift of Life” 

to waiting recipients. The ability to provide the connection 

between life and death is the reason LOTS staff members come 

to work every day—to achieve the organization’s mission to 

save and improve lives.

P.1 Organizational Description

P.1a Organizational Environment

P.1a(1) For more than 25 years, 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.

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 of partners, collaborators, and suppliers to ensure that

organs and tissues are always available for the organization’s

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

i

Organizational Profile

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	

Picture Sally, who is only 16 years old, a typical teenager 

who loves her friends, family, and dog, Spot, and is a beloved 

daughter, sister, and friend. Following a critical injury 

during a car accident, she is now in the intensive care unit. 

After evaluating Sally’s injuries and performing life-saving 

measures, doctors have diagnosed conclusively that Sally 

is brain-dead. Machines keep her organs functioning, while 

a team from LifeBridge Organ and Tissue Sharing (LOTS) 

talks compassionately to Sally’s family about donating her 

organs and tissues. On the most agonizing day of this family’s 

life, family members find the courage to say “yes.” Sally 

saved multiple lives that day, including a three-year-old boy 

from North Takoma who received Sally’s left kidney and was 

then excited to go home with his family after being in the 

hospital since birth; a 56-year-old father, a factory worker 

from South Takoma, who had been waiting for a liver for 

four years; and a nine-year-old fire victim who was airlifted 

to a state hospital with burns on over 50 percent of her body 

who received Sally’s skin tissue that helped keep out infection 

while the victim’s skin regenerated. The ability to impact 

countless lives motivated Sally’s family to provide the literal 

“Gift of Life” to waiting recipients. The ability to provide the 

connection between life and death is the reason LOTS staff 

members come to work every day—to achieve the organization’s mission to save and improve lives.

P.1 Organizational Description

P.1a Organizational Environment

P.1a(1) For	more	than	25	years,	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.

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	of	partners,	collaborators,	and	suppliers	to	ensure	that	

organs	and	tissues	are	always	available	for	the	organization’s	

key	customers.

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 Improvement

LifeBridge

Organ and

Tissue Sharing

Partners Customers

Collaborators

Key Suppliers

LIVES

SAVED

Figure P.1-2: Partnership Model

i

Organizational Profile

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	

Picture Sally, who is only 16 years old, a typical teenager 

who loves her friends, family, and dog, Spot, and is a beloved 

daughter, sister, and friend. Following a critical injury 

during a car accident, she is now in the intensive care unit. 

After evaluating Sally’s injuries and performing life-saving 

measures, doctors have diagnosed conclusively that Sally 

is brain-dead. Machines keep her organs functioning, while 

a team from LifeBridge Organ and Tissue Sharing (LOTS) 

talks compassionately to Sally’s family about donating her 

organs and tissues. On the most agonizing day of this family’s 

life, family members find the courage to say “yes.” Sally 

saved multiple lives that day, including a three-year-old boy 

from North Takoma who received Sally’s left kidney and was 

then excited to go home with his family after being in the 

hospital since birth; a 56-year-old father, a factory worker 

from South Takoma, who had been waiting for a liver for 

four years; and a nine-year-old fire victim who was airlifted 

to a state hospital with burns on over 50 percent of her body 

who received Sally’s skin tissue that helped keep out infection 

while the victim’s skin regenerated. The ability to impact 

countless lives motivated Sally’s family to provide the literal 

“Gift of Life” to waiting recipients. The ability to provide the 

connection between life and death is the reason LOTS staff 

members come to work every day—to achieve the organization’s mission to save and improve lives.

P.1 Organizational Description

P.1a Organizational Environment

P.1a(1) For	more	than	25	years,	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.

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	of	partners,	collaborators,	and	suppliers	to	ensure	that	

organs	and	tissues	are	always	available	for	the	organization’s	

key	customers.

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 Improvement

LifeBridge

Organ and

Tissue Sharing

Partners Customers

Collaborators

Key Suppliers

LIVES

SAVED

Figure P.1-2: Partnership Model
iiii

drive	to	meet	the	mission: We save and improve lives. 

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,	improvement,	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 7.3-14).	

P.1a(3) LOTS	is	a	24/7	business	in	which	many	of	the	

employees	are	decentralized.	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.	For	the	purpose	of	reporting	and	

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).	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	

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) The	mission	of	LOTS	is	to	save	and	improve	lives	

(Figure P.1-1).	LOTS’s	vision	is	Organs and tissues are 

always available. 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	culture	is	a	strong	

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

Leadership Team 10%

Staff 90%

Male 35%

Female 65%

1 Year 20%

2–5 Years 41%

6–10 Years 21%

11+ Years 18%

African American 20%

(DSA 25%*)

White 70% 

(DSA 70%*)

Other 10% 

(DSA 5%*)

*Based on 2010 Census Job Type Tenure

Gender Ethnicity

Figure P.1-3: Finding the Heroes

Deaths Reported

Referrals

Eligible

Authorization

Donors

ORGAN

TISSUE

ii

drive	to	meet	the	mission: We save and improve lives. 

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,	improvement,	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 7.3-14).	

P.1a(3) LOTS	is	a	24/7	business	in	which	many	of	the	

employees	are	decentralized.	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.	For	the	purpose	of	reporting	and	

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).	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	

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) The	mission	of	LOTS	is	to	save	and	improve	lives	

(Figure P.1-1).	LOTS’s	vision	is	Organs and tissues are 

always available. 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	culture	is	a	strong	

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

Leadership Team 10%

Staff 90%

Male 35%

Female 65%

1 Year 20%

2–5 Years 41%

6–10 Years 21%

11+ Years 18%

African American 20%

(DSA 25%*)

White 70% 

(DSA 70%*)

Other 10% 

(DSA 5%*)

*Based on 2010 Census Job Type Tenure

Gender Ethnicity

Figure P.1-3: Finding the Heroes

Deaths Reported

Referrals

Eligible

Authorization

Donors

ORGAN

TISSUE

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). 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

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) The mission of LOTS is to save and improve lives

(Figure P.1-1). LOTS’s vision is Organs and tissues are 

always available. 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 culture is a strong

drive to meet the mission: We save and improve lives. 

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, improvement, 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 7.3-14).

P.1a(3) LOTS is a 24/7 business in which many of the

employees are decentralized. 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. For the purpose of reporting and
iii

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 staff survey cycles have validated three of the

highest-scoring survey attributes: the staff 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 system-wide

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 staff working in hospitals also apply to nonclinical

staff. Similarly, typical office-related safety requirements

apply to nonclinical staff. At LOTS, such issues are addressed

through annual training and standard operating procedures

(SOPs). Due to the 24-hour nature of some work, for “afterhours” 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. LOTS leases a twinengine turbo prop plane equipped with medical equipment

to transport donors to the LOTS facility for organ and tissue

recovery. Utilizing technology, LOTS provides staff with

collaborative tools, real-time access to key data including

an electronic medical record (EMR) system, and reporting

services that provide customized reports.

P.1a(5) LOTS operates under a highly regulated environment and identifies key regulatory requirements in Quality

Compliance Management (Figure P.1-5). In addition, local

environmental and regulatory initiatives apply for fire and

sanitation measures; biohazard trash disposal meets all local

and state regulations.

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,

physicians, and donor family members. 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 staff.

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) and tissue processors (Tissue Transformations, LifeBank, and Advantage Life) are LOTS’s key

customer groups. LOTS collaborates with the donor families

iii

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 staff survey cycles have validated three of the 

highest-scoring survey attributes: the staff 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 system-wide 

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 staff working in hospitals also apply to nonclinical 

staff. Similarly, typical office-related safety requirements 

apply to nonclinical staff. At LOTS, such issues are addressed 

through annual training and standard operating procedures 

(SOPs). Due to the 24-hour nature of some work, for “afterhours” 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. LOTS leases a twinengine turbo prop plane equipped with medical equipment 

to transport donors to the LOTS facility for organ and tissue 

recovery. Utilizing technology, LOTS provides staff with 

collaborative tools, real-time access to key data including 

an electronic medical record (EMR) system, and reporting 

services that provide customized reports. 

P.1a(5) LOTS operates under a highly regulated environment and identifies key regulatory requirements in Quality 

Compliance Management (Figure P.1-5). In addition, local 

environmental and regulatory initiatives apply for fire and 

sanitation measures; biohazard trash disposal meets all local 

and state regulations.

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, 

physicians, and donor family members. 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 staff. 

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) and tissue processors (Tissue Transformations, LifeBank, and Advantage Life) are LOTS’s key 

customer groups. LOTS collaborates with the donor families 

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

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
iv

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), Transplant Technologies, and

Columbia Cremation (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, Wright Brothers Charter, and

Columbia Cremation 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. 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 staff 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, two-way communication occurs during

the Pre-Donation Phase via face-to-face conversations (OWS)

and by phone (TWS). The 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. Inputs from

partners and collaborators, as well as other key stakeholders,

feed into the SPP (Figure 2.1-1) and help drive organizational

improvements. LOTS’s key supply-network requirements for

suppliers include timely communication, accurate information,

and service quality (Figure P.1-6).

iv

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),	Transplant	Technologies,	and	

Columbia	Cremation	(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,	Wright	Brothers	Charter,	and	

Columbia	Cremation	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.	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	staff	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,	two-way	communication	occurs	during	

the	Pre-Donation	Phase	via	face-to-face	conversations	(OWS)	

and	by	phone	(TWS).	The	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.	Inputs	from	

partners	and	collaborators,	as	well	as	other	key	stakeholders,	

feed	into	the	SPP	(Figure 2.1-1)	and	help	drive	organizational	

improvements.	LOTS’s	key	supply-network	requirements	for	

suppliers	include	timely	communication,	accurate	information,	

and	service	quality	(Figure P.1-6).

Figure P.1-6: Key Stakeholder Requirements

Customers Requirements

Transplant	Centers—Organ • Maximize Donation

• Information

• Competence

Tissue	Processors • Maximize Donation

• Information

• Accountability

Partners

Donor	Hospitals	

Medical	Examiners	

Hospice

• Respect/Sensitivity

• Information

• Service Quality

Collaborators

Organ	and	Tissue

	 Donor	Families

• Compassion

• Stewardship of the Gift

• Honor the Donor

Funeral	Homes • Communication

• Service

Stakeholders

Communities	within	

	 Service	Area

• Comply with Legal,

Ethical, and Regulatory

Requirements While

Providing Quality Organs

and Tissues

Workforce • Connection with V/M/V

• Excellent Benefits

• Coworkers

Board	of	Directors • Strategic Planning

• Administration

• Financial Management

Suppliers Expectations

Guardian	Ambulance	

Wright	Brothers	Charter

TT	

Transplant	Technologies	

Columbia	Cremation

• Accurate Information

• Service Quality

• Timely Communication

P.2 Organizational Situation

P.2a Competitive Environment

P.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	

P.2 Organizational Situation

P.2a Competitive Environment

P.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
v

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 partners 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 the

changes to the Affordable Care Act will be a challenge for

the health care industry, the scope of its changes to the OPO

industry is uncertain at this time. As such, the organization has

decided to focus on what it can control; 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 (SA) to manage

future challenges. Key factors influencing the success of

LOTS include

■	 A mission-driven workforce that is highly motivated and

engaged in saving lives (CC)

■	 Strong relationships formed through partnering and

collaboration

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

competitors.

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

the organization’s key comparative data sources. The organ

industry has select 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.

P.2b Strategic Context

Strategic Challenges (SCs) and Advantages (SAs; Figure P.2-1)

provides a summary that reflects the current strategic state of

LOTS. SCs and SAs 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 improvement 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 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, foster improvement, and seek out strategic opportunities. A continuous

process improvement environment 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.

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 Plan-Do-Study-Act (PDSA) problem-solving methodology. This methodology is embedded in LOTS’s improvement

processes.

v

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	partners	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	the	

changes	to	the	Affordable	Care	Act	will	be	a	challenge	for	

the	health	care	industry,	the	scope	of	its	changes	to	the	OPO	

industry	is	uncertain	at	this	time.	As	such,	the	organization	has	

decided	to	focus	on	what	it	can	control;	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	(SA)	to	manage	

future	challenges.	Key	factors	influencing	the	success	of	

LOTS	include

■	 A	mission-driven	workforce	that	is	highly	motivated	and	

engaged	in	saving lives	(CC)

■	 Strong	relationships	formed	through	partnering	and	

collaboration

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

competitors.

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

the	organization’s	key	comparative	data	sources.	The	organ	

industry	has	select	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.

P.2b Strategic Context

Strategic	Challenges	(SCs)	and	Advantages	(SAs;	Figure P.2-1)	

provides	a	summary	that	reflects	the	current	strategic	state	of	

LOTS.	SCs	and	SAs	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	improvement	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	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,	foster	improvement,	and	seek	out	strategic	opportunities.	A	continuous	

process	improvement	environment	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.

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	Plan-Do-Study-Act	(PDSA)	problem-solving	methodology.	This	methodology	is	embedded	in	LOTS’s	improvement	

processes.

Figure P.2-1: Strategic Challenges and Advantages

Challenges

Business • Industry Changes

Operational • Authorization

Societal	Responsibility • Increase Registry

Workforce • Retention

Advantages

Business • Stakeholder Satisfaction

Operational • Facilities and Equipment

Societal	Responsibility • Baldrige Business Model

Workforce • Supportive Culture
RESPONSES

ADDRESSING ALL

CRITERIA ITEMS
1

Category 1: Leadership

1.1 Senior Leadership

1.1a Vision and Values

1.1a(1) LOTS 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. This revalidation

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

■	 Incorporating the stories of donor families, recipients,

and patients waiting for a transplant into multiple

communication methods

The LT members 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 LT uses a 360-degree

review to provide systematic feedback to all LT members from

peers and direct reports pertaining to the 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.

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

standards of ethical behavior by promoting the principles

and 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 is in place to ensure

confidentiality. The entire LOTS workforce, including the LT

and BOD, is trained annually on the CCP policy. In addition,

compliance policies are reviewed by LOTS Quality staff.

1

Category 1: Leadership

1.1b Communication 

The	LT	communicates	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	informationsharing	mechanisms	that	were	then	shared	via	the	Communication	Process	(Figure 1.1-3).	Completion	of	the	Communication	Process	is	accomplished	through	knowledge	sharing	and	

feedback,	ensuring	a	closed	communication	loop.	

To	promote	frank,	two-way	communication	with	employees,	

the	LT	uses	the	Communication	Process,	which	supports	an	

open-door	policy,	and	RFO,	the	consistent	practice	of	asking	

specific	questions	to	obtain	actionable	information.	LT	members	“round”	with	each	of	their	direct	reports	to	gain	knowledge,	including	the	support	needed	to	help	the	staff	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	

1.1 Senior Leadership

1.1a Vision and Values

1.1a(1) LOTS	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.	This	revalidation	

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	

■	 Incorporating	the	stories	of	donor	families,	recipients,	

and	patients	waiting	for	a	transplant	into	multiple	

communication	methods

The	LT	members	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	LT uses	a	360-degree	

review	to	provide	systematic	feedback	to	all	LT	members	from	

peers	and	direct	reports	pertaining	to	the	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.	

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

standards	of	ethical	behavior	by	promoting	the	principles	

and	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	is	in	place	to	ensure	

confidentiality.	The	entire	LOTS	workforce,	including	the	LT

and	BOD,	is	trained	annually	on	the	CCP	policy.	In	addition,	

compliance	policies	are	reviewed	by	LOTS	Quality	staff.

Figure 1.1-1: Leadership System (LS) Enabled by Organizational Structure (Figure 1.2-2)

Monitor the Performance

 • Performance Measurement System 

(Figure 4.1-1)

 • Performance Evaluation Process 

(Figure 5.1-2)

3

Operationalize the Strategy 

 • Communication Process (Figure 1.1-3)

 • Strategic Planning Process (Figure 2.1-1)

 • Learning and Development System (Figure 5.2-2)

 • Operational Management Process (Figure 6.1-1)

2

Create the Environment

 • V/M/V (Figure P.1-1)

 • VOC (Figure 3.1-1)

1

1.1b Communication 

The LT communicates 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 informationsharing mechanisms that were then shared via the Communication Process (Figure 1.1-3). Completion of the Communication Process is accomplished through knowledge sharing and

feedback, ensuring a closed communication loop.

To promote frank, two-way communication with employees,

the LT uses the Communication Process, which supports an

open-door policy, and RFO, the consistent practice of asking

specific questions to obtain actionable information. LT members “round” with each of their direct reports to gain knowledge, including the support needed to help the staff 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
2

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 and tissue processors 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. In addition, social media are used

to communicate and highlight donor family and recipient

stories via 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

2

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	and	tissue	processors	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.	In	addition,	social	media	are	used	

to	communicate	and	highlight	donor	family	and	recipient	

stories	via	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	

Figure 1.1-2: Corporate Compliance Program (CCP) Annual Review/Feedback Report

Legend:

“1” 5 Proactive; “2” 5 Reactive

Communities

Within DSA

  2 Website

Key Suppliers

1 Contracts

2 Anonymous Hotline

Donor Families

 VOS (Figure 4.2-1)

2 Anonymous 

 Hotline

Hospital/Non-Hospital Partners

1 Contract Expectation

  2 Anonymous Hotline

  2 Website

Transplant Center, 

Tissue Processor

1 Contract Expectation

1 Physician Code of 

 Professional Conduct

2 Anonymous Hotline

2 Website 

BOD, WF

Annual Review & Acknowledgement:

1 Code of Professional Conduct 

 (WF Only)

1 Conflict of Interest

1 Corporate Compliance Training

2 Anonymous Email & 

 24-Hour Hotline

Core Value: Honesty

Communication Process (1.1-3)

Communication Process (1.1-3)

Figure 1.1-3: Communication Process

Staff Meetings 

Electronic Means 

Publications

One-Way Communication 

2

Work System Meetings 

Operations Meetings 

Department Meetings

Two-Way Communication 

3

 Strategic Operational 

 Discussions Discussions 

SPP (Figure 2.1-1) OMP (Figure 6.1-1)

Key 

Decisions

Knowledge Sharing & Feedback

Rounding for Outcomes 

Electronic Means 

Relationship Management 

VOC (Figure 3.1-1)

VOS (Figure 4.2-1)

Two-Way Communications 

4

1

2

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	and	tissue	processors	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.	In	addition,	social	media	are	used	

to	communicate	and	highlight	donor	family	and	recipient	

stories	via	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	

Figure 1.1-2: Corporate Compliance Program (CCP) Annual Review/Feedback Report

Legend:

“1” 5 Proactive; “2” 5 Reactive

Communities

Within DSA

  2 Website

Key Suppliers

1 Contracts

2 Anonymous Hotline

Donor Families

 VOS (Figure 4.2-1)

2 Anonymous 

 Hotline

Hospital/Non-Hospital Partners

1 Contract Expectation

  2 Anonymous Hotline

  2 Website

Transplant Center, 

Tissue Processor

1 Contract Expectation

1 Physician Code of 

 Professional Conduct

2 Anonymous Hotline

2 Website 

BOD, WF

Annual Review & Acknowledgement:

1 Code of Professional Conduct 

 (WF Only)

1 Conflict of Interest

1 Corporate Compliance Training

2 Anonymous Email & 

 24-Hour Hotline

Core Value: Honesty

Communication Process (1.1-3)

Communication Process (1.1-3)

Figure 1.1-3: Communication Process

Staff Meetings 

Electronic Means 

Publications

One-Way Communication 

2

Work System Meetings 

Operations Meetings 

Department Meetings

Two-Way Communication 

3

 Strategic Operational 

 Discussions Discussions 

SPP (Figure 2.1-1) OMP (Figure 6.1-1)

Key 

Decisions

Knowledge Sharing & Feedback

Rounding for Outcomes 

Electronic Means 

Relationship Management 

VOC (Figure 3.1-1)

VOS (Figure 4.2-1)

Two-Way Communications 

4

1
3

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. The commitment to the mission of

saving and improving lives, along with the value of improvement, drives LOTS to stay aware of industry knowledge and

best practices. 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 improvement in order to save

and improve more lives.

The LT creates an environment that encourages and supports

improvement, and this improvement is measured over time

with 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.

LT members, including the CEO, develop succession plans for

their positions to ensure that appropriate interim leadership is

available should a vacancy occur, as well as plans for future

leaders to grow within the organization. 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 all current leaders. LT

development has included training through Learning Development Institutes, attendance at state and national industry

conferences, and attendance at nation-wide non-industry

conferences.

1.1c(2) Through the LS (Figure 1.1-1), the LT creates 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 seek 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 staff 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.

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

■	 Holding management accountable for operational results

through evaluation of the monthly Status Report, which

shows SO target progress

■	 Reviewing and approving the strategic plan, budget, Quality Assessment and Performance Improvement (QAPI), and

topline metrics annually

■	 Achieving fiscal accountability by review of financial

reports, which are reviewed in detail at board meetings

■	 Ensuring 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 Medical Advisory Board, 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.
4

■	 Maintaining 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.

■	 Developing and approving a formal succession plan for

the CEO. Authority has been delegated by the BOD to the

CEO to oversee succession plan development for other ELT

members.

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 self-evaluation 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 for improvement. The survey includes a selfassessment of their 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 7.4-2). Board survey results help guide BOD

meetings and communication.

1.2b Legal and Ethical Behavior

1.2b(1) To date, LOTS has not been involved with any

adverse event that had societal impact on the organization’s

services and operations. 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. 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.

Media alerts and position statements created by industry

organizations are used in response to national news stories

and are distributed to the workforce and BOD as appropriate.

A Crisis Communication Plan has been developed to ensure an

appropriate response to public concerns, if needed.

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. As

an example, multiple efforts are made across the organization

to reduce paper usage, including the use of a board portal

and screen projection of all meeting data and the transition of

several support departments to use paperless systems. LOTS

prepares for impacts and concerns proactively through effective supply-network management processes, which include a

secure electronic database and established par levels.

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 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 and assist LOTS

with proactively addressing issues related to key compliance

processes, measures, and goals. Additionally, the audits push

the organization to exceed regulatory and legal requirements

by serving as methods used for addressing risks associated

with key services and operations (Figures 7.4-4 and 7.4-6).

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 LT promote 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.

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 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
55

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	an	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.	

1.2c(2) The	BOD	identifies	LOTS’s	key	communities,	and	

the	LT	reviews	and	validates	them	annually	as	part	of	the	SPP	

(Figure 2.1-1).	LOTS’s	key	communities	include	donor	families,	transplant	recipients,	and	their	families	within	the	DSA.

LOTS	supports	and	strengthens	key	communities	in	multiple	

ways.	To	support	donor	families,	LOTS	constructed	a	Donor	

Memorial	Monument	and	park	for	donor	and	recipient	families	

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

more	formal	ways	to	honor	a	donor	family’s	loved	one	are	

memorial	events	in	which	staff	members	actively	participate	at	

events	hosted	across	the	organization’s	DSA.	

Figure 1.2-2: Organizational Structure

Level Roles Outcomes

BOD

• Validate V/M/V

• Establish

accountability

• Long-term strategic

direction

• Organizational

sustainability

Leadership 

Team

(ELT and LT)

• Create the

environment

• Operationalize

the strategy

• Monitor the

performance

• Organizational

culture

• Strategic plan

deployment

• People	&	

performance

management

Workforce

• Support and

facilitate organ	&	

tissue donation

• Maximize donation

1

2

3

Feedback Feedback

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

7.4-5

Compliance	with	FDA	requirements FDA	audits FDA	approval No adverse findings 7.4-5

Voluntary	compliance	to	meet	organ	

donation	industry	standards

Internal	audits	

QA/Training

AOPO	accreditation Full	accreditation 7.4-5

Voluntary	compliance	to	meet	tissue	

donation	industry	standards

Internal	audits	

QA/Training

AATB Full	accreditation 7.4-5

Compliance	with	CMS	regulations	

impacting	reimbursement

CMS	audit

Internal	audit

CMS certification Full certification 7.4-5

Compliance	with	IRS	regulations	

impacting not-for-profit 

organizations

External	Financial	audits Minimal	audit	

adjustments

Unqualified opinion 7.4-4

AOS 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

7.4-6

FLSA	posted Posting

Safe	work	place Safety officer

Safety	committee	

Employee	training

OSHA	site	audits	

Reportable	events

Full	compliance	

No	reportable	events

7.4-5

7.3-7

Compliance	with	DOR	requirements DOR	audit DOR	approval No adverse findings 7.4-5

1.2c Societal Contributions

1.2c(1) The	accomplishment	of	the	mission—we save and 

improve lives—is	LOTS’s	greatest	gift	and	contribution	to	

5

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	an	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.	

1.2c(2) The	BOD	identifies	LOTS’s	key	communities,	and	

the	LT	reviews	and	validates	them	annually	as	part	of	the	SPP	

(Figure 2.1-1).	LOTS’s	key	communities	include	donor	families,	transplant	recipients,	and	their	families	within	the	DSA.

LOTS	supports	and	strengthens	key	communities	in	multiple	

ways.	To	support	donor	families,	LOTS	constructed	a	Donor	

Memorial	Monument	and	park	for	donor	and	recipient	families	

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

more	formal	ways	to	honor	a	donor	family’s	loved	one	are	

memorial	events	in	which	staff	members	actively	participate	at	

events	hosted	across	the	organization’s	DSA.	

Figure 1.2-2: Organizational Structure

Level Roles Outcomes

BOD

• Validate V/M/V

• Establish

accountability

• Long-term strategic

direction

• Organizational

sustainability

Leadership 

Team

(ELT and LT)

• Create the

environment

• Operationalize

the strategy

• Monitor the

performance

• Organizational

culture

• Strategic plan

deployment

• People	&	

performance

management

Workforce

• Support and

facilitate organ	&	

tissue donation

• Maximize donation

1

2

3

Feedback Feedback

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

7.4-5

Compliance	with	FDA	requirements FDA	audits FDA	approval No adverse findings 7.4-5

Voluntary	compliance	to	meet	organ	

donation	industry	standards

Internal	audits	

QA/Training

AOPO	accreditation Full	accreditation 7.4-5

Voluntary	compliance	to	meet	tissue	

donation	industry	standards

Internal	audits	

QA/Training

AATB Full	accreditation 7.4-5

Compliance	with	CMS	regulations	

impacting	reimbursement

CMS	audit

Internal	audit

CMS certification Full certification 7.4-5

Compliance	with	IRS	regulations	

impacting not-for-profit 

organizations

External	Financial	audits Minimal	audit	

adjustments

Unqualified opinion 7.4-4

AOS 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

7.4-6

FLSA	posted Posting

Safe	work	place Safety officer

Safety	committee	

Employee	training

OSHA	site	audits	

Reportable	events

Full	compliance	

No	reportable	events

7.4-5

7.3-7

Compliance	with	DOR	requirements DOR	audit DOR	approval No adverse findings 7.4-5

1.2c Societal Contributions

1.2c(1) The	accomplishment	of	the	mission—we save and 

improve lives—is	LOTS’s	greatest	gift	and	contribution	to	

1.2c Societal Contributions

1.2c(1) The 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 an 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.

1.2c(2) The BOD identifies LOTS’s key communities, and

the LT reviews and validates them annually as part of the SPP

(Figure 2.1-1). LOTS’s key communities include donor families, transplant recipients, and their families within the DSA.

LOTS supports and strengthens key communities in multiple

ways. To support donor families, LOTS constructed a Donor

Memorial Monument and park for donor and recipient families

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

more formal ways to honor a donor family’s loved one are

memorial events in which staff members actively participate at

events hosted across the organization’s DSA.
6

Category 2: Strategy

2.1 Strategy Development

2.1a Strategy Development Process

2.1a(1) Through cycles of learning, the focus of strategic

planning 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 OPO business ecosystem is one that requires

LOTS to be agile to ensure its ability to meet customer

and, ultimately, recipient needs. 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.

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 4

of the SPP, focused strategic discussions 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 LT participates in strategic discussions

(SDs) that take place during leadership and work system meetings, creating consistency across the SPP. During these SDs,

6

Category 2: Strategy

2.1 Strategy Development

2.1a Strategy Development Process

2.1a(1) Through	cycles	of	learning,	the	focus	of	strategic	

planning	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	OPO	business	ecosystem	is	one	that	requires	

LOTS	to	be	agile	to	ensure	its	ability	to	meet	customer	

and,	ultimately,	recipient	needs.	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.	

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	4	

of	the	SPP,	focused	strategic	discussions	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	LT	participates	in	strategic	discussions	

(SDs)	that	take	place	during	leadership	and	work	system	meetings,	creating	consistency	across	the	SPP.	During	these	SDs,	

Figure 2.1-1: Strategic Planning Process (SPP)

Strategic Discussions

(Occurs annually at SPP and ongoing)

1. DEFINE

Idea Generation

Key Work Process Design

Resource Utilization

2. DEPLOY

Create, Modify, Implement, an

3

d

. MONITOR

Organizational Performance (PMS, PEP)

Communicate Actions

Meetings:

• Leadership 

• Work System

• Other 

Strategy Implementation

Assess & Review

Workforce/Succession Planning 

Financial Impact 

AP Selection

Develop

Prioritize and Cascade 

Organizational Goals into APs, 

Ensuring Balance for Partners and 

Key Stakeholders

Deploy Strategic Plan

Communicate Strategic Direction 

(Fig. 1.1-3)

5 6 7

8

Meetings:

• Leadership

• Work System

• Other

Strategic Planning

Strategy Development

1 Validate/Revalidate

2 Analyze

Identify

Strategic Challenges, Advantages, & Opportunities 

Current/Future Core Competencies

Strategic Objectives and Organizational Goals

3

Project

Performance for 1–3 years

4

Re-validate Performance 

Projections

Board of Directors Input
7

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 LT that

fosters an environment for action and continuous improvement

to support LOTS’s life-saving mission. 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.

2.1a(2) The commitment to the mission of saving and 

improving lives, along with the value of improvement, drives

LOTS to stay on the top of industry knowledge and best

practices. Operational improvements are identified and implemented through the SPP and the OMP (Figure 6.1-1). As part

of the improvement approach, improvement suggestions and

ideas are identified through multiple inputs and then vetted

through the LT and a PDSA cycle. This might include the utilization of improvement teams, comprising multidisciplinary

and diverse departments and staff. The teams perform data

review, and, using PI tools including PDSA, they complete

brainstorming and prioritization sessions. The improvement

system has undergone several cycles of learning to ensure that

all parts of the PDSA system are identified and acted on.

The SWOT (Strengths, Weaknesses, Opportunities, and

Threats) list is reviewed during the SPP (Step 2) and validated

through ongoing SDs (Step 8). Strategic opportunities are

identified in step 3 of the SPP and during ongoing SDs that

promote “out-of-the-box” thinking. For the 2018 planning

cycle, the key strategic opportunities identified are registry

enrollment and customer satisfaction.

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)

Following analysis of the present situation, which includes a

review of historical data, step 4 involves the completion of a

performance projection exercise to effectively forecast activity

levels for key organizational metrics for the next two years.

During step 3 (Identify) of the annual SPP, LOTS collects

and analyzes relevant data to assist in the identification or

validation of the SCs and SAs, using information gleaned

from step 2. This process 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. 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. These data may be collected from industry or

nonindustry organizational conferences (AATB, AOPO, etc.).

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’s

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) The decision to outsource a process or to manage it

internally is initiated through the SPP and includes assessment

of many factors including core competencies, business ecosystem changes, and changes in regulation. Ongoing analysis

of key supplier and partner expertise and/or skill sets via the

OMP provides key information to aid in the determination of

which key processes will be accomplished internally or externally. For 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 all infectious disease testing

and Human Leukocyte Antigen (HLA) typing. This allows

LOTS to focus on saving and improving lives.

The key work systems are the OWS and the TWS (Figure 2.1-2).

Work system decisions are made via step 8 of the SPP.

Incorporation of organizational knowledge, new technology,

product excellence, and agility are also accomplished through

the OMP (Figure 6.1-1). Within step 3 of the SPP, LOTS

defines and validates its SAs, SCs, SOs, current and future

CCs, and organizational goals based on current performance

and the environmental scanning analysis completed in step 2.

All CCs are assessed to ensure that they are based on a

strategic assessment of measurable attributes (7.4b).

2.1b Strategic Objectives

2.1b(1) Critical to LOTS’s sustainability are the two strategic

objectives that are most critical to saving lives: maximize

donors and maximize stakeholder relationships. Performance

projections reflecting efforts to accomplish the SOs are established in step 4 of the SPP and are highlighted in Figure 2.1-3.

LOTS has minimal planned changes with customers, markets,

suppliers, and partners.
88

2.1b(2) The	SOs	are	complementary	by	nature	to	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	maximize	

donation	to	achieve	the	SO	of	increasing	organ	and	tissue	

donors.	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)	and	strategic	opportunities.

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) 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	several	of	the	key	short-	and	long-term	organizational	

goals	that	are	cascaded	to	the	workforce.	Some	goals	are	

complex	enough	to	warrant	multiple	APs,	while	others	are	

maintained	through	current	business	practices	and	therefore	do	

not	require	additional	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	

Figure 2.1-3: Strategic Linkages

SO Organizational Goals

2018

(Actual)

2019* 

1-year

(short-term)

2020* 

2-year

(long-term)

Strategic 

Challenges/ 

Advantages 

(SC/SA) Results

Maximize 

 Donors

 OWS

Achieve	Organ	Donors	at	110 102 110 120 SC 7.1-3

Achieve	Organs	Transplanted	at	360 352 375 400 SC 7.1-5

Achieve	Total	Bone	Donors	Released	at	750 755 800 850 SC 7.1-6

Optimize

Stakeholder

Relationships 

TWS

Sustain	Transplant	Center	Satisfaction 4.81 4 .5 4 .5 SA 7.2-1

Sustain	Tissue	Processor	Satisfaction 4.8 4 .5 4 .5 SA 7.2-2

Staff	Retention	Rate 70% 75% 80% SC 7.3-13

*Complete list of APs AOS

Figure 2.1-2: Work System Alignment

Relationship Management

Support Departments

ORGAN WORK SYSTEM

TISSUE WORK SYSTEM

Support Departments

Relationship Management

Authorization Procurement Allocation Post Donation

2.1b(2) The SOs are complementary by nature to 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 maximize

donation to achieve the SO of increasing organ and tissue

donors. 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) and strategic opportunities.

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).

8

2.1b(2) The	SOs	are	complementary	by	nature	to	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	maximize	

donation	to	achieve	the	SO	of	increasing	organ	and	tissue	

donors.	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)	and	strategic	opportunities.

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) 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	several	of	the	key	short-	and	long-term	organizational	

goals	that	are	cascaded	to	the	workforce.	Some	goals	are	

complex	enough	to	warrant	multiple	APs,	while	others	are	

maintained	through	current	business	practices	and	therefore	do	

not	require	additional	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	

Figure 2.1-3: Strategic Linkages

SO Organizational Goals

2018

(Actual)

2019* 

1-year

(short-term)

2020* 

2-year

(long-term)

Strategic 

Challenges/ 

Advantages 

(SC/SA) Results

Maximize 

 Donors

 OWS

Achieve	Organ	Donors	at	110 102 110 120 SC 7.1-3

Achieve	Organs	Transplanted	at	360 352 375 400 SC 7.1-5

Achieve	Total	Bone	Donors	Released	at	750 755 800 850 SC 7.1-6

Optimize

Stakeholder

Relationships 

TWS

Sustain	Transplant	Center	Satisfaction 4.81 4 .5 4 .5 SA 7.2-1

Sustain	Tissue	Processor	Satisfaction 4.8 4 .5 4 .5 SA 7.2-2

Staff	Retention	Rate 70% 75% 80% SC 7.3-13

*Complete list of APs AOS

Figure 2.1-2: Work System Alignment

Relationship Management

Support Departments

ORGAN WORK SYSTEM

TISSUE WORK SYSTEM

Support Departments

Relationship Management

Authorization Procurement Allocation Post Donation

2.2 Strategy Implementation

2.2a Action Plan Development and Deployment

2.2a(1) 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 several of the key short- and long-term organizational

goals that are cascaded to the workforce. Some goals are

complex enough to warrant multiple APs, while others are

maintained through current business practices and therefore do

not require additional 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
9

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, and having a mission-driven workforce (CC)

further define the roadmap for LOTS to accomplish its SOs.

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 the 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. 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 8 (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. A financial 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 return on investment (ROI) calculations.

2.2a(4) 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. These discussions determine the potential

impact on the workforce, as well as workforce needs for the

accomplishment of the short- and long-term APs. Management one-to-one meetings, RFO, and C&C discussions with

management representation from every department provide

LOTS with the ability to review increasing C&C needs, as

well as any potential changes that could impact the workforce.

These ongoing SDs and operational discussions (ODs) aid

in addressing training and development needs related to

workforce capability, while assessing the potential need for

modification in the workforce should demands change.

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).

Tracking the effectiveness of APs is further accomplished

through AP status reviews at LT meetings. AP status is also

reviewed by managers in their respective one-to-one meetings

with their direct managers and with their staff members during

RFO. To promote transparency of the ongoing assessment

of organizational performance, APs are updated regularly

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

members of the workforce. The prior year’s APs are assessed

for completion and effectiveness and are summarized in a

Q1 LT meeting. Through ongoing SDs, the LT ensures 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.

This 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.

2.2b Action Plan Modification

Systematic reviews occurring during work system meetings,

LT meetings, and ongoing SDs (Figure 2.1-1, Step 8) provide

the opportunity to identify performance measures that are lagging and to modify existing APs or create new ones as needed.

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 for improvement, may be performed,

depending on the outcome of the analysis. Deployment of

APs and modified APs are 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 decision-making process is communicated. The ability

to effectively track APs and their modifications enables the

organization to allocate resources effectively.
10

Category 3: Customers

3.1 Customer Expectations

3.1a Customer Listening

3.1a(1) 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 and

tissue processors 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 (AOS) that incorporates feedback reports and provides

results to the survey participants and 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

10

3.1 Customer Expectations

3.1a Customer Listening

3.1a(1) 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	and	

tissue	processors	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	

Category 3: Customers

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	(AOS)	that	incorporates	feedback	reports	and	provides	

results	to	the	survey	participants	and	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	

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

Method

Frequency Life Cycle Phase Customers M 

 Monthly 

O 

 Ongoing

A  Annual Q  QuarterlySA = Semi-AnnualPre-Donation

Donation Procurement Allocation

Post-DonationLocal Organ Transplant 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
11

obtain customer feedback is the online survey. LOTS has an

established website and social media presence on Facebook,

Vimeo, Twitter, and Instagram. Given the highly regulated

nature of the donation and transplant industry, there is no

sharing of confidential information across social media

sites. LOTS focuses social media efforts on communication

strategies that strengthen the organization’s brand, reinforce

company culture, and celebrate stakeholder successes.

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).

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.

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 mechanisms allow LOTS

to obtain actionable information on its services, customer

support, and transactions. For example, two additional tissue

processor customers were added in 2017 as a result of prior

effective relationship management and changes in the tissue

marketplace.

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]).

3.1b Customer Segmentation and Product Offerings

3.1b(1) The SPP (Figure 2.1-1) coordinates information

leveraged through multiple process inputs to validate current

customer and anticipate future customer groups and market

segments. Information gathered from the VOC (Figure 3.1-1)

is also used to identify and anticipate market segments.

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. Information collected in the VOC, along with the

analysis completed in the PMS, is used to assess potential

business growth opportunities. The OMP is used to determine

which customer groups to emphasize for business growth.

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 (AOS), and results are validated during the SPP

(Figure 2.1-1). These requirements serve as critical inputs for

the design of work processes and identification of opportunities for improvement. LOTS focuses on process improvement

efforts to consistently meet and exceed customer needs and

expectations.

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

maximizing each donation opportunity to its fullest potential

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).

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 improvement differentiates

its services and creates opportunities to expand and deepen

relationships with current customers.

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 SPP and 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. 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.

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
12

includes assessments to drive improvements in both satisfaction and engagement.

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. 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 and/or 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. 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.

3.2a(2) Local organ transplant centers and tissue processors

are empowered 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. Methods

of customer support do not vary between customers, customer

groups, or market segments.

Key customer support requirements are determined through

the VOC, validated through the Customer Survey Process

(AOS), and deployed to all people and processes involved

in customer support via the Communication Process. The

Customer Survey Process has undergone learning and cycles

of improvement.

3.2a(3) 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 

7.2-3 and 7.2-3A–B). 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 or tissue processor 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.

12

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 

7.2-3 and 7.2-3A–B).	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	or	tissue	processor	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.	

includes	assessments	to	drive	improvements	in	both	satisfaction	and	engagement.

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.	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	and/or	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.	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.	

3.2a(2) Local	organ	transplant	centers	and	tissue	processors	

are	empowered	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.	Methods	

of	customer	support	do	not	vary	between	customers,	customer	

groups,	or	market	segments.

Key	customer	support	requirements	are	determined	through	

the	VOC,	validated	through	the	Customer	Survey	Process	

(AOS),	and	deployed	to	all	people	and	processes	involved	

in	customer	support	via	the	Communication	Process.	The	

Customer	Survey	Process	has	undergone	learning	and	cycles	

of	improvement.

3.2a(3) 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	

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 Referral

Figure 3.2-1: Customer Life Cycle (Phases)

12

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 

7.2-3 and 7.2-3A–B).	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	or	tissue	processor	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.	

includes	assessments	to	drive	improvements	in	both	satisfaction	and	engagement.

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.	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	and/or	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.	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.	

3.2a(2) Local	organ	transplant	centers	and	tissue	processors	

are	empowered	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.	Methods	

of	customer	support	do	not	vary	between	customers,	customer	

groups,	or	market	segments.

Key	customer	support	requirements	are	determined	through	

the	VOC,	validated	through	the	Customer	Survey	Process	

(AOS),	and	deployed	to	all	people	and	processes	involved	

in	customer	support	via	the	Communication	Process.	The	

Customer	Survey	Process	has	undergone	learning	and	cycles	

of	improvement.

3.2a(3) 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	

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 Referral

Figure 3.2-1: Customer Life Cycle (Phases)
13

3.2b Determination of Customer Satisfaction 

and Engagement

3.2b(1) Local organ transplant center and tissue processor

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 uses multiple methods, including surveys, to capture

customer dissatisfaction as shown in the VOC (Figure 3.1-1).

Local organ transplant center and tissue processor 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. The implementation of the Feedback Process creates

the framework for analysis based on the services provided at

certain intervals in the Customer Life Cycle (Figure 3.2-1) as

it relates to customer requirements.

LOTS measures customer engagement based on the theory

that relationship strength is correlated with customer loyalty,

and that loyalty is obtained via those customers that 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.

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 2017 and 2018.

3.2b(2) Due to designation of its service area by CMS, LOTS

does not have customer competitors in the OWS. In the TWS,

LOTS collaborates to obtain industry benchmarks on customer

satisfaction from other OPOs (Figure 4.1-4). Processors

provide metrics using industry comparisons, which provide

information on key tissue metrics.

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 OMP and SPP, ensuring that a customer-focused culture

exists in the organization. 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. APs to bridge gaps

in performance and minimize complaints are deployed to

appropriate members of the workforce (3.1b[1]) as an output

of the Customer Survey Process (AOS). 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. 
14

Category 4: Measurement, Analysis, and Knowledge Management

4.1 Measurement, Analysis, and Improvement 

of Organizational Performance

4.1a Performance Measurement 

4.1a(1) LOTS uses the PMS (Figure 4.1-1), which has

undergone a cycle of learning, to monitor all key business

and daily operational processes. Key performance measures

are selected, collected, aligned, and integrated in the SPP

(Figure 2.1-1). The SPP is 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

key decision-making processes, SPP, and OMP (Figure 6.1-1).

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. Information is

readily available to assist in tracking daily operations through

the Data Mall, a central repository for 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 a web-based performance measurement system, and APs are reviewed at LT meetings 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) deploys and

integrates 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

an AP or modified AP 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.

14

Category 4: Measurement, Analysis, and Knowledge Management

4.1 Measurement, Analysis, and Improvement 

of Organizational Performance

4.1a Performance Measurement 

4.1a(1) LOTS	uses	the	PMS	(Figure 4.1-1),	which	has	

undergone	a	cycle	of	learning,	to	monitor	all	key	business	

and	daily	operational	processes.	Key	performance	measures	

are	selected,	collected,	aligned,	and	integrated	in	the	SPP	

(Figure 2.1-1).	The	SPP	is	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	

key	decision-making	processes,	SPP,	and	OMP	(Figure 6.1-1).

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.	Information	is	

readily	available	to	assist	in	tracking	daily	operations	through	

the	Data	Mall,	a	central	repository	for	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	a	web-based	performance	measurement	system,	and	APs	are	reviewed	at	LT meetings	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)	deploys	and	

integrates	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	

an	AP	or	modified	AP	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.

Figure 4.1-2: Topline Scorecard

2019 Year to Date End-of-Year Projection Last Year

Topline Key Metrics Actual Target % Gap Annualized Year-End Target 2018

First-Year	Turnover	Rate 22.0% 31.5% 30% 22.0% 31.5% 38%

Organ	Conversion 58% 60% 23% 58% 60% 58%

Organ	Donors 120 125 24% 160 110 150

Organs	Transplanted 335 330 2% 440 375 430

Donor	Services	

Authorization	Rate

55% 55% 0% 55% 55% 53%

Bone	Donors	 500 520 23.8% 667 800 650

Figure 4.1-1: Performance Measurement System (PMS)

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)

14

Category 4: Measurement, Analysis, and Knowledge Management

4.1 Measurement, Analysis, and Improvement 

of Organizational Performance

4.1a Performance Measurement 

4.1a(1) LOTS	uses	the	PMS	(Figure 4.1-1),	which	has	

undergone	a	cycle	of	learning,	to	monitor	all	key	business	

and	daily	operational	processes.	Key	performance	measures	

are	selected,	collected,	aligned,	and	integrated	in	the	SPP	

(Figure 2.1-1).	The	SPP	is	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	

key	decision-making	processes,	SPP,	and	OMP	(Figure 6.1-1).

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.	Information	is	

readily	available	to	assist	in	tracking	daily	operations	through	

the	Data	Mall,	a	central	repository	for	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	a	web-based	performance	measurement	system,	and	APs	are	reviewed	at	LT meetings	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)	deploys	and	

integrates	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	

an	AP	or	modified	AP	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.

Figure 4.1-2: Topline Scorecard

2019 Year to Date End-of-Year Projection Last Year

Topline Key Metrics Actual Target % Gap Annualized Year-End Target 2018

First-Year	Turnover	Rate 22.0% 31.5% 30% 22.0% 31.5% 38%

Organ	Conversion 58% 60% 23% 58% 60% 58%

Organ	Donors 120 125 24% 160 110 150

Organs	Transplanted 335 330 2% 440 375 430

Donor	Services	

Authorization	Rate

55% 55% 0% 55% 55% 53%

Bone	Donors 500 520 23.8% 667 800 650

Figure 4.1-1: Performance Measurement System (PMS)

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)
1515

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).	

4.1a(3) LOTS	formally	reviews	the	PMS	(Figure 4.1-1)	and	

modifies	it	as	appropriate	during	the	SPP,	ensuring	that	the	

organization	is	current	with	accreditation,	regulatory,	operational,	and	financial	needs	and	requirements.	The	organization	

addresses	rapid	or	unexpected	changes	and	their	impact	on	

the	PMS	during	ODs	and	SDs	and	within	the	work	system	

meetings	(Figure 6.1-1).	The	formal	PDSA	improvement	

methodology,	in	conjunction	with	the	organizational	structure	

(Figure 1.2-2)	and	ongoing	SDs,	ensures	that	the	organization	

is	agile	and	able	to	respond	quickly	to	issues	that	arise.	

4.1b Performance Analysis and Review

The	LT	reviews	the	key	organizational	performance	measures	and	capabilities	during	work	system	meetings	as	part	

of	ODs	and	during	quarterly	C&C	meetings.	Individual	

LT	members	are	also	responsible	for	conducting	monthly	

reviews	of	work	system	and	department	scorecards	within	

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.	These	

reviews	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	statistical	tools,	

and	they	work	collaboratively	with	LT	members	to	ensure	

LOTS’s	ability	to	meet	goals	and	objectives.	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,	and	APs	during	SDs	and	through	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	to	department	

scorecards.	Scorecard	reviews	provide	a	mechanism	to	

rapidly	respond	to	changes	identified	through	the	SPP	or	

OMP,	as	well	as	to	ensure	changes	to	APs	as	appropriate,	

which	might	include	a	response	to	a	transformational	

change	in	structure	or	work	system.	The	workforce	is	

provided	with	updates	on	key	organizational	metrics	and	

APs	at	various	meetings,	and	they	have	the	opportunity	to	

ask	the	LT	questions	regarding	organizational	performance	

and	direction.	

4.1a(2) LOTS	uses	the	Comparative	Data	Process	(Figure 4.1-4)

to	select	and	effectively	use	key	comparative	data	and	information	to	support	operational	decision	making.	In	the	OWS,	

national	regulatory	agencies	select	key	performance	indicators	

and	establish	performance	threshold	levels	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 7.1-19A).	

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.	Processors	track	OPO	

Figure 4.1-4: Comparative Data Process

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

 • DHSS

 • US DoL

Key Support 

Processes

TWS

OWS

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 Comparative Data Process (Figure 4.1-4)

to select and effectively use key comparative data and information to support operational decision making. In the OWS,

national regulatory agencies select key performance indicators

and establish performance threshold levels 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 7.1-19A).

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. 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).

4.1a(3) LOTS formally reviews the PMS (Figure 4.1-1) and

modifies it as appropriate during the SPP, ensuring that the

organization is current with accreditation, regulatory, operational, and financial needs and requirements. The organization

addresses rapid or unexpected changes and their impact on

the PMS during ODs and SDs and within the work system

meetings (Figure 6.1-1). The formal PDSA improvement

methodology, in conjunction with the organizational structure

(Figure 1.2-2) and ongoing SDs, ensures that the organization

is agile and able to respond quickly to issues that arise.

4.1b Performance Analysis and Review

The LT reviews the key organizational performance measures and capabilities during work system meetings as part

of ODs and during quarterly C&C meetings. Individual

LT members are also responsible for conducting monthly

reviews of work system and department scorecards within

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. These

reviews 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 statistical tools,

and they work collaboratively with LT members to ensure

LOTS’s ability to meet goals and objectives. 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, and APs during SDs and through 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 to department scorecards. Scorecard reviews provide a mechanism

to rapidly respond to changes identified through the SPP

or OMP, as well as to ensure changes to APs as appropriate, which might include a response to a transformational

change in structure or work system. The workforce is

provided with updates on key organizational metrics and

APs at various meetings, and they have the opportunity to

ask the LT questions regarding organizational performance

and direction.

15

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).	

4.1a(3) LOTS	formally	reviews	the	PMS	(Figure 4.1-1)	and	

modifies	it	as	appropriate	during	the	SPP,	ensuring	that	the	

organization	is	current	with	accreditation,	regulatory,	operational,	and	financial	needs	and	requirements.	The	organization	

addresses	rapid	or	unexpected	changes	and	their	impact	on	

the	PMS	during	ODs	and	SDs	and	within	the	work	system	

meetings	(Figure 6.1-1).	The	formal	PDSA	improvement	

methodology,	in	conjunction	with	the	organizational	structure	

(Figure 1.2-2)	and	ongoing	SDs,	ensures	that	the	organization	

is	agile	and	able	to	respond	quickly	to	issues	that	arise.	

4.1b Performance Analysis and Review

The	LT	reviews	the	key	organizational	performance	measures	and	capabilities	during	work	system	meetings	as	part	

of	ODs	and	during	quarterly	C&C	meetings.	Individual	

LT	members	are	also	responsible	for	conducting	monthly	

reviews	of	work	system	and	department	scorecards	within	

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.	These	

reviews	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	statistical	tools,	

and	they	work	collaboratively	with	LT	members	to	ensure	

LOTS’s	ability	to	meet	goals	and	objectives.	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,	and	APs	during	SDs	and	through	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	to	department	

scorecards.	Scorecard	reviews	provide	a	mechanism	to	

rapidly	respond	to	changes	identified	through	the	SPP	or	

OMP,	as	well	as	to	ensure	changes	to	APs	as	appropriate,	

which	might	include	a	response	to	a	transformational	

change	in	structure	or	work	system.	The	workforce	is	

provided	with	updates	on	key	organizational	metrics	and	

APs	at	various	meetings,	and	they	have	the	opportunity	to	

ask	the	LT	questions	regarding	organizational	performance	

and	direction.	

4.1a(2) LOTS	uses	the	Comparative	Data	Process	(Figure 4.1-4)

to	select	and	effectively	use	key	comparative	data	and	information	to	support	operational	decision	making.	In	the	OWS,	

national	regulatory	agencies	select	key	performance	indicators	

and	establish	performance	threshold	levels	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 7.1-19A).	

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.	Processors	track	OPO	

Figure 4.1-4: Comparative Data Process

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

 • DHSS

 • US DoL

Key Support 

Processes

TWS

OWS

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
16

The BOD reviews the organization’s performance by reviewing the Topline Scorecard and monthly financial statements.

The CEO reports on gaps in performance; progress is also

reported on achieving strategic SOs and APs.

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 in the OMP (Figure 6.1-1) to identify opportunities for

improvement and innovation in the in-process and outcome

measures. These findings form the foundation for the organization’s continuous improvement approach. Discussion in the

OMP also provides opportunities for identifying possible

improvements or innovations. If indicated, a team may be identified to look at possible opportunities. The team develops ideas

that are vetted through the LT for prioritization and disposition.

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.

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.

4.2a(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

real-time 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 decisionmaking time for LOTS’s partners. Tissue processors can

access critical data through a dedicated SharePoint portal and

can receive real-time 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 strategic 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.

4.2b Organizational Knowledge

LOTS relies on electronic means, as well as personal communication, to manage 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
17

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 into 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

17

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	into	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	

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-Hospital Referral SourcesGuardianWright BrothersTTTransplant Tech.Columbia CremationBoard of DirectorsWorkforce

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 • • • • • • • • • • •
18

EMR (Transplant Technology). For example, combining the

SRTR data with the Transplant Technology data to analyze

2018 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 LT meetings 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) The scorecards and Comparative Data Process

within the PMS (Figure 4.1-1) provide the organization’s

workforce with tools to monitor organizational performance,

including identification of best practices. 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

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 7.1-17)

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) LOTS has a number of processes in place to ensure

that learning is embedded in the organization. The primary

mechanism for this is the LDS (Figure 5.2-2), which is

aligned and integrated with multiple organizational processes.

Specific processes include regular training offerings in

response to staff feedback and organizational gaps, and personal learning goals for staff members. Knowledge sharing is

a standing agenda item in work system meetings. For example,

an improvement team was used to increase satisfaction with

staff meetings, which resulted in the addition of manager

report-outs and a Q/A session with the CEO at each meeting.
19

Category 5: Workforce

5.1 Workforce Environment

5.1a Workforce Capability and Capacity

5.1a(1) Workforce C&C is assessed through the Workforce

Planning Process (Figure 5.1-1). The organization has identified the skills and competencies that are needed to perform

each role within the organization successfully. To better define

capability, LOTS identifies necessary skills in job descriptions, and job competencies are monitored through the PEP

(Figure 5.1-2). 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 training file.

LOTS systematically assesses staffing levels by soliciting

feedback through RFO, ongoing SDs at work system

meetings, LT meetings, ELT meetings, and C&C

discussions. Using the PMS, LOTS forecasts staffing

needs in the SPP (Figure 2.1-1). The SPP assists with

projecting potential staffing needs one year out, ensuring a right-sized workforce for the organization. As an

example, in the Communication Center department, the

capability to provide ongoing support and training for

staff members approaching families was identified as a

department need. Ongoing SDs and C&C meetings led

to the addition of a trainer to the department in 2016.

Subsequent C&C meetings and SDs led to the transition

of the trainer to a manager/trainer in early 2018. The

resulting organ authorization rate for the Communication

Center for 2018 was the highest in organizational history

(Figure 7.1-17).

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 (AOS),

LOTS’s mission is the highest scoring key factor for

staff 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).

To ensure that the workforce represents the diverse

cultures of the community, LOTS uses diverse recruiting

methods, including local community colleges and universities,

as well as social media sites. Donor families and recipients

are also considered for appropriate positions within the

organization. These individuals reflect the thinking of the

organization’s key communities by already possessing a strong

connection to the mission. The fit of organizational culture

with new staff is ensured through several hiring and onboarding processes including shadowing and behavioral-based

interviewing practices.

19

Category 5: Workforce

5.1 Workforce Environment

5.1a Workforce Capability and Capacity

5.1a(1) Workforce	C&C	is	assessed	through	the	Workforce	

Planning	Process	(Figure 5.1-1).	The	organization	has	identified	the	skills	and	competencies	that	are	needed	to	perform	

each	role	within	the	organization	successfully.	To	better	define	

capability,	LOTS	identifies	necessary	skills	in	job	descriptions,	and	job	competencies	are	monitored	through	the	PEP	

(Figure 5.1-2).	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	training	file.	

LOTS	systematically	assesses	staffing	levels	by	soliciting	

feedback	through	RFO,	ongoing	SDs	at	work	system	

meetings,	LT	meetings,	ELT	meetings,	and	C&C	

discussions.	Using	the	PMS,	LOTS	forecasts	staffing	

needs	in	the	SPP	(Figure 2.1-1).	The	SPP	assists	with	

projecting	potential	staffing	needs	one	year	out,	ensuring	a	right-sized	workforce	for	the	organization.	As	an	

example,	in	the	Communication	Center	department,	the	

capability	to	provide	ongoing	support	and	training	for	

staff	members	approaching	families	was	identified	as	a	

department	need.	Ongoing	SDs	and	C&C	meetings	led	

to	the	addition	of	a	trainer	to	the	department	in	2016.	

Subsequent	C&C	meetings	and	SDs	led	to	the	transition	

of	the	trainer	to	a	manager/trainer	in	early	2018.	The	

resulting	organ	authorization	rate	for	the	Communication	

Center	for	2018	was	the	highest	in	organizational	history	

(Figure 7.1-17).	

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	(AOS),	

LOTS’s	mission	is	the	highest	scoring	key	factor	for	

staff	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).	

To	ensure	that	the	workforce	represents	the	diverse	

cultures	of	the	community,	LOTS	uses	diverse	recruiting	

methods,	including	local	community	colleges	and	universities,	

as	well	as	social	media	sites.	Donor	families	and	recipients	

are	also	considered	for	appropriate	positions	within	the	

organization.	These	individuals	reflect	the	thinking	of	the	

Figure 5.1-1: Workforce Planning Process

SPP (Figure 2.1-1) │ RFO │ C&C │ LDS (Figure 5.2-2)

Data analysis

Determine appropriate action

Right-size workforce 

Hire/Reduce/Realign or train

Prioritize & select needs to address

Communicate the action (Figure 1.1-3)

PMS │ SDs

organization’s	key	communities	by	already	possessing	a	strong	

connection	to	the	mission.	The	fit	of	organizational	culture	

with	new	staff	is	ensured	through	several	hiring	and	onboarding	processes	including	shadowing	and	behavioral-based	

interviewing	practices.

Figure 5.1-2: Performance Evaluation Process (PEP)

VMV

(1)

Goal Setting 

During SPP 

Figure 2.1-1

(2)

Goal & 

AP Updates

(3)

Annual 

Evaluations 

with LT & Staff

19

Category 5: Workforce

5.1 Workforce Environment

5.1a Workforce Capability and Capacity

5.1a(1) Workforce	C&C	is	assessed	through	the	Workforce	

Planning	Process	(Figure 5.1-1).	The	organization	has	identified	the	skills	and	competencies	that	are	needed	to	perform	

each	role	within	the	organization	successfully.	To	better	define	

capability,	LOTS	identifies	necessary	skills	in	job	descriptions,	and	job	competencies	are	monitored	through	the	PEP	

(Figure 5.1-2).	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	training	file.	

LOTS	systematically	assesses	staffing	levels	by	soliciting	

feedback	through	RFO,	ongoing	SDs	at	work	system	

meetings,	LT	meetings,	ELT	meetings,	and	C&C	

discussions.	Using	the	PMS,	LOTS	forecasts	staffing	

needs	in	the	SPP	(Figure 2.1-1).	The	SPP	assists	with	

projecting	potential	staffing	needs	one	year	out,	ensuring	a	right-sized	workforce	for	the	organization.	As	an	

example,	in	the	Communication	Center	department,	the	

capability	to	provide	ongoing	support	and	training	for	

staff	members	approaching	families	was	identified	as	a	

department	need.	Ongoing	SDs	and	C&C	meetings	led	

to	the	addition	of	a	trainer	to	the	department	in	2016.	

Subsequent	C&C	meetings	and	SDs	led	to	the	transition	

of	the	trainer	to	a	manager/trainer	in	early	2018.	The	

resulting	organ	authorization	rate	for	the	Communication	

Center	for	2018	was	the	highest	in	organizational	history	

(Figure 7.1-17).	

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	(AOS),	

LOTS’s	mission	is	the	highest	scoring	key	factor	for	

staff	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).	

To	ensure	that	the	workforce	represents	the	diverse	

cultures	of	the	community,	LOTS	uses	diverse	recruiting	

methods,	including	local	community	colleges	and	universities,	

as	well	as	social	media	sites.	Donor	families	and	recipients	

are	also	considered	for	appropriate	positions	within	the	

organization.	These	individuals	reflect	the	thinking	of	the	

Figure 5.1-1: Workforce Planning Process

SPP (Figure 2.1-1) │ RFO │ C&C │ LDS (Figure 5.2-2)

Data analysis

Determine appropriate action

Right-size workforce 

Hire/Reduce/Realign or train

Prioritize & select needs to address

Communicate the action (Figure 1.1-3)

PMS │ SDs

organization’s	key	communities	by	already	possessing	a	strong	

connection	to	the	mission.	The	fit	of	organizational	culture	

with	new	staff	is	ensured	through	several	hiring	and	onboarding	processes	including	shadowing	and	behavioral-based	

interviewing	practices.

Figure 5.1-2: Performance Evaluation Process (PEP)

VMV

(1)

Goal Setting 

During SPP 

Figure 2.1-1

(2)

Goal & 

AP Updates

(3)

Annual 

Evaluations 

with LT & Staff
20

5.1a(3) LOTS prepares the workforce for changes in C&C

needs through the Workforce Planning Process (Figure 5.1-1).

Information about changing C&C requirements and needs,

including workforce growth, is gathered through several

methods including C&C meetings and RFO. Through the

Workforce Planning Process, LOTS manages the needs of the

workforce and the organization, ensures continuity, prevents

workforce reductions, and considers periods of growth

(2.2a[4]). Additionally, the Hiring Process (Figure 5.1-3)

supports continuity by encouraging promotion from within, as

well as cross-training for applicable roles, whenever possible.

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.

5.1a(4) 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).

The LT provides work system oversight and strategic direction

through the LS (Figure 1.1-1), which serves as the foundation

for key decision making.

Systematic cascading of goals/scorecards 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). The integration of the LDS (Figure 5.2-2)

with the LS reinforces the V/M/V and provides training

for performing daily tasks and meeting customer needs.

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 7.2-4).

The SPP (Figure 2.1-1) creates focus, establishes priorities, and sets 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 PEP system 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.

20

The	LT	provides	work	system	oversight	and	strategic	direction	

through	the	LS	(Figure 1.1-1),	which	serves	as	the	foundation	

for	key	decision	making.	

Systematic	cascading	of	goals/scorecards	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).	The	integration	of	the	LDS	(Figure 5.2-2)	

with	the	LS	reinforces	the	V/M/V	and	provides	training	

for	performing	daily	tasks	and	meeting	customer	needs.	

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 7.2-4).

The	SPP	(Figure 2.1-1)	creates	focus,	establishes	priorities,	and	sets	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	PEP	system	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.

5.1a(3) LOTS	prepares	the	workforce	for	changes	in	C&C	

needs	through	the	Workforce	Planning	Process	(Figure 5.1-1).	

Information	about	changing	C&C	requirements	and	needs,	

including	workforce	growth,	is	gathered	through	several	

methods	including	C&C	meetings	and	RFO.	Through	the	

Workforce	Planning	Process,	LOTS	manages	the	needs	of	the	

workforce	and	the	organization,	ensures	continuity,	prevents	

workforce	reductions,	and	considers	periods	of	growth	

(2.2a[4]).	Additionally,	the	Hiring	Process	(Figure 5.1-3)	

supports	continuity	by	encouraging	promotion	from	within,	as	

well	as	cross-training	for	applicable	roles,	whenever	possible.

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.

5.1a(4) 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).	

Figure 5.1-3: Hiring Process

Workforce Needs Identified

Capability and capacity meetings

Position/Opportunity Posted

Phase 1

Initial interview with HR

Phase 2

Interview with hiring manager/point person

Applicants Identified

Selection

 • Manager & HR decide 

best-fit candidate

 • Reference check 

completed

 • Conditional offer made

Phase 3

Peer interview

Candidate 

Not Selected

 • External: Notify

 • Internal: Provide 

developmental 

feedback

Employee Hired

Figure 5.1-4: Examples of Cascading Goals

Goal: Increase Local Organs Transplanted

Front-line Workforce Level

 • Educate partners

Director Level

 • Build relationships w/transplant partners

 • Review cases

SO: Maximize Donation

OPC/Front-line Workforce Level

 • Donor management protocols

 • Follow allocation processes

SPP SPP

20

The	LT	provides	work	system	oversight	and	strategic	direction	

through	the	LS	(Figure 1.1-1),	which	serves	as	the	foundation	

for	key	decision	making.	

Systematic	cascading	of	goals/scorecards	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).	The	integration	of	the	LDS	(Figure 5.2-2)	

with	the	LS	reinforces	the	V/M/V	and	provides	training	

for	performing	daily	tasks	and	meeting	customer	needs.	

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 7.2-4).

The	SPP	(Figure 2.1-1)	creates	focus,	establishes	priorities,	and	sets	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	PEP	system	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.

5.1a(3) LOTS	prepares	the	workforce	for	changes	in	C&C	

needs	through	the	Workforce	Planning	Process	(Figure 5.1-1).	

Information	about	changing	C&C	requirements	and	needs,	

including	workforce	growth,	is	gathered	through	several	

methods	including	C&C	meetings	and	RFO.	Through	the	

Workforce	Planning	Process,	LOTS	manages	the	needs	of	the	

workforce	and	the	organization,	ensures	continuity,	prevents	

workforce	reductions,	and	considers	periods	of	growth	

(2.2a[4]).	Additionally,	the	Hiring	Process	(Figure 5.1-3)	

supports	continuity	by	encouraging	promotion	from	within,	as	

well	as	cross-training	for	applicable	roles,	whenever	possible.

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.

5.1a(4) 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).	

Figure 5.1-3: Hiring Process

Workforce Needs Identified

Capability and capacity meetings

Position/Opportunity Posted

Phase 1

Initial interview with HR

Phase 2

Interview with hiring manager/point person

Applicants Identified

Selection

 • Manager & HR decide 

best-fit candidate

 • Reference check 

completed

 • Conditional offer made

Phase 3

Peer interview

Candidate 

Not Selected

 • External: Notify

 • Internal: Provide 

developmental 

feedback

Employee Hired

Figure 5.1-4: Examples of Cascading Goals

Goal: Increase Local Organs Transplanted

Front-line Workforce Level

 • Educate partners

Director Level

 • Build relationships w/transplant partners

 • Review cases

SO: Maximize Donation

OPC/Front-line Workforce Level

 • Donor management protocols

 • Follow allocation processes

SPP SPP
21

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 7.3-5) 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 7.3-9),

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.

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

staff 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 7.3-6). These performance measures are

designed to 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, which is available to staff

members as well as their family members.

LOTS supports its workforce by providing a comprehensive

insurance benefit 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 (PTO) plan, Extended Medical Bank (EMB) 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. Employees who choose the Employee

Key Requirement (EKR) of benefits in the 2017 staff survey

scored their satisfaction at 85%, meeting the industry comparative (Figure 7.3-15). 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

21

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 7.3-5)	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 7.3-9),	

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.	

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	

staff	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 7.3-6).	These	performance	measures	are	

designed	to	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,	which	is	available	to	staff	

members	as	well	as	their	family	members.

LOTS	supports	its	workforce	by	providing	a	comprehensive	

insurance	benefit	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	(PTO)	plan,	Extended	Medical	Bank	(EMB)	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.	Employees	who	choose	the	Employee	

Key	Requirement	(EKR)	of	benefits	in	the	2017	staff	survey	

scored	their	satisfaction	at	85%,	meeting	the	health	care	

top-quartile	benchmark	(Figure 7.3-15).	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	

Figure 5.1-5: Workplace Environment

Factors Measures Results

Health EAP

OSHA	Compliance	

Wellness	Program

Wellness	Screening	Participation

AOS	

7.3-7

AOS	

7.3-5

Security Limited	access	by	job	function

ERP

Training

AOS

AOS	

AOS

Accessibility ADA	compliant

EEOC	compliant	

IT	resources

AOS

AOS	

AOS
22

providers was to gain a deeper understanding of employee

engagement, validation of the key drivers of employee satisfaction and engagement, and actionable feedback. The vendor

chosen for the 2017 survey, Excel Employee Engagement,

allowed the staff individual selection of satisfier and engagement drivers (EKRs). 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. Segmented

survey results, including several benchmarks, are AOS.

5.2a(2) LOTS assesses workforce engagement through the

Workforce Survey Process (AOS). Through learning and

strategic 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

2017 workforce survey validated LOTS’s CC of a missiondriven workforce (Figures 7.3-11, 7.3-12, and 7.3-12A). The

Workforce Survey Process allows measurement of engagement across workforce groups and segments, including work

system, tenure, and department (AOS). Workforce retention

is measured on the Topline Scorecard and has remained a

priority (Figure 7.3-13). 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; AOS). Productivity of the workforce is

acknowledged through the Rewards and Recognition Program

(Figure 5.2-1).

5.2b Organizational Culture

The LS (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 Process

(Figure 1.1-3), RFO fosters open communication. The 2017

workforce survey noted satisfaction with clear, effective

communication at 75%, exceeding the health care median by

15% (AOS). 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 (AOS) 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 smallgroup 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).

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 2017, staff

members scored their connection to the mission at 93.7%,

the highest of all 22 EKRs, exceeding the health care median

benchmark (Figure 7.3-11). In addition, values are part of the

PEP (Figure 5.1-2) system and are highlighted at various staff

meetings to demonstrate how that value may be applicable in

day-to-day work for staff. 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,

and 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 7.2-4).

22

providers	was	to	gain	a	deeper	understanding	of	employee	

engagement,	validation	of	the	key	drivers	of	employee	satisfaction	and	engagement,	and	actionable	feedback.	The	vendor	

chosen	for	the	2017	survey,	Excel	Employee	Engagement,	

allowed	the	staff	individual	selection	of	satisfier	and	engagement	drivers	(EKRs).	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.	Segmented	

survey	results,	including	several	benchmarks,	are	AOS.

5.2a(2) LOTS	assesses	workforce	engagement	through	the	

Workforce	Survey	Process	(AOS).	Through	learning	and	

strategic	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	

2017	workforce	survey	validated	LOTS’s	CC	of	a	missiondriven	workforce	(Figures 7.3-11, 7.3-12, and 7.3-12A).	The	

Workforce	Survey	Process	allows	measurement	of	engagement	across	workforce	groups	and	segments,	including	work	

system,	tenure,	and	department	(AOS).	Workforce	retention	

is	measured	on	the	Topline	Scorecard	and	has	remained	a	

priority	(Figure 7.3-13).	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;	AOS).	Productivity	of	the	workforce	is	

acknowledged	through	the	Rewards	and	Recognition	Program	

(Figure 5.2-1).

5.2b Organizational Culture

The	LS	(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	Process	

(Figure 1.1-3),	RFO	fosters	open	communication.	The	2017	

workforce	survey	noted	satisfaction	with	clear,	effective	

communication	at	75%,	exceeding	the	health	care	median	by	

15%	(AOS).	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	(AOS)	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	smallgroup	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).	

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	2017,	staff	

members	scored	their	connection	to	the	mission	at	93.7%,	

the	highest	of	all	22	EKRs,	exceeding	the	health	care	median	

benchmark	(Figure 7.3-11).	In	addition,	values	are	part	of	the	

PEP (Figure 5.1-2)	system	and	are	highlighted	at	various	staff	

meetings	to	demonstrate	how	that	value	may	be	applicable	in	

day-to-day	work	for	staff.	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,	

and	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 7.2-4).	

Figure 5.2-1: Rewards and Recognition Given by LT Given by Staff

Reward/RecognitionOrganization-WideDepartmentalIndividual

 Congratulatory	slide	at	staff	meeting   

 Sharing	of	recipient	thank-you	letters   

  Personal	notes/emails/cards   

  Peer-to-peer	recognition   
23

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 2017 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, is AOS.

5.2c Performance Management and Development 

5.2c(1) The Workforce Performance Measurement System

supports high performance and engagement of the workforce

and LT through the fully deployed PEP (Figure 5.1-2). The

PEP consists of several layers that are structured and systematic. Utilizing the SPP as 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

PEP also 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 AP progress in real-time. The PEP

is 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.

While staff members name the mission, coworkers, and

benefits as the highest-scoring EKRs, 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 consultant to

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).

The PEP, via the LDS (Figure 5.2-2), is used to evaluate

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 improvement, performance improvement,

organizational change, and innovation 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). For all LT members,

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, and development of decision-making skills.

To support ethics and ethical business practices, annual policy

training includes review of the Conflict of Interest Policy,

Code of Professional Conduct, Corporate Compliance Training, and ongoing procedure 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;

CCP training 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 that assesses performance.
24

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	

staff	success,	which	in	turn	drives	organizational	sustainability	

and	supports	the	CC	of	a	mission-driven	workforce.	The	LDS	

system	(Figure 5.2-2)	is	validated	as	part	of	the	SPP;	past	

improvements	have	included	the	addition	of	skills	days	and	a	

formal	exit	interview	process	(AOS).	In	the	2017	staff	survey,	

the	EKR	of	continuous	learning,	training,	and	development	

showed	an	80.6%	satisfaction	level,	exceeding	the	health	care	

mean	(Figure 7.3-16).	The	Human	Resources	staff	evaluates	

the	effectiveness	of	training	by	conducting	evaluations	of	

internal	and	external	opportunities	at	the	organization,	work	

system,	and	department	levels,	affording	employees	the	opportunity	to	provide	feedback	about	the	training	they	received	and

also	to	identify	any	subsequent	training	needs	of	interest	that

will	support	the	mission	(Figure 5.2-2,	Step	4).	Depending	

on	the	nature	of	the	training,	learning	is	linked	to	an	outcome	

measured	in	the	goal	plan	for	each	employee.	Staff	members	

who	attend	training	off-site	are	asked	to	share	the	information	

they	learned	at	their	department	meetings,	work	systems,	or	

LT	meetings	to	help	other	team	members	gain	insight	from	the	

training.	

5.2c(4) At	LOTS,	most	job-	and	career-related	development	

involves	job	enhancement	opportunities	within	the	organization.	Due	to	the	organization’s	size	and	structure,	career	

development	is	often	supported	in	horizontal	transitions	to	

different	roles.	Over	half	of	the	workforce	is	in	a	different	

position	today	than	originally	hired	for,	and	many	of	those	

have	transitioned	multiple	times.	The	PEP	helps	identify	

high	performers	who	can	utilize	their	skills,	knowledge,	and	

abilities	in	various	ways.

The	LDS	is	used	to	prepare	the	workforce	for	replacement	

and	succession	planning.	The	succession	plan	is	reviewed	

annually	through	the	SPP	(Figure 2.1-1,	Step	5)	and	modified	

as	needed	by	the	CHRO,	CEO,	COO,	CMO,	and	each	LT

member;	the	plan	provides	strategy	for	short-	and	long-term	

coverage	for	each	LT	position.	The	LT	succession	plan	focuses	

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	team	dynamics,	difficult	conversations,	and	team	motivation.	

Figure 5.2-2: Learning and Development System (LDS)

Identification & Evaluation of 

Learning and Development Needs

1

Evaluate Effectiveness 4 Knowledge 

Sharing

3

 • Orientation

 • On-the-Job Training

 • Policies & 

Procedures

 • Intranet

 • On-the-Job Training

 • Leadership 

Development

 • Industry Networking

 • Leadership 

Development

 • Industry 

Conferences

 • Regulatory 

Information

Job/Task 

Learning

Internal Learning External Learning Growth/ Development

Staff 

Knowledge

2

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

staff success, which in turn drives organizational sustainability

and supports the CC of a mission-driven workforce. The LDS

system (Figure 5.2-2) is validated as part of the SPP; past

improvements have included the addition of skills days and a

formal exit interview process (AOS). In the 2017 staff survey,

the EKR of continuous learning, training, and development

showed an 80.6% satisfaction level, exceeding the health care

mean (Figure 7.3-16). The Human Resources staff evaluates

the effectiveness of training by conducting evaluations of

internal and external opportunities at the organization, work

system, and department levels, affording employees the opportunity to provide feedback about the training they received and

also to identify any subsequent training needs of interest that

will support the mission (Figure 5.2-2, Step 4). Depending

on the nature of the training, learning is linked to an outcome

measured in the goal plan for each employee. Staff members

who attend training off-site are asked to share the information

they learned at their department meetings, work systems, or

LT meetings to help other team members gain insight from the

training.

5.2c(4) At LOTS, most job- and career-related development

involves job enhancement opportunities within the organization. Due to the organization’s size and structure, career

development is often supported in horizontal transitions to

different roles. Over half of the workforce is in a different

position today than originally hired for, and many of those

have transitioned multiple times. The PEP helps identify

high performers who can utilize their skills, knowledge, and

abilities in various ways.

The LDS is used to prepare the workforce for replacement

and succession planning. The succession plan is reviewed

annually through the SPP (Figure 2.1-1, Step 5) and modified

as needed by the CHRO, CEO, COO, CMO, and each LT

member; the plan provides strategy for short- and long-term

coverage for each LT position. The LT succession plan focuses

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 team dynamics, difficult conversations, and team motivation.
25

Category 6: Operations 

6.1 Work Processes

6.1a Product and Process Design

6.1a(1) Key work product and process requirements are

determined 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 its 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 (AOS), and the hospital

partner satisfaction exceeded prior years (Figure 7.1-1A).

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 organizational sustainability

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.

6.1a(3) The OMP (Figure 6.1-1) demonstrates the methods

used to design, refine, and construct key work processes to

meet requirements. The OMP ensures that key requirements

driving work processes are analyzed, reviewed, and translated

into priorities 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 staff members drive organizational improvements

using the SPP, OMP, and the PMS (Figures 2.1-1, 6.1-1, and

4.1-1) to assess performance, look for improvements, 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, staff knowledge, and

stakeholder and environmental information to ensure that

they meet key process requirements. Within the OMP, the

PMS (Figure 4.1-1) ensures 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, staff

25

Figure 6.1-1: Operational Management Process (OMP)

Operational Discussions

 • Operations Mtgs

 • Department Mtgs

PMS

(Figure 4.1-1)

Staff Knowledge 

(RFO)

VOC

(Figure 3.1-1) 

VOS

(Figure 4.2-1)

Environmental 

Information

Knowledge Feedback Loop/Analyze

SPP

(Figure 2.1-1) ANALYSIS

DECISION

MAKING

AL GI NMENT WITH V/M/V

6.1 Work Processes

6.1a Product and Process Design

6.1a(1) Key	work	product	and	process	requirements	are	

determined	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	its	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	(AOS),	and	the	hospital	

partner	satisfaction	exceeded	prior	years	(Figure 7.1-1A) .

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	organizational	sustainability	

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.	

6.1a(3) The	OMP	(Figure 6.1-1)	demonstrates	the	methods	

used	to	design,	refine,	and	construct	key	work	processes	to	

meet	requirements.	The	OMP	ensures	that	key	requirements	

driving	work	processes	are	analyzed,	reviewed,	and	translated	

into	priorities	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	staff	members	drive	organizational	improvements	

using	the	SPP,	OMP,	and	the	PMS	(Figures 2.1-1, 6.1-1, and

4.1-1)	to	assess	performance,	look	for	improvements,	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,	staff	knowledge,	and	

stakeholder	and	environmental	information	to	ensure	that	

they	meet	key	process	requirements.	Within	the	OMP,	the	

PMS	(Figure 4.1-1)	ensures	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,	staff	

Category 6: Operations 
26

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 6.1-2. 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 CAPA deviation

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) The OMP (Figure 6.1-1) demonstrates the process

used to determine the key work system requirements to

construct the key support processes: Laboratory Testing,

Donor Chart Review and Release Process, Supply and Equipment Management, Financial Management, HR Management,

IT Management, PI, and Quality Compliance Management.

Day-to-day operation of the support processes’ ability to meet

key business support requirements is ensured by the OMP.

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

26

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 6.1-2. 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 CAPA deviation 

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) The OMP (Figure 6.1-1) demonstrates the process 

used to determine the key work system requirements to 

construct the key support processes: Laboratory Testing, 

Donor Chart Review and Release Process, Supply and Equipment Management, Financial Management, HR Management, 

IT Management, PI, and Quality Compliance Management. 

Day-to-day operation of the support processes’ ability to meet 

key business support requirements is ensured by the OMP. 

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 

Figure 6.1-2: Key Work Processes

PHASE PRE-DONATION DONATION

Key Work Process Referral Management Authorization Procurement/Allocation

Work System 

Alignment

OWS TWS OWS TWS OWS TWS

Key Requirement 

Results

Hospital 

Partner 

Satisfaction: 

OWS

(7.1-1A)

Hospital 

Partner 

Satisfaction: 

TWS

(7.1-2A)

Referrals 

(7.1-1)

Referrals 

(7.1-2)

Organ Donors 

(7.1-3)

Tissue Donors 

(7.1-4)

In-Process

Measures

Missed Organ 

Referrals

(7.1-15)

LOTS Tissue 

Approach Rate

(7.1-16)

Organ 

Authorization 

(7.1-17)

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)

Outcome Measures Organ 

Referrals 

(7.1-1)

Tissue 

Referrals 

(7.1-2)

Local Organ 

Donors (7.1-3)

Organ 

Conversion 

(7.1-19)

Total Tissue 

Donors (7.1-4)

Local Organs 

Transplanted 

(7.1-5)

Skin Donors 

Released 

(7.1-7)

How Determined

• Regulatory

CMS FDA CMS 

UNOS/OPTN

UAGA

AOPO

UAGA AATB VOC (3.1-1) 

UNOS/OPTN

AOPO

VOC (3.1-1) 

AATB
27

an online laboratory requisition module that reduced the

number of errors dramatically (AOS).

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 improvement opportunities. The

overarching approach to support work process and product

improvements is the PDSA. 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 staff (CC) are also part of the OMP, ensuring a

multifaceted and systematic analysis and discussion of product

and process improvements.

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 staff buy-in to ensure improvement in outcomes.

For example, one partner hospital referral compliance for 2017

was 68%. The Hospital Services staff person worked with the

hospital to PDSA several improvements, including training,

additional approaches to communication (including daily

emails), new staff orientation, and follow-up with hospital

administration. As a result of this focused PDSA, the hospital’s 2018 compliance improved to 85% (AOS).

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 take into account 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 supplier performance (Guardian Ambulance, Columbia

Cremation, Transplant Technologies, and Wright Brothers

Charters) is monitored, tracked, and trended and is included

in regular feedback with the key suppliers (Figures 7.1-30,

7.1-31, 7.1-32, 7.1-33, and 7.1-34). These key suppliers are

also vetted based on their abilities to align and collaborate

with LOTS. 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.

Organizational alignment and collaboration with suppliers

include ensuring that two-way communication is utilized.

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. Improvement or innovation is

initiated and managed through the OMP (Figure 6.1-1), LDS,

and SPP. Improvement discussions can originate in the SPP,

OMP, and/or LDS, and an improvement team may be formed.

An improvement team comprises staff members from departments across the organization and is led by the PI staff. During

improvement team meetings, the team uses various PI tools

and data analysis from the PMS to develop new processes to

test and implement new ideas or processes.

The SA of financial stability positions the organization to

actively pursue innovative ideas and improvements. Idea

assessment includes the scope of a potential project, schedule,

and needed resources, including financial resources. These are

reviewed at the LT meetings. Financial and other resources are

made available through a robust budgeting process and multiple financial analysis tools, including financial projections.

Decisions to discontinue pursuing opportunities at the appropriate time are evaluated through the OMP. The OMP allows 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 inhouse or outsourced. Robust discussions and analysis addressed

financial, capability, and customer satisfaction. Ultimately, the
28

Organ Biopsy Process was outsourced, resulting in decreased

cost and higher customer satisfaction (AOS).

6.2 Operational Effectiveness 

6.2a Process Efficiency and Effectiveness 

Overall costs of the operations, cycle time, productivity,

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

Figure 6.1-2. An example of cost control is the development

of LOTS’s in-house OR, which incorporated customer

feedback and has resulted in process efficiencies and substantial costs savings. 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 staffing (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 have led to reductions in on-site deferrals,

which have impacted overall tissue donor numbers (AOS).

Originating from the annual SPP session, a well-defined

audit calendar 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. 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 sharing of information and best practices to proactively evaluate and improve operations. Input from missiondriven workforce members (CC) during audit preparation

meetings ensures that the organization’s workforce contributes

to process improvement opportunities 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 OMP drives 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

The IS used includes software, data, network infrastructure,

computer hardware, and key assets. An overview 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. 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

(Figure 7.1-30).

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. 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 from local/regional

disasters; 4.2a[1]).

LOTS has established multiple policies and procedures to

ensure the security and cybersecurity of sensitive or privileged

data and information. 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. The organization’s password policy

outlines the appropriate parameters for selecting and securing

system- and user-level passwords. Staff members with EMR

access are required to sign confidentiality agreements, and IT

audits performed by QS verify appropriate access and current

users.

TT is LOTS’s primary infrastructure contractor. TT monitors

security, including real-time alerts from threat-detection

systems. TT prepares all desktop and laptop computers prior

to use to ensure that they include the latest security patches,

antivirus engines, and hard-drive encryption. All users are

trained, and policies require staff members to lock their

computers when they are away. LOTS uses fully redundant

firewalls to ensure network and Internet security. The firewall

includes intrusion detection and prevention features. Security

patches are applied monthly for all physical servers, virtual

machines, desktops, and laptops. LOTS has a mail encryption
29

policy, which requires encryption of all emails that contain

personally identified information (PII) or personal health

information (PHI).

Cybersecurity threat and emerging security issue awareness

are maintained through a number of approaches. LOTS

receives security bulletins directly from a third-party vendor

and can respond to eminent, day-zero threats. Antivirus

engines are required to be current, and they continuously scan

the LOTS environment.

Identification and prioritization of technology system protection from cybersecurity attacks are provided through the

utilization of SaaS, which provides hosting of solutions from

complete separate servers and data centers. LOTS’s payroll,

accounting, EMR, and Business Intelligence systems, for

example, are all hosted by different vendors at different data

centers. In addition, necessary integration occurs behind

LOTS’s firewalls.

Detection of cybersecurity breaches is provided by monitoring

tools that are in place to continuously scan the environment for

suspicious activity. A cybersecurity breach has not occurred at

LOTS. The response and recovery from a potential cybersecurity breach would include detection of the attack, and compromised servers would be recovered. Recovery would typically

include running antivirus software and other security tools to

remove and clean any viruses, Trojans, or monitoring agents.

Any compromised data would be deleted and recovered from

backups.

6.2c Safety and Emergency Preparedness

6.2c(1) LOTS has established a Safety Program, managed

by the Safety Officer, that utilizes systematic processes,

including the LDS, 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 7.3-7). In addition, a 2018 staff safety survey noted

overall satisfaction with safety at 85%, an increase of 2% over

the prior survey (AOS). Accident prevention, embedded in the

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 staff members

being provided the hepatitis B vaccine. In addition, workforce

safety concerns are identified in ODs, department meetings,

RFO, staff surveys, 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 (AOS) includes monthly safety programs

encompassing personal safety, CPR, automated external defibrillators (AED), 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/injuries in

the tissue procurement department, which was a result of

improved training in orientation and the requiring of protective

gloves. 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 staff 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 members.

6.2c(2) LOTS has a well-documented, executable disaster

preparedness plan that 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; AOS). The plan is

a guideline that prepares the staff to respond to safety and

operational disruptions in the event of an emergency. 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. In

the event of a disaster, an extreme volume of cases, or critical

staffing shortages, LOTS has agreements with multiple other

OPOs to reciprocate emergency staffing and facilities 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.
30

Category 7: Results

7.1 Product and Process Results

7.1a Customer-Focused Product and Service Results

At LOTS, most job- and career-related progression involves

job enhancement opportunities within the organization. Due

to the organization’s size and structure, career enhancement is

often supported in horizontal transitions to different roles. Over

half of the workforce is in a different position today than originally hired for, and many of those have transitioned multiple

times. The PEP helps identify high performers who can utilize

their skills, knowledge, and abilities in various ways.

The LDS is used to prepare the workforce for replacement

and succession planning. The succession plan is reviewed

annually through the SPP (Figure 2.1-1, Step 5) and modified

as needed by the CHRO, CEO, COO, CMO, and each LT

member; the plan provides strategy for short- and long-term

coverage for each LT position. The LT succession plan focuses

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 team dynamics, difficult conversations, and team motivation.

LOTS has three key work processes within the work systems:

Referral Management, Authorization, and Procurement/

Allocation (Figure 6.1-2). Referral Management, the first

key process in both work systems, is measured by organ and

tissue referrals. Referral is the start of collaboration; hospital

satisfaction with the donation is reflected in Figures 7.1-1A

and 7.1-2A. Organ referrals (Figure 7.1-1) have experienced

organizational best levels in 2018. Tissue referrals have

increased, allowing LOTS to achieve “tenth in the nation”

status in 2018 (Figure 7.1-2). (GPR is a national organization

providing comparative satisfaction and engagement data.)

0

1,200

2,400

2016 2017 2018 2019 ytd

Referrals

Figure 7.1-1: Organ Referrals

LOTS Internal Target

INTERNAL METRIC

Organ Referrals Remain Consistent

Good

0

2,500

5,000

2016 2017 2018 2019 ytd

Referrals / M Pop

Figure 7.1-2: Tissue Referrals

LOTS AOPO Top Quartile

Tenth in the Nation in 2018

Good

INTERNAL METRIC
31

The key outcome measurement for authorization in the

OWS is organ donors (Figure 7.1-3) and organ authorization

(Figure 7.1-17), and the authorization outcome measure in the

TWS is tissue donors (Figure 7.1-4). Organ donor numbers

remain high. Tissue donor numbers have remained steady over

the last three years, meeting the industry comparative.

The last key process of both work systems is procurement,

which is measured by local organs transplanted in the OWS

(Figure 7.1-5). In the TWS, the measures are Age-Targeted

Bone Donors Released (Figure 7.1-6) and Skin Donors

Released (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.

Age-targeted bone donors released show a favorable trend;

skin donors released, a more recently added metric, exceeds the

internal target for 2018 and shows a beneficial trend.

The two work systems include two service lines that are

segmented into two customer groups: local organ transplant

centers and tissue processors (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

transplanted per million (Figures 7.1-8, 7.1-9, 7.1-10, 7.1-11,

0

25

50

2016 2017 2018 2019 ytd

Donors / M Pop

Figure 7.1-3: Local Organ Donors by 

Population

LOTS OPTN Top Quartile

Good

Increasing Lives Saved

0

250

500

2016 2017 2018 2019 ytd

Tissue Donors / M Pop

Figure 7.1-4: Total Tissue Donors by 

Population

LOTS AOPO Top Quartile

Good

Tissue Donors Remain Steady

0

75

150

2016 2017 2018 2019 ytd

Organs TXP/M Pop

Figure 7.1-5: Local Organs Transplanted by 

Population

LOTS OPTN Top Quartile

Good

Near Top Quartile in 2018

0

450

900

Bone Donors Released

2016 2017 2018 2019 ytd

Figure 7.1-6: Age-Targeted Bone Donors 

Released

LOTS Allograft Resources Best in Class

Good

Increasing Bone Donors Released

0

450

900

2016 2017 2018 2019 ytd

Skin Donors Released

Figure 7.1-7: Skin Donors Released

LOTS Internal Target

Meeting Internal Release Quotas

Good

0

10

20

2016 2017 2018 2019 ytd

Hearts TXP/M Pop

Figure 7.1-8: Local Hearts Transplanted

LOTS OPTN Top Quartile

Near Top-Quartile Performance

Good
32

0

25

50

2016 2017 2018 2019 ytd

Lungs TXP/M Pop

Figure 7.1-9: Local Lungs Transplanted

LOTS OPTN Top Quartile

Strong Performance Continues

Good

0

25

50

2016 2017 2018 2019 ytd

Livers TXP/M Pop

Figure 7.1-10: Local Livers Transplanted

LOTS OPTN Top Quartile

Near Top-Quartile Performance

Good

0

7

14

2016 2017 2018 2019 ytd

Pancreata TXP/M Pop

Figure 7.1-12: Local Pancreata Transplanted

LOTS OPTN Top Quartile

Near Top-Quartile Performance

Good

0

45

90

2016 2017 2018 2019 ytd

Kidneys TXP/M Pop

Figure 7.1-11: Local Kidneys Transplanted

LOTS OPTN Top Quartile

Steady Achievement

Good

0

800

1,600

2016 2017 2018 2019 ytd

Donors

Figure 7.1-13: Total Bone Donors

LOTS AOPO Top Quartile

Suitability Impacts PerformanceGood

0

750

1,500

2016 2017 2018 2019 ytd

Donors

Figure 7.1-14: Total Skin Donors

LOTS AOPO Top Quartile

Meeting Processor Needs

Good

and 7.1-12). 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 2018.

Livers transplanted per million remains steady, nearing the

top quartile. Kidneys transplanted 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 (Figure 7.1-13) and

skin donors (Figure 7.1-14). Bone and skin donor numbers

have been impacted by the opioid epidemic, resulting in

decreased suitability, and processor limits have also resulted in

decreases.
33

7.1b Work Process Effectiveness Results

7.1b(1) LOTS’s key process effectiveness and efficiency

results are noted in Figure 6.1-2 as “in-process measures.”

The relationship management efficiency and effectiveness

results for OWS are missed organ referrals (Figure 7.1-15).

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 7.1-16). Hospital

Services staff have worked closely with hospital partners

to transition the Tissue Authorization Process to the LOTS

Communication Center department. In 2018, LOTS performed

the approach for tissue authorization at 99% of the hospitals,

an increase of nearly 8% in the last three years.

The authorization in-process measure for OWS is the organ

authorization rate (Figure 7.1-17), 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 6.1-2. 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

expected results with lungs (Figure 7.1-19A). Donor Management Protocol Compliance (Figure 7.1-20) continues to show

100% compliance and represents the ability of the clinical

organ staff to manage donors effectively. Organ Donor Cases

0%

2%

4%

2016 2017 2018 2019 ytd

Missed Referrals

Figure 7.1-15: Missed Organ Referrals

LOTS Hospital Partners

Allograft Resources Best in Class

Good

Relationship Management Results

0%

50%

100%

2016 2017 2018 2019 ytd

Figure 7.1-17: Organ Authorization

LOTS OPTN Top Quartile

Top-Quartile Performance

Good

0%

50%

100%

2016 2017 2018 2019 ytd

Figure 7.1-18: Tissue Authorization

LOTS AOPO Top Quartile

Top-Quartile Performance

Good

0.00

2.00

4.00

2016 2017 2018 2019 ytd

Organs TXP/Donor

Figure 7.1-19: Organ Donor Yield

LOTS OPTN Top Quartile

APs in Place to Drive Yield

Good
34

0.00

1.00

2.00

2016 2017 2018 2019 ytd

Observed : Expected

Figure 7.1-19A: Observed vs Expected 

by Organ

Kidneys Heart Liver

Lungs Pancreas Expected

APs in Place to Drive Yield

Good

0%

50%

100%

2016 2017 2018 2019 ytd

Rate

Figure 7.1-20: Donor Management Protocol 

Compliance

LOTS Internal Target

INTERNAL METRIC

Process Compliance Ensures High Results

Good

0%

50%

100%

% Eligible Cases In

2016 2017 2018 2019 ytd

-House

Figure 7.1-21: Organ Donor Cases In-House

LOTS AOPO Top Quartile

Growing In-House Cases

Good

0%

50%

100%

2016 2017 2018 2019

Bone w/No Growth

Figure 7.1-22: Bone No-Growth Rates

LOTS Allograft Resources Best in Class

Meeting Customer Requirements

Good

0

3,000

6,000

2016 2017 2018 2019 ytd

Avg. Skin Yield (cm2) Figure 7.1-23: Skin Yield

LOTS Allograft Resources Best in Class

APs in Place to Drive Results

Good

0:00

4:48

9:36

14:24

19:12

2018 2019 ytd

Time (hh:mm)

Figure 7.1-24: Laboratory Turnaround Time by 

Work System

LOTs Organ LOTs Tissue

Internal Benchmark Organ Internal Benchmark Tissue

Turnaround time Ensuring Safe Organs and Tissues

Good

In-House (Figure 7.1-21) is the practice responsible for creating significant cost savings and customer satisfaction. This

is a partner/customer satisfier for the donor hospitals and the

transplant centers. LOTS outperforms the external benchmark

comparisons with organizational high outcomes for 2019.

The TWS procurement in-process measures include bone

no-growth and skin yield. LOTS met the Allograft Resources

partner benchmark for Bone No-Growth Rates (Figure 7.1-22).

Skin Yield (Figure 7.1-23) shows favorable trends; APs were

developed to address benchmark performance gaps.

The key organizational performance indicators for key support

processes are shown in Figure 7.1-27 through Figure 7.1-33.

Laboratory testing turnaround time (Figure 7.1-24) has seen

steady performance, with LOTS meeting its internal benchmark. Chart Release Cycle Time—Organ (Figure 7.1-25) has

seen steady performance in the number of days needed for

organ charts to be reviewed and uploaded to meet regulatory

requirements. Chart Release Cycle Time—Tissue (Figure 7.1-26)

reflects a critical step in the TWS Process during which charts

are completed, quality checked, and released to the processors,
35

0%

50%

100%

2016 2017 2018 2019 ytd

% Completed on Time

Figure 7.1-25: Chart Release Cycle Time—

Organ

LOTS UNOS/OPTN

Steady Performance

Good

0

25

50

2016 2017 2018 2019 ytd

Days to Clear

Figure 7.1-26: Chart Release Cycle Time—

Tissue

LOTS Allograft Resources Requirement

Releasing More Charts in Less Time

Good

fulfilling a tissue processor requirement and triggering

reimbursement to LOTS. The tissue chart cycle time is meeting or exceeding the Allograft Resources partner requirement.

Sterilizer Accuracy (Figure 7.1-27) shows the documentation

compliance that impacts clinical equipment availability. IT

management (Figure 7.1-28) continuously shows the ability of

the IT department to have server availability 24/7 in order to

support business operations. As seen in Figure 7.1-29, process

improvement is an indicator of PI utilization across the

company and shows consistent use over the last three years.

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

LOTS’s accreditation results in voluntary and required

certifications, meeting or exceeding FDA, UNOS, AOPO, and

AATB requirements.

7.1b(2) Emergency preparedness actions taken to minimize

interruptions in the delivery of LOTS’s services are AOS.

0%

50%

100%

2016 2017 2018 2019 ytd

Accuracy

Figure 7.1-27: Sterilizer Accuracy

LOTS Internal Target

Consistently High Accuracy

Good

0%

50%

100%

2016 2017 2018 2019 ytd

Uptime

Figure 7.1-28: Server Uptime

LOTS Internal Target

Continuous Availability

Good

0

200

2017 2018 2019 ytd

Ticket Requests

Figure 7.1-29: PI Help Desk Tickets

Scorecard / Report Data Mining

Procedure or Process Enhancement Survey

Committed to Improvement 

7.1c Supply-Network Management Results

Supply Optimization (Figure 7.1-30) via an electronic inventory system has resulted in 97% availability for supplies for

all in-house cases. Wright Brothers Charters, a key supplier,

provides air service logistics for donation activity outside

of the Columbia, NT, metropolitan area. Wright Brothers

provides 24/7 access to aircraft with a 90-minute launch

requirement, and as demonstrated in Figure 7.1-31, delays

due to provider issues occurred in less than 5% of the 260-plus
36

0%

50%

100%

2016 2017 2018 2019 ytd

Availability

Figure 7.1-30: Supply Optimization

LOTS Internal Target

Strong Compliance

Good

0%

50%

100%

2013 2016 2017 2018

% of Total Legs Delayed

Figure 7.1-31: Wright Brothers Delays

LOTS Wright Brothers

Good

Few Delays Attributed to Vendor

0:00

1:00

2:00

2016 2017 2018 2019 ytd

Time (h:mm)

Figure 7.1-32: Guardian Cycle Time

LOTS Requirement Guardian

Good

Meeting Our Requirements

0.00

1.50

3.00

2016 2017 2018 2019 ytd

Time (Hours)

Figure 7.1-33: Columbia Cremation Cycle Time

LOTS Requirement Columbia CremationGood

Improvement Efforts Drive Compliance

0%

20%

40%

0

40

80

2016 2017 2018 2019 ytd

Defects

Features Published

Figure 7.1-34: Transplant Technologies 

Change Requests

Features Published Defects 

Major EMR Enhancements Released in 2018

Good

0

50

100

2017 2018 2019 YTD

Avg # Tickets

Figure 7.1-35: IT Help Desk Tickets in Queue

IT Helpdesk Queue

Good

Significant Reduction in Helpdesk Tickets

launches annually. Guardian Ambulance exceeds requirements

100% of the time (Figure 7.1-32). Columbia Cremation,

another key supplier, has seen improvements since 2016,

exceeding delivery time requirements in 2018 (Figure 7.1-33).

Transplant Technologies, a key supplier, has seen increasing

numbers of major releases with complex features in 2018 that

exposes more opportunities for defects. Transplant Technologies continues to work with LOTS to resolve opportunities in a

timely manner (Figure 7.1-34). Titan Technologies, a recently

added key supplier, has managed to reduce the number of open

IT Help Desk Tickets in Queue (Figure 7.1-35).
37

7.2 Customer Results

7.2a Customer-Focused Results

7.2a(1) As the federally designated OPO within its service

area, LOTS does not have organ procurement competitors.

Regardless, maximizing customer satisfaction and engagement is an organizational goal, and LOTS works closely with

its customer groups to meet and exceed their requirements.

Customer satisfaction data are gathered through the VOC

methods as listed in Figure 3.1-1, including the Customer

Survey Process (AOS), which has undergone multiple cycles

of learning and strategic improvement. (Key measures include

overall satisfaction, and segmentation by customer group and

service line are AOS.)

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 three 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 7.1-5). Organ transplant center

satisfaction can be segmented by position, which includes

Transplant Physician, Coordinator, and Administrator

(Figure 7.2-1C), and shows strong results for 2018 in all

three segments.

0.0

2.5

5.0

2017 2018 2019 ytd

Satisfaction

Figure 7.2-1C: Transplant Center 

Satisfaction—Organ

Administrator Coordinator Physician

Good

Overall Satisfaction
38

Satisfaction levels among LOTS’s tissue processors

(Figure 7.2-2) are critical to ensuring organizational success.

Overall satisfaction demonstrates near high performance. Customer satisfaction meeting the first key requirement “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 7.1-4). Tissue processor satisfaction can be

segmented by individual processor (Figure 7.2-2D). Satisfaction by processor has remained strong; 2019 year-to-date

results show beneficial trends for all processors. APs are in

place for 2019 that target specific areas for focus to continue

exceptional results. Full segmented results by customer and

service line are AOS.

0%

50%

100%

0.0

2.5

5.0

2016 2017 2018 2019

Engagement

Overall Satisfaction (All TPs)

Figure 7.2-2: Tissue Processor Satisfaction

Overall Satisfaction (All TPs)

Allograft Resources Partner (Satisfaction)

%Top Box (Engagement)

High Levels of Overall Satisfaction

Good

0%

50%

100%

2016 2017 2018 2019 ytd

Accuracy

Figure 7.2-2A: Vein Accuracy Rates

Saphenous Vein

Femoral Vein

CardioSolutions Saphenous Vein

CardioSolutions Femoral Vein

Key Requirement: Accountability

Good

0%

50%

100%

2016 2017 2018 2019 ytd

Accuracy

Figure 7.2-2B: Heart Valve Accuracy Rates

LOTS CardioSolutions Top Quartile

Key Requirement: Accountability

Good

0%

50%

100%

0.0

2.5

5.0

2016 2017 2018

Engagement

Satisfaction

Figure 7.2-2C: Tissue Processor Satisfaction

Satisfaction %Top Box (Engagement)

Key Requirement: Information

Good

0.0

2.5

5.0

2016 2017

Satisfaction

Figure 7.2-2D: Tissue Processor Satisfaction

Allograft Resources CardioSolutions Regeneration Associates

Increasing Overall Satisfaction

Good
39

To determine dissatisfaction levels with local organ transplant

centers and tissue processors, 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 7.2-3). The

implementation of a formalized CAPA system provides standardization 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 and tissue are at or near 0%, with

both maintaining low trends since 2016 (Figures 7.2-3A and

7.2-3B).

0%

5%

10%

2016 2017 2018 2019 ytd

Complaints / Cases

Figure 7.2-3: Customer Complaints

Organ Tissue

Systematic Process Drives improvements

Good

0%

5%

10%

2016 2017 2018 2019

Dissatisfaction

Figure 7.2-3A: Customer Dissatisfaction—

Organ

Dissatisfaction

Good

Scored as "Poor" or "Very Poor"

0%

5%

10%

2016 2017 2018 2019 ytd

Dissatisfaction

Figure 7.2-3B: Customer Dissatisfaction—

Tissue

Dissatisfaction

Good

Scored as "Poor" or "Very Poor"

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. This methodology is based upon The Loyalty Effect 

(Fred Reichheld), which theorizes that relationship strength

is directly related to customer loyalty and engagement (3.2).

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 7.2-4).

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.

0

10

20

2016 2017 2018 2019

Active Customers

Figure 7.2-4: Customer Loyalty

Organ Tissue

Sustaining Customer Relationships

Good
40

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

5.1-2 and 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 outcomebased 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 three years as services have expanded.
41

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

security, as well as employer-provided services and benefits,

are monitored continuously to ensure effectiveness.

In an effort to exhibit concern and care for the 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 7.3-5). LOTS takes great

care in ensuring that all employees are trained upon hire and

annually thereafter on proper procedures and safety protocols

in each position and department. Workplace Preparedness

(Figure 7.3-6) demonstrates multiple efforts deployed to

ensure the safety of the workforce. 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 7.3-7).

Radiation Exposure (Figure 7.3-8) rates are used to assess

the amount of radiation organ clinical staff members are

exposed to when utilizing imaging equipment. LOTS policies

and procedures ensure that employees are safe from radiation

exposure.

Multiple security measures are in place to create the most

secure environment for the workforce (Figure 7.3-9).

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).

41

Figure 7.3-6: Workplace Preparedness

Preparations Goal 2016 2017 2018 2019 YTD

Safety	Training All	Employees 100% 100% 100% 100%

Fire	Alarm	Testing Quarterly 4 4 4 3

Aero	Charter	Safety	Training All	Aplicable	Employees 100% 100% 100% 100%

Generators	and	System	Availability	Testing Weekly 100% 100% 100% 100%

Injury	Investigation All	Injuries 100% 100% 100% 100%

Data/VOIP	(Communication)	Testing Real	Time 100% 100% 100% 100%

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	

security,	as	well	as	employer-provided	services	and	benefits,	

are	monitored	continuously	to	ensure	effectiveness.

In	an	effort	to	exhibit	concern	and	care	for	the	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 7.3-5).	LOTS	takes	great	

care	in	ensuring	that	all	employees	are	trained	upon	hire	and	

annually	thereafter	on	proper	procedures	and	safety	protocols	

in	each	position	and	department.	Workplace	Preparedness	

(Figure 7.3-6)	demonstrates	multiple	efforts	deployed	to	

ensure	the	safety	of	the	workforce.	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 7.3-7).	

Radiation	Exposure	(Figure 7.3-8)	rates	are	used	to	assess	

the	amount	of	radiation	organ	clinical	staff	members	are	

exposed	to	when	utilizing	imaging	equipment.	LOTS	policies	

and	procedures	ensure	that	employees	are	safe	from	radiation	

exposure.	

Multiple	security	measures	are	in	place	to	create	the	most	

secure	environment	for	the	workforce	(Figure 7.3-9).

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).	
42

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	top-quartile	performance	(Figure 7.3-11).	Results	

in	the	Excel	Employee	Engagement	survey	assessing	the	

organization’s	overall	engagement	exceed	the	health	topquartile	benchmark.	In	addition,	segmentation	by	work	system	

demonstrates	strong	engagement	scores	in	both	the	tissue	and	

organ	work	systems	(Figure 7.3-12A).

LOTS	continues	to	have	consistent	organizational	retention;	

departmental	APs	are	in	place	for	2018	to	address	opportunities	(Figure 7.3-13).	Over	the	last	several	years,	LOTS	has	

focused	on	ensuring	workforce	satisfaction.	Overall	workforce	

satisfaction	survey	results	show	a	sustained	trend	and	favorable	comparison	to	the	external	benchmark	(Figure 7.3-14).	

Overall	benefits	satisfaction	(Figure 7.3-15)	shows	strong	

results,	equal	to	the	health	care	industry	top	quartile.	

Figure 7.3-9: 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

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).

Results in the Excel Employee Engagement survey assessing

the organization’s overall engagement exceed the health topquartile benchmark. In addition, segmentation by work system

demonstrates strong engagement scores in both the tissue and

organ work systems (Figure 7.3-12A).

LOTS continues to have consistent organizational retention;

departmental APs are in place for 2018 to address opportunities (Figure 7.3-13). Over the last several years, LOTS has

focused on ensuring workforce satisfaction. Overall workforce

satisfaction survey results show a sustained trend and favorable comparison to the external benchmark (Figure 7.3-14).

Overall benefits satisfaction (Figure 7.3-15) shows strong

results, equal to the health care industry top quartile.
43

7.3a(4) LOTS supports the training and development of the

entire workforce, as seen in Overall Training and Development Satisfaction (Figure 7.3-16) and LOTS’s financial

investment in training expenditures per full-time equivalent

(FTE; Figure 7.3-17). LOTS also measures levels and trends

in leader development through the annual workforce survey.

Figure 7.3-18 shows leader results indicating satisfaction with

employer-sponsored training and development meeting the

industry top quartile.
44

7.4 Leadership and Governance Results

7.4a Leadership, Governance, and Societal 

Contribution Results

7.4a(1) Leader Communication (Figure 7.4-1) reflects senior

leader communication with the workforce. Communication

has remained steady, and there are multiple APs in place in

2019 to continue to drive performance to exceed top-quartile

benchmarks.

7.4a(2) LOTS Board Self-Assessment (Figure 7.4-2)

compares favorably to the benchmark. Full survey data and

resultant actions are AOS.

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 established as a best practice in governance to expand

fiscal accountability. External financial audits sanctioned by

this committee have always achieved the highest rating of

“unqualified” opinion (Figure 7.4-4).

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 7.4-3).

44

Figure 7.4-3: Regulatory & Legal Compliance Key Measures

Measures & Indicators Results

AATB	Accreditation	(3	years) Full	Accreditation

AOPO	Accreditation	(3years) Full	Accreditation

CMS	Certification	(4	years) Full	Certification

DHSS	(3	years) Full	Compliance

DOR No	Adverse	Findings

EEOC 0	Issues

FDA	Approval No	Adverse	Findings

FLSA 0	Issues

IRS	Compliance 0	Issues

OSHA Full	Compliance

UNOS/OPTN	(3	years) Member	in	Good	Standing

Unblemished	Performance

Figure 7.4-4: External Financial Audit

Year External Auditor Determination

2013 Brother,	Sister,	&	Auditor Unqualified	Opinion

2014 Brother,	Sister,	&	Auditor Unqualified	Opinion

2015 Brother,	Sister,	&	Auditor Unqualified	Opinion

2016 Brother,	Sister,	&	Auditor Unqualified	Opinion

2017 Brother,	Sister,	&	Auditor Unqualified	Opinion

Excellent	Fiscal	Accountability

7.4 Leadership and Governance Results

7.4a Leadership, Governance, and Societal 

Contribution Results

7.4a(1) Leader	Communication	(Figure 7.4-1)	reflects	senior	

leader	communication	with	the	workforce.	Communication	

has	remained	steady,	and	there	are	multiple	APs	in	place	in	

2019	to	continue	to	drive	performance	to	exceed	top-quartile	

benchmarks.

7.4a(2) LOTS	Board	Self-Assessment	(Figure 7.4-2)	

compares	favorably	to	the	benchmark.	Full	survey	data	and	

resultant	actions	are	AOS.

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	established	as	a	best	practice	in	governance	to	expand	

fiscal	accountability.	External	financial	audits	sanctioned	by	

this	committee	have	always	achieved	the	highest	rating	of	

“unqualified”	opinion	(Figure 7.4-4).	

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 7.4-3).	

44

Figure 7.4-3: Regulatory & Legal Compliance Key Measures

Measures & Indicators Results

AATB	Accreditation	(3	years) Full	Accreditation

AOPO	Accreditation	(3years) Full	Accreditation

CMS	Certification	(4	years) Full	Certification

DHSS	(3	years) Full	Compliance

DOR No	Adverse	Findings

EEOC 0	Issues

FDA	Approval No	Adverse	Findings

FLSA 0	Issues

IRS	Compliance 0	Issues

OSHA Full	Compliance

UNOS/OPTN	(3	years) Member	in	Good	Standing

Unblemished	Performance

Figure 7.4-4: External Financial Audit

Year External Auditor Determination

2013 Brother,	Sister,	&	Auditor Unqualified	Opinion

2014 Brother,	Sister,	&	Auditor Unqualified	Opinion

2015 Brother,	Sister,	&	Auditor Unqualified	Opinion

2016 Brother,	Sister,	&	Auditor Unqualified	Opinion

2017 Brother,	Sister,	&	Auditor Unqualified	Opinion

Excellent	Fiscal	Accountability

7.4 Leadership and Governance Results

7.4a Leadership, Governance, and Societal 

Contribution Results

7.4a(1) Leader	Communication	(Figure 7.4-1)	reflects	senior	

leader	communication	with	the	workforce.	Communication	

has	remained	steady,	and	there	are	multiple	APs	in	place	in	

2019	to	continue	to	drive	performance	to	exceed	top-quartile	

benchmarks.

7.4a(2) LOTS	Board	Self-Assessment	(Figure 7.4-2)	

compares	favorably	to	the	benchmark.	Full	survey	data	and	

resultant	actions	are	AOS.

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	established	as	a	best	practice	in	governance	to	expand	

fiscal	accountability.	External	financial	audits	sanctioned	by	

this	committee	have	always	achieved	the	highest	rating	of	

“unqualified”	opinion	(Figure 7.4-4).	

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 7.4-3).	
45

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.

Ethical behavior is ensured by providing annual CCP training

to all employees. Currently, 100% of the workforce and board

is CCP-trained. Limited corporate compliance issues are noted

in Report of Corporate Compliance Hotline Issues (Figure 7.4-6),

which illustrates program effectiveness.

Stakeholder (BOD) requirements show a high level of satisfaction (Figure 7.4-5) 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 (Figure 7.4-7).

45

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.	

Ethical	behavior	is	ensured	by	providing	annual	CCP	training	

to	all	employees.	Currently,	100%	of	the	workforce	and	board	

is	CCP-trained.	Limited	corporate	compliance	issues	are	noted	

in	Report	of	Corporate	Compliance	Hotline	Issues	(Figure 7.4-6),

which	illustrates	program	effectiveness.	

Stakeholder	(BOD)	requirements	show	a	high	level	of	satisfaction	(Figure 7.4-5)	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	(Figure 7.4-7).	

Figure 7.4-6: Reported Corporate Compliance 

Hotline Issues

Year Results

2014 0	Complaints	Reported

2015 0	Complaints	Reported

2016 1	Complaint	Reported

2017 1	Complaint	Reported

2018 1	Complaint	Reported

2019	YTD 4	Complaints	Reported

Commitment	to	Integrity

Good

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 7.4-8).

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 7.4-8).
46

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. LOTS also uses budgets to

optimize outcomes and continue being a leader in the industry.

Consolidated Results of Operations (Figure 7.5-1) demonstrates that LOTS is in a strong position with good performance levels compared to budget, with 2018 organizational

results of $3.36 million. LOTS demonstrates favorable financial 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 7.5-9). These results reflect

LOTS’s identified strategic advantage of possessing a strong

financial position and support organizational sustainability.
47

Operating Reserves (Figure 7.5-8) includes cash, investments,

and accounts receivable. The amount of operating reserves is

set by BOD policy and allows LOTS to ensure mission attainment 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-inclass results. LOTS’s strong financial and operating returns

demonstrate viability and continue to improve over time.

Overall financial performance measurements are similar,

exceeding industry comparisons, and perform well against the

budgetary plan.
48

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. Tissue activity levels remain strong.

Market Share Growth (Figure 7.5-13) shows LOTS’s contribution to the total Tissue Transformations tissue volume.
49

7.5b Strategy Implementation Results

Results for accomplishing the organizational APs are found

in Figure 7.4-9. APs are put in place each year at LOTS, and

success in accomplishing those APs is mission-critical in

achieving the SOs.

The key metrics for strategy achievement of the mission

include Deaths on Local Waiting List (Figure 7.4-8) and organ

and tissue donors by population (Figures 7.1-3 and 7.1-4).

Results for building and strengthening the CC of missiondriven workforce are given in Overall Workforce Engagement

(Figures 7.3-12 and 7.3-12A).
The ratio of the Baldrige Program’s benefits 

for the U.S. economy to its costs is estimated

at 820 to 1.

110 Baldrige Award winners serve as national 

role models.

2010–2018 award applicants represent 

641,693 jobs, 

3,072 work sites, over $166 billion in 

revenue/budgets, and about 451 million 

customers served.

352 Baldrige examiners volunteered 

roughly $7.9 million in 

services in 2018.

State Baldrige-based examiners 

volunteered around $29 million in

services in 2017.

What People Are Saying

I have always envisioned 

Stellar to be a company that 

is built to last. . . . And if you ask 

how we can ensure that we are 

built to last, I would say the 

answer is Baldrige.

Celeste Ford

CEO and Founder

Stellar Solutions

Palo Alto, CA

Baldrige Award recipient

We believe that government 

can be great. We believe that 

local government can be great. 

And we believe that the 

Baldrige framework is ideally 

suited to help local government 

go from here to here

[low to high].