OLYMPIC PARADISE RIO DE JANEIRO

Transcription

1 DONORLAND CASE STUDY 2016 OLYMPIC PARADISE RIO DE JANEIRO Overview: The first successful organ transplantation in Brazil was performed in Rio de Janeiro, in Four years previously to this major event (1960), Federal Government was transferred from Rio to Brasilia, the brand new country s D.C., designed by two young architects, Oscar Niemeyer and Lucio Costa and based on the American Federative model, Washington D.C. At that time, health care at this beautiful and famous city was considered the best in the country and this was where people would run to whenever a serious health problem would show up. Fifty years later, however, reality has changed quite a bit. Loosing the capital status was just the beginning of a long lasting decline in economical status and, consequently, lowering of health care quality. As expected, organ and tissue transplantation activity in Rio de Janeiro has been very slow for the last few years and less than 100 organ donors were counted each year for a population close to 16 million people. The number of patients on the waiting list increase and a growing number of them started to transfer to São Paulo, a nearby state where health care and transplantation activity is considered much better and the number of effective donors is much higher. You have been named by the Health Secretary of State - the ultimate authority in health, care who reports directly to the Governor - as the new CEO of Rio de Janeiro s OPO (Riotransplante). Your mission is to recover Rio de Janeiro s status in organ and tissue transplantation, starting with an increase organ and tissue donation in the state. You ll have three months to present a strategic plan to both Health Secretary of State and the Governor, who is aware of your nomination and has promised full support. Costs? Not a problem! The State is facing a very special moment due to the investment related to the Olympic Games to be held soon. You are also free to make as many changes as you wish, transforming the whole program and creating a new name, if necessary. This is a very important assignment as the Governor will be up for reelection next year and there s no place for error. Four other professionals have assumed this position in the last four years. It is a big challenge and the Governor will understand if you run away from this but...in case you accept it, chances are you will make a big difference in many people s lives. You re expected to assume your job right

2 away. A press conference is scheduled for the next week, where your name will be announced to society. Background: Brazil is considered by many as one of the world s fastest emerging economies. According to Brazilian Federal agencies - IBGE (Instituto Brasileiro de Geografia e Estatísticas), the country is approaching 200 million population with a GDP of... (Figure 1). BRAZIL: POPULATION: 194,946,000 LIVE BIRTHTS/year: 3,129,000 DEATHS/year: 1,214,000 LIFE EXPECTANCY: 72.2 years SOURCE: IBGE, 2011 Figure 1: Brazil demographics The country is organized as a Federation, quite similar to the United States of America, with a President as the head of the Executive office, sided by a Legislative (Chamber of Deputies and Senate) and a Supreme Court (Judiciary Power).

3 Organ and tissue transplantation are regulated by Federal Legislation was since 1997, when the National Transplant Organization (Sistema Nacional de Transplantes- SNT) was created, based on the Spanish Model (Organization Nacional de Trasplantes - ONT 1 ) (Figure 2). Figure 2: Brazilian Transplant Organization (Sistema Nacional de Transpantes) All transplantation activity in the country is centrally coordinated by the SNT from Brasilia (D.C.) and is operated by regional organ procurement organizations (OPOs), named CNCDO (Central de Notificações, Distribuição e Doação de Órgãos). CNCDOs are the extension of SNT in each state, controlling all operational and regulational tasks associated to organ and tissue donation. State Transplant Coordinators (Coordenadores Estaduais de Transplantes) are the general managers (CEOs) for each CNCDO and are designated by each State Governor through its Health Secretaries of States (Secretários de Saúde). A typical CNCDO Coordinator is a medical doctor with some experience in organ transplantation with no necessary management experience. (It is, in most states, a part time job that pays the equivalent of U$2,000.00/month for a 40-hour/week shift).

4 Rio de Janeiro, Brazil Rio de Janeiro (city) is the capital of Rio de Janeiro State, one Brazil s 23 states. Rio de Janeiro has created the first organized organ and tissue donation program back in 1987, named Riotransplantes. Basically, it started as an HLA typing laboratory that, in the years 1980 s, wanted to organize organ allocation based on histocompatibiity criteria. European agencies such as Francetransplant and Eurotransplant served as models. As an attempt to improve long term results in kidney transplantation, these agencies organized patient waiting lists aiming to find the best compatible donor - according to HLA typing, cross-matching and waiting time for each deceased donor. As time went by, different organ transplantation programs were created, mostly in public hospitals. As a consequence, organ transplantation (and donation) is generally is perceived as a public activity, that should not involve costs to the patients. Every Brazilian and permanent foreign residents in the country have access to public health coverage and health care is considered as a right, according to the Brazilian Constitution. Private health insurance and hospitals, however, may operate in the country following regulations established by a Federal Agency (Agência Nacional de Saúde Suplementar. Following the recent boost in Brazilian economy, private health care coverage continues to expand its activities and up to 30% of Brazilians have some type of additional insurance nowadays. Intensive care units (ICUs) can be classified as private or public and health care professionals quite often share their activities among different hospitals. A typical Brazilian health care professional, either a nurse or medical doctor, usually have more than a job, working for one public and one private institution. Although ICUs in the country are public, there is a marked difference in terms of investments and spendings when compared to private institutions, with most investments going to the private ICUs, although they less than 30% of the country s population have access to these institutions. Rio de Janeiro OPO Riotransplantes is an OPO serving near 16 million inhabitants, covering the whole area of Rio de Janeiro state (Figure3).

5 Fig. 3: Rio de Janeiro State. Geo-demographics. SOURCE: Secretaria Estadual de Saúde - RJ Road transportation is the main connection between cities and some medical centers may be as distant as 250 miles (400 Km or a 6 hour drive) from the capital, where most transplant centers are located. Federal legislation obliges that every brain death should be referred to the OPO through a number (in Rio: ) but problems related to communication are frequent. When asked about this obligation, ICU doctors complain that quite often calls are not returned or that the telephone rings without an answer, discouraging future referrals. Most public ICUs are not equipped with EEG nor other methods that cold confirm brain death as required by federal legislation. Also, many time referrals are followed by a long time on the phone, answering numerous questions concerning patients details such as identification, history or hemodynamic status, leaving the perception that nurses or doctors on call at the OPO do not want to move to the referring hospital. Transportation is also a problem; two ambulances are available 24/7 to transport the OPO staff and surgical teams but one of them has a broken tire (estimated cost for repair: U$1,500.00) and the other presents break problems and is considered at risk for the team. Staff is composed mainly of nurses that are public employees with a fixed status (Brazilian legislation gives stability to its employees admitted through an open selection process, after a few years of work; Managers may transfer an employee to another function but cannot fire them). Nurses and medical doctors are payed the same (close to U$ for a 24-hour/week shift) and are required to do the same task: receive referrals, evaluate potential donors, perform family interviews and coordinate the

6 logistics when donation is accorded. Typically, health professionals at the OPO work 12 hours continuously and may go to sleep at home since accommodation at the OPO for a night shift are in very poor conditions. This has been denounced to local authorities that have started a judgment process that could result in a fine to the State Government. Recently, a State transplant coordinator has quite his job following suspicion that allocation criteria were no strictly followed. A judicious process is on its way and so far there is no evidence of illegal acts. Anyway, doctors are not willing to assume this role. Whenever organ donation is authorized by the family (a two-year presumed consent period in legislation was followed by a return to family consent donation due to public mistrust), it is a big challenge to find a transplant surgeon and anesthesiologists to the retrieval surgery, since these professionals are typically members of the transplant programs and are not reimbursed for the donation surgery only for the implant in case they keep the organs. Kidney transplantation is restricted to four public (three university and one federal) programs and liver transplantation is being performed in only two centers. Cornea transplantation activity approaches zero, placing the state in the last positions in the National ranking (Fig. 8) With problems accumulating, Riotransplantes has been struggling to increase the number of donors in the last few years, since a record-high 107 organ donors obtained in 2004 (Fig. 4). Projections made at the beginning of this 4 th trimester of 2009 show that this will be another difficult year and, most likely, less than 70 organ donors will be recovered by Dec. 31 st. Supporting Data: The following charts reveal some important information related to organ donation and transplantation activity in Rio de Janeiro (2009):

7 Fig. 4: Brain death referrals and effective donations in Rio de Janeiro. SOURCE: Riotransplantes.

8 Effective organ donors by state Brazil, 2009 Fig. 5: Potential donors (referrals) and affective donors according to states in Brazil, 2009 SOURCE: ABTO

9 Kidney transplantation activity in Brazil (2 Kidney transplantation activity in Brazil (2009) LIVING DONORS DECEASED DONORS Fig. 6: Kidney transplantation activity in Brazil (2009). SOURCE: ABTO Liver transplantation activity in Brazil (20 Liver transplantation activity in Brazil (2009) LIVING DONORS DECEASED DONORS Fig. 7: Liver transplantation activity in Brazil (2009). SOURCE: ABTO

10 Cornea transplantation activity in Brazil (2009) Fig. 8: Cornea transplantation activity in Brazil (2009). SOURCE: ABTO Summary of Case problem An unexpected invitation! To assume a job as a leader, facing a challenge where many have failed. Time for reflection is necessary, but not much time is available. How to increase organ and tissue donation in a place where everything seems out of order? Logistics, communication, operations and team motivation appear as the first challenges to a new appointed CEO for this large OPO. How can one manage a public program that is recognized as nonfunctional, with a bad public image? Where to start? How to manage a team if one cannot fire nor hire people? How to count on non-motivated part-timers? However, things are not completely bad. Political support, so necessary for this function, is there. At least for a few months. The governor is considered by the public as a strong leader and will recognize and fund a well established project. Seems like you definitely need to establish a strategic plan and call for action.

11 Please wait!... we re not over yet. A dramatic change in scenario has just occurred and this may directly affect your plans. The Governor was diagnosed with a severe disease and resigned, leading to a dramatic change in the whole staff that supports the government. The Secretary of State decided to retire as well and the new Secretary comes from a different medical field. He has no experience in Organ Donation or Transplantation and decides to keep you on the same position. His only concern is that the economic activity indexes show a major drop in revenues; in other words, you may cut at least 30% of your initial budget, keeping the same goals of increasing organ and tissue donation in the State of Rio de Janeiro. There is also a strong belief that the National Transplant Organization leadership will be changed soon, due to major political changes in the country (some people fear that even the president may drop from service! Too late to run away How would you plan short and long term adjustments to your project? Please list 3 to 5 major changes that could be made to increase performance and reduce the cost of organ donation activity in Rio de Janeiro. If you win this challenge, you definitely deserve a GOLD MEDAL.