Organ donation’s lifesaving role in healthcare is crucial. One organ donor can save as many as eight lives, and one tissue donor can improve the lives of 75 or more people (Health Resources & Services Administration [HRSA], 2025). Currently, 107,339 men, women, and children are waiting for a life-saving transplant across the United States (Organ Procurement and Transplantation Network [OPTN], 2025).

These figures are more than statistics; they represent people waiting for a chance. Despite strong clinical teams and an established partnership with the organ procurement organization (OPO), missed opportunities were evident due to gaps in knowledge, collaboration, and timeliness. As nursing professional development (NPD) practitioners, we recognized the opportunity to close these gaps through interprofessional education and collaboration.

This article describes how our team launched a quality improvement initiative, engaged key partners, and achieved measurable outcomes. The project demonstrates the critical role NPD practitioners play in closing practice gaps and advancing outcomes through interprofessional partnership. This initiative exemplifies NPD roles as leader and change agent, emphasizing the NPD Standards of Collaboration, Education, and Scholarly Inquiry (Harper & Maloney, 2022).

Standards 1 and 2: Assessment and Diagnosis

Recognizing and Defining the Need for Change: A review of organ donation metrics by the Organ Donation Action Team (ODAT) revealed the need for change, prompting the development of this initiative. Through the annual nursing needs assessment and informal staff interviews, the team identified knowledge gaps and workflow inconsistencies. Nearly 2,100 nurses across inpatient and outpatient settings participated in the needs assessment, expressing the need for enhanced education on organ donation and a dedicated course on recognizing referral triggers and conducting donation discussions. Staff reported limited exposure to referral processes, inconsistent workflows, and low confidence in applying evidence-based practices.

Conducting a Gap Analysis: A comprehensive gap analysis using performance data, peer benchmarks, and dashboard metrics confirmed these findings. Delays in referral workflows and inconsistent application of best practices were identified. Quantitative data was below CMS performance targets: 12% below goal for timely organ referrals, 10% below goal for planned donation conversations, and 3% below goal for maintaining donor rate. Monthly ODAT reviews of missed opportunities further revealed gaps in knowledge, communication, and role clarity. Interprofessional education was minimal, and collaboration across disciplines underdeveloped, creating barriers to consistent practice.

Identified Practice Gaps and Learning Needs

The analysis identified three primary opportunities for improvement:

1. Inconsistent application of referral protocols, leading to delayed or missed referrals.
2. Limited staff confidence and knowledge in identifying donor eligibility and initiating donation discussions.
3. Fragmented interprofessional communication, creating variability in donor management.

These findings underscored the need for enhanced education on recognizing clinical triggers, strengthening understanding of interprofessional roles, and integrating evidence-based practices into daily workflows through targeted education and collaboration.

Standard 3: Outcome Identification

Based on the identified gaps, the initiative defined one primary measurable outcome and several supporting strategies to guide improvement. The primary outcome focused on improving key performance metrics for timely organ referrals and donor management compliance.

Supporting Strategies

• Enhance staff knowledge and confidence in identifying clinical triggers.
• Strengthen interprofessional communication and collaboration throughout the donation process.
• Integrate evidence-based practices and standardized workflows to ensure consistency in donor management.
• Provide targeted education to reinforce best practices for referral and donation discussions.

These outcomes and strategies established a clear framework for design and evaluation, aligning with organizational priorities and NPD Standards. Recognizing these gaps positioned NPD practitioners as change agents, leading interprofessional education efforts to close practice gaps and improve outcomes.

Standard 4: Planning

Engaging Key Partners: We collaborated with hospital leaders, content experts, community organizations, and the OPO to design, implement, and evaluate the initiative. This partnership ensured representation across the donation continuum and emphasized cultural sensitivity, integration of best evidence, workflow consistency, and clear role delineation.

Designing and Implementing Education: Guided by the needs assessment, gap analysis, and interprofessional collaboration, we developed an interactive education program that followed the journey of an organ donor from referral through transplantation and aftercare. Active learning strategies, including case study analysis, discussion, gamification, interactive polling, storytelling, and demonstration, were intentionally embedded to promote engagement, reflection, and knowledge retention.

Course Development and Logistics: Launching the course required close coordination with key partners to develop content, integrate active learning, and align with best practices. Planning efforts focused on ensuring accessibility for internal staff and community professionals, expanding reach across the care continuum.

Standard 5: Implementation

Delivering the Education Program: The session began with interprofessional team building, allowing participants to share experiences with organ donation. It then progressed through the referral process using OPO-shared real-life scenarios to discuss clinical triggers, evidence-based criteria, and the importance of timely communication. Interactive polling and gamified activities reinforced key concepts.

Next, learners explored donation conversations and donor management. A donor family ambassador shared their experience of saying “yes” to donation, followed by guided discussion on compassion and cultural sensitivity. Donor management specialists reviewed donor stabilization, organ allocation, and interdisciplinary coordination using visuals and open discussion. The grass roots movement for honor guard was presented by the originator, with a video and letter from one of the first honor walk families.

The session transitioned to tissue donation and coroner collaboration, featuring a tissue recipient ambassador sharing their connection story and a coroner liaison who used case studies to illustrate multidisciplinary coordination, workflow integration, and the importance of maintaining organizational and community partnerships.

The program concluded with bringing the donation journey full circle. Family care and transplant coordinators discussed bereavement support, recipient evaluation, and post-transplant management, culminating with an organ recipient sharing their story highlighting the human connection between donor families and recipients. Visual media, including photos and videos, enhanced emotional engagement and demonstrated unity, respect, and interprofessional collaboration.

Collaboration in Action: OPO representatives and content experts co-facilitated each session, sharing practical tools and real-world examples. Participants included nurses, physicians, respiratory therapists, child-life specialists, and other interprofessional team members, reinforcing the broad impact of shared learning and collaboration across all stages of care.

Standard 6: Evaluation

Refining Through Feedback: The Plan-Do-Study-Act (PDSA) framework guided ongoing curriculum improvement. Key partners participated in each phase of review, with data informing every revision. Evaluation sources included end-of-course feedback, informal learner input, organ donation dashboard metrics, and ODAT reviews of missed referrals and identified gaps. A six-month post-course survey assessed sustained practice change, requested topic suggestions, and identified the most valuable course elements.

Over five years, the curriculum evolved based on evaluation findings and staff feedback. For example, in response to requests for stronger personal connections, additional community ambassadors were incorporated into every session. Their stories personalized the content, strengthened emotional engagement, and deepened understanding of the human impact of organ donation.

Measuring the Impact:

Improvements were evident within months of implementation and continued to progress throughout the five-year initiative.

Quantitative Outcomes

• Timely donor referrals: 7% above peer benchmark and 1% below CMS target.
• Maintained donor rate: 5% above peer benchmark and 2% above CMS target.
• Planned donation conversations: Comparable to peer benchmark but 9% below target.

Qualitative and Practice-Based Outcomes

• Staff confidence: Six-month evaluations showed greater confidence in initiating referrals and collaborating with the OPO.
• Collaboration: Strengthened interprofessional communication and teamwork.
• Referral recognition: Improved consistency in identifying and responding to donation opportunities.
• Evidence-based practice: More reliable application of donor management best practices.

The initiative fostered a culture of teamwork, shared ownership, and collaboration across departments and organizations. Long-term follow-up confirmed sustained improvement in evidence-based practice and donor management outcomes. The program gained recognition beyond the organization, inspiring local and regional partners to replicate similar education models.

Lessons Learned for NPD Practitioners

Leverage Data: Use dashboards and benchmarks to identify gaps, monitor trends, and track progress. Partnering with leadership and interprofessional colleagues ensures data are regularly reviewed, shared, and used to guide improvement.

Build Collaborative Partnerships: Engage everyone involved in the process, including nurses, physicians, leaders, chaplains, social workers, ancillary therapy, community partners, and advocates. Organizational champions can reinforce change at the bedside, while community ambassadors share powerful lived experiences. Collaboration builds shared ownership, inclusivity, and sustainable change.

Standardize Processes and Resources: Develop algorithms and EHR notifications to identify outcome related triggers. Develop clear, consistent communication pathways to ensure timely notification and transparency across teams. Provide hands-on resources and quick reference tools staff can readily use. Standardization reduces variation, builds confidence, and supports reliable, outcome-driven practice.

Make It Practical: Use learning strategies that translate directly to practice. Interactive activities, case studies, and personal stories connect concepts to real-world care, while gamification and polling deepen engagement. Practical learning boosts confidence and supports lasting behavior change.

Sustain the Momentum: Start small, adapt to feedback, and celebrate progress. Provide ongoing education, monitor metrics, celebrate successes, and evaluate missed opportunities. Continuous reinforcement helps ensure lasting improvements. Sustaining the work transforms short-term improvements into long-term impact.

Moving Forward

Focusing on interprofessional collaboration and evidence-based processes, our team created a model that improved outcomes and strengthened organizational culture. This initiative exemplifies collaboration in practice, uniting clinicians, OPO partners, and the community to advance donation practices and strengthen care. While our efforts are centered on organ donation, the same approach can be applied to any practice gap.

The path forward begins with strong foundations: conduct a needs assessment and gap analysis, engage key partners, and design purposeful education. Develop an implementation plan, collaborate across disciplines, and use data to guide ongoing refinement. These steps allow teams to translate opportunities into action, implement sustainable solutions, and achieve measurable improvements.

For NPD practitioners, this work underscores our unique role as learning facilitators, leaders, and change agents. By leading collaboration, fostering shared ownership, and supporting continuous improvement, we can transform practice gaps into growth opportunities, creating a culture where improvement is sustained and shared across the system.

Reference

Harper, M. G., & Maloney, P. (Eds.). (2022). Nursing professional development: Scope and standards of practice (4^th ed.). Association for Nursing Professional Development.