AOPO Hospital Development Standards

Potential Donor Assessment


HD 1: The OPO shall have documentation of its ability to assess donor potential compliance with CMS rule regarding the performance of medical record reviews (MRR).

HD 1.1: A written methodology exists to identify the number of potential organ donors and compare the potential with the number of referred and realized donors.

HD 1.2: The written methodology in 1.1 above shall include use of a standardized review mechanism which includes documentation of: (1) hospital unit (2) date and time of referral (3) patient demographics (4) cause of death (5) outcome (e.g., medical rule-out, family refusal, donor, etc.)

Hospital Demographics


HD 2: The OPO shall document and maintain pertinent information on each hospital in its service area. Each profile includes the following information:

  • Demographic (type of facility, i.e., teaching, trauma, etc.)
  • Number of hospital beds, ICUs, and ICU bed-deaths per year
  • Referrals, potentials, timely referrals, and donors by year
  • Available services (ventilators, acute care, neuro staff)
  • Policies and procedures (organ donation, routine notification, brain death, organ donation after cardiac death, John Doe, coroner and M.E.)
  • Referral/donor patterns
  • Key contacts
  • Hospital agreements/contracts
  • Information on donation team/council, if applicable

Referral Tracking


HD 3: The OPO shall maintain a referral tracking mechanism to include:

  • Hospital
  • Unit
  • Name of referring party
  • Name of attending physician and/or service
  • Outcome referral
  • Date and time of referral
  • Timely referral

Hospital Development Plans


HD 4: The OPO shall document a plan of service in hospitals with any potential for organ donation. This plan must be evaluated annually at a minimum.

HD 4.1: Documentation of evaluation of hospital needs assessment (via survey, focus group, one-on-one meetings) must be included

HD 4.2: Documentation of individualized plan to reach selected hospital's unrealized potential.

HD 4.3: Documentation that the hospital development plan has been developed collaboratively with key hospital personnel, and shared with identified hospital leadership.

Documentation of Hospital Development Activities


HD 5: The OPO maintains documentation of activities by hospital to include, for example, the following:

  • Meetings with key contacts
  • Post-donor follow-up and assessment
  • Referral follow-up meetings
  • Professional education
  • Hospital rounds
  • Program documentation

Hospital Development Staff Training


HD 6: The OPO maintains documentation of hospital development staff orientation, on-going training and evaluation.


Statements of Affiliation


HD 7: Written statements of affiliation shall document the relationship between the OPO and at least 90 percent of the hospitals and other health care entities in its service area which have facilities for organ donation.