Compliance Guide

For

Hospital Joint Commission, CMS or Department of Health Surveys

Self Assessment Checklist

Standard/Guideline / Yes / No / Partial / Example of Compliance / Action Needed / Completion Date
Written agreement with appropriate organ procurement organization (OPO); must include the following :
  • Criteria for referral, including the referral of all individuals whose death is imminent or who have died in the hospital;

  • Definition of “imminent death”;

  • Definition of “clinical trigger” (clinical trigger is developed jointly with hospital staff and OPO);

  • Definition of “timely notification” (ideally within one hour of clinical trigger);

  • Referral will occur prior to the withdrawal of any life-sustaining therapies including medical or pharmacological support;

  • Addresses the OPO’s responsibility to determine medical suitability for organ donation;

  • Specifies how the tissue and/or eye bank will be notified about potential donors;

  • Ensures that the designated requestor training program offered by the OPO has been developed in cooperation with the tissue and eye banks designated by the hospital;

  • Permits the OPO, tissue bank and eye bank access to the hospital’s death record information according to a designated schedule;

  • Includes that the hospital is not required to perform credentialing reviews for, or grant privileges to, members of organ recovery teams as long as the OPO sends only “qualified, trained individuals” to perform organ recovery;

  • Interventions the hospital will utilize to maintain potential organ donor patients so that the patient organs remain viable;

  • Did the hospital governing body approve the hospital’s organ procurement policies?

  • Is hospital staff aware of the hospital’s policies and procedures for organ, tissue and eye procurement?

  • Are the organ, tissue and eye donation programs integrated into the hospital’s QAPI program?

Written agreement with at least one tissue bank and at least one eye bank to cooperate in the retrieval, processing, preservation, storage and distribution of tissues and eyes.
Procedures, developed in collaboration with the OPO, for notifying the family of each potential donor of the options to donate organs, tissues, or eyes, including the option to decline to donate.
  • Does the hospital have QAPI mechanisms in place to ensure that the families of all potential donors are informed of their options to donate?

The individual designated by the hospital to initiate the request to the family must be an organ procurement representative or a trained designated requestor.
  • How does the hospital ensure that only OPO, tissue bank, or eye bank staff or trained designated requestors are approaching families about donation?

  • Written documentation by the organization’s designated requestor indicates that the patient or family accepts or declines the opportunity for the patient to become an organ or tissue donor.

  • Training schedules and personnel files are accessible to verify that all designated requestors have completed the required training.

Staff education includes training in the use of discretion and sensitivity to the circumstances, beliefs, and desires of the families of potential donors.
  • Does the designated requestor training program address the use of discretion?

  • Does the hospital complaint file contain any relevant complaints?

Ensure that the hospital works cooperatively with the designated OPO, tissue bank and eye bank to educate staff on donation issues.
  • Training should be conducted with new employees, annually, whenever there are policy/procedure changes, or when problems are determined through the hospital’s QAPI program.

  • Are in-service training schedules and attendance sheets accessible?

  • How does the hospital ensure that all appropriate staff has attended education regarding donation and how to work with the donation agencies?

Review death records to improve identification of potential donors.
  • Determine by review of policies and records that the hospital works with the donation agencies in reviewing death records.

  • Verify that the effectiveness of record reviews is monitored as part of the hospital’s QAPI program.

Ensure that the necessary testing and placement of potential donated organs, tissue and eyes takes place, in order to maximize the viability of donor organs for transplant and maintain potential donors while preliminary suitability is determined.
  • Review hospital brain death policy to ensure brain death is declared within an acceptable time frame by an appropriate practitioner.

  • Develop a donation policy that addresses opportunities for asystolic recovery (donation after cardiac death, i.e. DCD), based on an organ potential for donation that is mutually agreed upon by the designated OPO, hospital, and medical staff.

If the organization performs transplants, it must be a member of the Organ Procurement and Transplantation Network (OPTN).
  • Confirm membership by contacting the CMS regional office or by calling UNOS at 1-804-330-8500.

  • One year of reports submitted to OPTN are available for review.

Create a donation friendly environment and a culture of accountability.
  • What evidence can you provide to show that donation is a mission at your hospital?

  • Does your hospital have a self-organizing OPO/hospital team or committee?

  • Are hospital leaders and medical staff actively involved in problems that prevent potential donors from being converted to actual donors?

The conversion rate data are collected and analyzed and, when possible, steps are taken to improve the rate.
  • What is your hospital’s conversion rate?

  • If your hospital’s conversion rate is less than 75%, what is the plan for improvement?

  • What is your hospital’s referral rate?

  • What is your hospital’s timely notification rate?

  • What is your hospital’s appropriate requestor rate?

The organization uses standardized procedures to acquire, receive, store and issue tissues.
  • Who is responsible for overseeing the tissue program throughout the organization including storage and issuance activity?

The organization’s records permit tracing of any tissue from the donor or source facility to all recipients or other final disposition.
The organization has a defined process to investigate adverse events to tissue or donor infections.

October 2010

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