Guidance for hospital administrators

We share the same goals as your care teams, and we’re aligned with the values of your hospital, too: we want to save lives, and we want to help families find comfort and meaning in a time of loss. Below, you’ll find information and guidance on the donation process and regulatory compliance, as well as ideas on how you can promote a culture of donation in your hospital.

If you find you have more questions that aren’t answered here, contact our Hospital Development team.

Click on the topics below to expand the corresponding section

Promoting a Culture of Donation

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The ideas below can help you spread a donation culture well beyond the ICU. For more ideas, or to share what has worked at your hospital, contact our Hospital Development team.

      • Public Relations
        • Connect your hospital marketing team to ours
        • Include a link to LifeCenter Northwest on your website
        • Raise a Donate Life flag at your hospital
        • Feature donation stories in your hospital newsletter, website, and on social media sites
        • Participate in Donate Life Campaigns such as National Donate Life Month and Blue & Green Day each April, National Minority Donor Awareness Month in August
        • Place registry brochures in key areas to inspire employees, colleagues, and the public to learn more about donation (a variety of languages available)
        • Collaborate with us to pitch your donation stories to your local media outlets
        • Host a donation celebration at your hospital
        • Create a “Wall of Heroes” display honoring organ and tissue donors
      • Volunteer Services
        • Spearhead a volunteer group to run a “Donation Heroes Quilt” program at your hospital
        • Initiate a thank-you card project for donor families
          • Include donation registry brochures in your new employee benefits package
          • Highlight your center’s commitment to donation at new employee orientation
          • Link to donation information on your internal website
          • Honor employee connections to donation in your employee newsletter
          • Establish an employee award for excellence in donation

Compliance Checklist

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The following checklist can help you ensure that you’re in compliance before Joint Commission, Health Department, CMS, and other audits.

  • Current contract signed and on file. With LifeCenter Northwest for organ and tissue recovery, or with another tissue agency and an eye recovery organization.
  • Updated policy and procedure. To reflect referral of all deaths and imminent deaths (no age limits) to the Donor Referral Line.
  • Donor referral number easily accessible and correct. Our referral number is 888-543-3287.
  • List of referrals called to the donor referral number. We can provide this annually or upon request, contact our Hospital Development team.
  • Record of death form has a place for documentation of referral.
  • Documentation of staff education on file. All patient care staff educated on policies and procedures related to organ, tissue, and eye donation.

Rapid Process Improvement Checklist

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The checklist below outlines some ways you can improve the donation process at your hospital:

Ensure an early donor referral call every time

  1. Make sure clinical triggers are clearly visible in the ICU and ER
    • Include clinical triggers in ICU and ER orientation materials
    • Provide ongoing nursing education regarding clinical triggers
    • Provide ongoing physician education regarding clinical triggers
    • Consistently follow up and analyze each late referral
  2. Keep the option for donation viable
    • Educate physicians on the importance of preserving the patient’s donation opportunity
    • Appoint a physician champion to serve as a resource for other physicians and a communication liaison to LifeCenter Northwest
    • Include donation education in physician orientation
    • Host case reviews on clinically challenging potential donor patients
    • Ensure physicians are well trained on declaration of brain death
  3. Make certain families are supported and approached appropriately
    • Implement a team approach on every potential donor
    • Conduct timeouts with LifeCenter Northwest prior to donation approach
    • Implement a system to ensure a multidisciplinary plan prior to each donation conversation
    • Target education for the hospital care team regarding separation of the grave prognosis and the donation conversation
    • Include team-approach best practices in orientation materials for ICU and ER
    • Review process improvement when any family is approached where best practices were not followed
  4. Review quality regularly to measure improvement
    • Review compliant referral rate monthly
    • Review conversion rate monthly
    • Review effective request rate after each request
    • Review organs transplanted per donor after each organ donor

Donor Designation and the Law

Families are usually relieved to find out that their loved one has already declared their wishes with regards to donation, and that the decision has already been made. (In Washington state, for example, more than 75% of licensed drivers have already registered their wish to be a donor.) Families often feel an ethical duty to honor the expressed wishes of their loved one—since giving the gift of life to others, whatever their values or motive, may have been very important to the donor.

If a patient is not a registered donor the donation decision falls to their Legal Next of Kin (LNOK).  There is a LNOK decision making hierarchy in every state.  Please Click here for frequently asked questions regarding donation and the law, as well as the hierarchies for the states that we serve.  LifeCenter Northwest and the hospital will always follow the hierarchy outlined by the state where the hospital is located.

In some cases, families may question their loved one’s designation, and at that point state laws must be followed so that neither LifeCenter Northwest nor your hospital can be held legally responsible for not honoring the patient’s designated wishes.

Below are some of the relevant regulations, but contact our Hospital Development team if you want more information on the legal issues surrounding donation. In general, we have found that in many cases when families question their loved one’s wishes, they just needed better timing or more information. For example:

  • Donation was raised too early with the family. Giving the family time will usually help them understand.
  • Someone has set an expectation with the family that authorizing donation is a decision they need to make. Avoid language that indicates they have a decision to make.
  • Families may have misconceptions about donation. Be thorough and respectful in addressing the family’s concerns.
  • Family is surprised that their loved one didn’t tell them. Help the family understand that it is not unusual for individuals to not discuss death with their family.

Donor designation is a documented, legally binding commitment by an individual to make an anatomical gift—and just like a will or testament, it can only be revoked by that individual. Below you can find links to the Uniform Anatomical Gift Act (UAGA) for  states in our region:

Conditions of Participation for Organ and Tissue Donation

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What are the Conditions of Participation (COP)?
COP is a Centers for Medicare & Medicaid Services (CMS) regulation that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. These health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries. The COP that covers organ and tissue donation is intended to increase organ donation and save lives.

All hospitals that receive Medicare reimbursement must identify and refer all deaths and imminent deaths to the Donor Referral Line (for LifeCenter Northwest, 888-543-3287).

Key points:

The COP requires hospitals to:

  • Notify the designated Donor Referral Line of all individuals who have died or whose death is imminent. “Imminent death” is defined as a severely neurologically injured ventilator dependent patient with either a Glasgow Coma Score </=5 or with discussion about withdrawal of support
  • Ensure the family of each potential donor is informed of their option to donate by a donation agency coordinator or trained designated requestor
  • Continue to apply discretion and sensitivity with respect to circumstances, views, and beliefs of the families of potential donors
  • Have an agreement with the designated organ procurement organization and at least one tissue and eye bank
  • Maintain a cooperative working relationship with the donation agencies for:
    • education of staff on donation issues
    • review of death records to improve identification of potential donors
    • maintaining potential donors

Does this mean every family will be approached with the option of donation?
Not necessarily. All referral calls are to be placed to the Donor Referral Line prior to approaching the family to evaluate medical suitability. This process ensures that families will only be approached with the appropriate options. For example, if the patient is unable to donate, there is no need to approach the next-of-kin. If donation is an option, the donation agency will facilitate approaching the family. The referral call and outcome must be documented in the patient chart.

Does this mean that all patient deaths must be reported to the Donor Referral Line, despite age?
Yes. All deaths and imminent deaths must be referred to the Donor Referral Line despite age and medical/social history. Calls are to be placed on all ventilated patients prior to withdrawal of support to preserve the option of organ donation.