The Alliance Executive

Insight Series

The executive insight series is designed for healthcare senior executives. These brief, bi-annual issues focus on topics relevant to top-tier hospital leadership. For each topic, you can find related references, resources, and tools.

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Hospital Directional Sign Intensive Care Unit

There are numerous federal regulations impacting hospital deaths and how hospitals must work with organ procurement
organizations (OPOs). Most of these regulations exist within the “Conditions of Participation for Hospitals Regarding Organ,
Tissue and Eye Donation.”

Organ Donation: CMS Essentials

There are numerous federal regulations impacting hospital deaths and how hospitals must work with organ procurement organizations (OPOs). Most of these regulations exist within the “Conditions of Participation for Hospitals Regarding Organ, Tissue and Eye Donation.” First published in 1998, current regulations make hospitals accountable to CMS for their donation programs in an effort to increase the number of organs and tissue available for transplantation. To meet regulatory compliance, the hospital must have a written agreement with their designated OPO. This agreement is typically called a Memorandum of Agreement (MOA) and must address the following:

1. Policy

Hospitals must have and implement written policies and procedures to address its donation responsibilities.

2. Referral Criteria

Hospitals must refer every death and every imminent death.

3. Imminent Death

“Imminent Death” refers to all patients with a severe, acute brain injury who:

  • Require ventilator support,
  • Are in an ICU or ED,
    • AND have a Glasgow Coma Score (GCS) of 5 or less,
    • OR are being evaluated for brain death,
    • OR a MD or DO has ordered life-sustaining therapies be withdrawn.

4. Timely Notification

Hospitals must contact their designated OPO as soon as possible (ideally within one hour) after a patient has died, has been placed on a ventilator due to a severe brain injury as outlined in Imminent Death, or has been declared brain dead, AND prior to the withdrawal of any life sustaining therapies (medical or pharmacological).

5. Medical Suitability

The OPO has the responsibility to determine medical suitability for organ donation. In the absence of a separate tissue or eye bank agreement with the hospital, the OP

6. Death Records

Hospitals must develop policies that allow the OPO, tissue bank and eye bank to have timely access to death records to ensure all deaths are being referred, and to improve identification of potential donors.

7. Credentialing Hospitals

Hospitals are not required to perform credentialing reviews of organ recovery teams, as long as the OPO sends only “qualified, trained individuals” to perform recoveries.


Hospitals must have policies to maintain potential donors in a manner that preserves organ viability, and donors are identified and declared dead by an appropriate practitioner.

9. Donation Requests

Hospitals and OPOs work collaboratively to decide who will initiate the request for donation. Any person who makes requests for organ, tissue and eye donation must be a designated requestor or formally trained in the donation request process


Leading the Charge

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A Special Thanks to This Series’ Contributors

DD6A2041 JD Edited
About the Editor |
Corey Bryant

Corey Bryant leads The Alliance’s communications, marketing and strategic efforts for unique national events, programming, partnerships and business development. With extensive corporate and non-profit experience, Corey has served in communications and public relations roles for Disney Parks and Resorts, Disney Cruise Line and TransLife (now OurLegacy), the OPO serving East Central Florida. He has also been an active board member of Donate Life Florida, having served as state team leader for Driver License Outreach. Corey is a proud alum of The University of Alabama and serves on the board of directors for Come Out With Pride Orlando as well as Five Horizons Health Services, a not-for-profit organization providing access to progressive HIV testing, prevention and LGBT+ focused healthcare throughout West Alabama and East Mississippi.

Deanna Fenton
About the Editor |
Deanna Fenton

Deanna is a knowledgeable and versatile professional with diverse experiences in healthcare, client relations, marketing, project management and demonstrated skills in leadership and advocacy. Prior to joining The Alliance, she worked in Hospital Development at her local OPO in the state of New Jersey where she served as the clinical liaison to a number of Level 1 Trauma & Neuroscience centers as well as community hospitals. Her personal connection as a donor family and friend fuels her passion to support her colleagues across the donation-transplantation continuum through the development of valuable educational resources that ultimately boost performance and improve outcome measures. Deanna holds a Bachelor of Arts in Psychology and a minor degree in Public Health from Montclair State University. In her spare time, Deanna enjoys visiting vineyards, spending time with her family, and traveling in hopes of visiting all seven wonders of the world.

Advancing All.

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