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The Alliance

Insight Series

The Alliance insight series offers critical resources for stakeholders across the donation and transplantation continuum. For each topic, you can find related action items, tools, and references.

February 2026
IN THIS ISSUE

  • Summary
  • Potential Barriers to Success
  • Action
  • Education
  • Identification of Contracted Services
  • Common Metrics
  • Resources
  • Contributors
  • Feedback

RESOURCE MATERIALS

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The Alliance Insight Series

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FEBRUARY 2026

TQC F2026 Event Page

CMS Conditions of Participation require transplant centers to monitor and evaluate the performance of all contracted services that may impact patient outcomes, regulatory compliance, and transplant program operations. Programs are increasingly expected, especially during CMS surveys, to demonstrate ongoing monitoring and reporting. These expectations highlight the need to standardize definitions, contractual expectations, documentation, and quality-monitoring frameworks.

  • Difficult to demonstrate true performance improvement.
  • Contracts are rarely terminated, even with poor performance.
  • Quality metrics are often missing from contracts.
  • Centers frequently must request metrics instead of receiving them proactively.
  • Reporting practices inconsistent—unclear placement in QAPI structures.
  • Tension between regulatory requirements and value-added monitoring.

TopicActions / Considerations
Identification of Contracted Services
  • Develop a clear definition of which contracted services meaningfully impact transplant outcomes.
  • Focus on general categories, not vendor-specific names.
  • Establish a process and template for documenting, storing, and managing:
    • Service lists
    • Contracts and renewal dates
    • Quality metrics
    • Risk assessments and indicators for requiring quality improvement
  • Consider use of platforms such as:
    • Contract management systems, or
    • Quality dashboards to centralize information.
  • Identify cadence for review (e.g., operations meeting).
Recommended Contract Practices
  • Ideal practice: Transplant program and quality participation in all phases of contract negotiations and ongoing review.
  • Include clear, appropriate quality metrics in every contract; alternatively, reference and subsequently develop a quality plan that can evolve.
  • Example language: Vendor will provide the Purchaser the reports and supporting information reasonably necessary to monitor service performance and confirm compliance with this Agreement, in the format and cadence requested by Purchaser. Vendor will work with Purchaser to improve performance and, if services do not meet contract requirements, will promptly investigate, provide corrective actions, and provide progress updates until the issue is resolved.
  • Where vendors cannot provide data:
    • Develop internal metrics that the center can reliably track and routinely report back to the vendor in an effort to improve involvement and understanding of service impact.
  • Standardize expectations for:
    • Quarterly/annual review
    • Documentation in quality meeting minutes
    • Escalation or performance improvement when metrics fall short
  • Active participation of vendors in RCAs/Case Review in the event of adverse or unexpected events.
Living Donor Contract Considerations
  • Ensure center-to-center agreements reflect shared quality expectations.
  • Develop partnership-driven review processes between recipient and donor hospitals.
  • Include metrics related to donor safety, communication timeliness, and sample handling.
Experience With Surveyors
Centers report that CMS surveyors increasingly request:
  • Contracts
  • Dashboards showing contract metrics
  • Minutes demonstrating the metrics were reviewed at a system level
  • Evidence of follow-up when performance issues arise
Simple yes/no compliance tracking is often acceptable as long as documentation is structured and consistent.
Questions for Centers to Consider
  • Which services meaningfully influence patient outcomes or regulatory compliance?
  • Do we have quality metrics in the contract? If not, what internal metrics can we use?
  • How are we storing contracts and metrics?
  • Are results regularly reviewed and escalated through QAPI?
  • Are we relying on vendor data or generating our own?
  • Do contracted services align with CMS expectations for performance monitoring?

CMS guidelines (X-099, §482.96) require QAPI programs to monitor and evaluate the performance of services provided under contract or arrangement. The updated December 2024 guidance includes expanded expectations for living donor–related contracted services and emphasizes documentation, communication, and durable quality oversight.

CategoryExamples
Organ & Recovery-Related Services
  • Organ procurement organization (OPO) partnerships
  • Organ recovery teams / third-party procurement
  • Machine perfusion / recovery devices
  • Organ acquisition logistics and coordination platforms
Laboratory & Diagnostic Services
  • HLA laboratory testing
  • Specimen storage and retrieval
  • Donor/recipient sample validation
Aviation & Transportation
  • Charter aircraft providers
  • Medical courier services
  • Organ shipment management
Care Coordination / Waitlist Management
  • Communication platforms
  • After-hours triage services
  • TIEDI / waitlist documentation support
  • Offer review / call teams
Data, Technology & Infrastructure
  • EMR-related platforms
  • Quality / operational dashboards
  • Patient engagement or donor digital tools
Living Donor–Specific Services
  • Paired exchange networks
  • Donor evaluation platforms
  • Donor sample storage
  • Remote evaluation services
CategoryCommon Metrics
Organ Procurement & Recovery
  • SRTR metric utilization
  • Adverse event review
  • Timeliness of billing
  • Dry runs, organ damage, packaging issues
  • Temperature deviations
HLA Laboratory
  • Turnaround time
  • Amended report frequency
  • False positive / false negative rates
Aviation
  • Turnaround and standby time
  • On-time arrival
  • Mileage and location accuracy
  • Aircraft availability
  • Subcontractor use
Machine Perfusion / Device Support
  • Time on device
  • Organ outcome report availability
  • % of organs placed on the device
  • Conversion to transplant
  • Device-related complications
  • Dry run rate
Logistics / Coordination
  • Waitlist removal timeliness
  • Offer acceptance rates
  • Service utilization
  • TIEDI form accuracy & timeliness
Platforms / Technology
  • Error rate
  • Support response time
  • System uptime
  • User satisfaction
Recovery Services
  • Dry run frequency
  • Packaging or temperature deviations
  • OR-related complications
Living Donor–Specific Metrics
  • Sample validation accuracy
  • Paired exchange transplant rate
  • Waitlist time for matched donors
  • Preemptive transplant frequency
  • Storage of living donor specimens

Response Time

  • Indicator: Time taken to enter a response into Donornet.
  • Target: <1 hour
  • Data Source: Call logs, organ offer timestamps.

Communication and Coordination

  • Indicator: Clarity and accuracy of communication among the on-call team, donor organ procurement organization (OPO), and lab.
  • Target: 95% clear, documented communication.
  • Data Source: Communication records, emails, and call recordings.

Protocol Adherence

  • Indicator: Compliance with protocols for evaluating organ suitability.
  • Target: 95% adherence
  • Data Source: Transplant offer logs, on-call checkliston call check list

Documentation Accuracy

  • Indicator: Completeness of records for all organ offers (accepted and declined).
  • Target: 95% complete documentation.
  • Data Source: Transplant logs, patient charts.

Patient Notification and Consent

  • Indicator: Time and method of patient notification for potential transplant.
  • Target: Initial call to the patient within 30 minutes of the patient’s acceptance of the offeroffer acceptance.
  • Data Source: Patient communication logs, consent forms.

Staff Training and Competency

  • Indicator: Staff awareness and readiness to handle organ offers.
  • Target: 100% of staff trained annually.
  • Data Source: Training records, staff competency assessments.

Technology and Infrastructure

  • Indicator: Functionality and reliability of communication tools and data systems.
  • Target: < 1% downtime.
  • Data Source: IT logs, incident reports.

Clinician Satisfaction and Feedback

  • Indicator: Functionality, reliability, and customer service
  • Target: >85%
  • Data Source: Quarterly survey of transplant surgeons, nurse coordinators, and other stakeholders to gauge satisfaction with the service effectiveness, communication clarity, and overall support in decision-making.

A SPECIAL THANKS TO THE TRANSPLANT QUALITY CORNER WORKGROUP

FEEDBACK

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