Standards Supporting Organ and Tissue Donation Programs

This page is intended to serve as a resource for hospital partners of the LifeNet Health Organ Procurement Organization.

Successful donation and transplantation programs are a collaborative effort involving many stakeholders. As the Organ Procurement Organization for most of Virginia, three counties in West Virginia, and one county in North Carolina, LifeNet Health supports hospitals in developing and maintaining these programs. We strive to establish meaningful partnerships with each facility, so we can work together to ensure families are presented with the option of donation as appropriate, and that the entire process goes as smoothly as possible. Learn more about the role of an OPO.

Key national and state standards outlined below reinforce the need for strong facility-OPO partnerships.

The Centers for Medicare & Medicaid Services

CMS requirements include:

  • All hospitals must provide timely notification to their OPO of all deaths and imminent deaths, including Medical Examiner cases. This must be done before medical suitability is determined and before the family is given the option of donation. Timely is defined as within 60 minutes of any imminent death trigger, or within 60 minutes of cardiac death. The OPO has the responsibility to determine medical suitability for organ donation.
  • The hospital must ensure that each potential donor family is presented with the option of donation. The OPO is responsible for approaching the family.
  • All hospitals must have a Memorandum of Agreement with its OPO.

The Joint Commission and DNV

Accrediting agencies such as The Joint Commission and DNV support the CMS requirements. Surveyors may ask to review the Memorandum of Agreement between a facility and its OPO. They may also ask for documentation of staff education programs related to donation, as well as policies and quality data related to the referral process. LifeNet can support your facility by providing data on hospital performance related to donation and transplantation efforts.

State Laws

Virginia and West Virginia laws require hospitals to evaluate medical suitability for transplant unless a patient is to known to have expressed a desire not to be a donor. Learn more: Virginia Code § 32.1-291.21 | West Virginia, Code §16-19-14(c).

Federal Laws

Federal privacy rules under HIPAA allow hospitals to disclose protected health information to facilitate donation and transplantation of organs, tissue, and corneas. More details are available at 45 C.F.R. § 164.512 (h).

How LifeNet Health Supports Your Facility

LifeNet Health will support your hospital by:

  • Guiding the health care through donation process, including best practices and innovations to save more lives.
  • Providing data on hospital performance related to donation and transplantation efforts.
  • Training staff and providing education, including orientation of new team members.
  • Supporting the health care team prior to and during hospital surveys.
  • Evaluating potential donors for medical suitability.
  • Huddling with the health care team prior to our approach of the family.
  • Leading the family conversation and facilitating the consent process.
  • Collaborating with the health care team to medically manage donors.
  • Supporting a hospital and family’s wishes to organize an honor walk for organ donors.
  • Coordinating the recovery of all medically suitable organs and tissues for transplant.
  • Helping hospitals honor donors and their families through events and structures such as memorial walls.

Clinical Resources