Hospital Services

Hospital Administrators

“Leadership’s commitment to creating a culture conducive to organ donation can have a significant impact on the overall success of the hospital’s organ procurement efforts.” -Rationale for Joint Commission Standard LD.3.110

As a hospital administrator, you play a critical role in creating a culture of donation in your hospital, developing implementation strategies for hospital policies and procedures and ensuring compliance at the local, state, and federal levels. As such, it is imperative that hospital administrators are current and knowledgeable regarding both The Joint Commission Standards and the Hospital Conditions of Participation (CoP) set forth by the U.S. Department of Health and Human Services (HHS) and Health Resources and Services Administration (HRSA) as related to donation.

Life Alliance has a team of Hospital Development Specialists who provide hospitals with information and guidance about the donor process and provide routine compliance reports to them. Each specialist is assigned to specific hospitals within our region. Such consultative services and partnerships with donor hospital staff ensure a smooth donation process, thereby increasing the number of lives saved every year through organ donation.

Your Hospital Development Specialist will work directly with you and your staff of doctors, nurses, respiratory therapists, social workers, clergy, administrators and others on issues such as:

  • Understanding the donation process
  • Maintaining hospital compliance with The Joint Commission standards for donation
  • Maintaining hospital compliance with CMS Conditions of Participation regarding donation
  • The development of donation policies and protocols
  • Providing Hospital Donation Dashboard reports
  • Collaboratively developing and implementing donation educational initiatives
  • Providing ongoing education through case after action reviews, in-services, conferences and routine rounds

To obtain more information, please call 1-800-232-2892 to contact Life Alliance’s Hospital Development department. You will then be connected with the HD Specialist for your hospital that can provide you with this information.

The Joint Commission has identified the 10 Cs of Donation Success for Hospital Administrators:

  1. Champion for the cause
  2. Commitment of leadership
  3. Culture of priority for organ donation
  4. Collaborative effort between hospital and OPO staff
  5. Communicate rapidly – referral calls to OPO within one hour
  6. Clinical triggers for call to OPO
  7. Conversion rate monitored and improved
  8. Counsel potential donor families
  9. Clarify policies and procedures with staff
  10. Criteria established for DCD

HIPAA Rules for Recovery Agencies

Health Insurance Portability and Accountability Act (HIPAA) Standards for Privacy of Individually Identifiable Health Information 164.512 Uses and disclosures for which consent, an authorization or opportunity to agree or object is not required.

(h) Standard: uses and disclosures for deceased organ, eye or tissue donation purposes. A covered entity may use or disclose protected health information to organ procurement organizations or other entities engaged in the procurement, banking of transplantation of deceased organs, eye or tissues for the purpose of facilitating organ, eye or tissue donation and transplantation.

Information for HIM Personnel

HIM In-Service Presentation