When the Joint Commission Agency for Healthcare Organizations (JCAHO) audited Benefis Health Care Systems in Great Falls, Montana, they found a program well-designed to meet the new federal requirements to ensure that all patients who die in hospitals are evaluated for their potential for organ and tissue donation. Working with the three donation programs that serve Montana, Benefis instituted new training, reporting, documentation, and quality control procedures that comply with all of the new regulations.

Since the August 1998 implementation of the Health Care Finance Administration’s (HCFA) Conditions of Participation (COP) of Medicare relative to organ, tissue and eye procurement, the Tissue Services and other regional procurement agencies have been working closely with regional hospitals to help ensure compliance with the regulation which HCFA contends will increase the number of organ and tissue donors. Non-compliance can jeopardize Medicare reimbursement.

Beginning in January 1999, the JCAHO adopted COP regulation provisions in their hospital standards. All JCAHO-accredited hospitals are required to meet JCAHO standards for organ, tissue and eye donation (Standard RI.2). JCAHO’s focus on the COP during inspections at regional hospitals has ranged from a review of all standard requirements to a brief inquiry.

If It’s Not Documented…
As with most regulatory agencies, JCAHO relies on documentation as evidence of compliance with standards. COP-related documentation of most concern during recent regional hospital inspections, includes:

• Copy of Memorandum of Agreement with an organ procurement agency, tissue bank and eye bank
• Hospital policy and procedure on donation that includes notification of the procurement agency on all deaths
• Hospital procedure on notification of family of each potential donor’s opportunity to donate
• Record of potential donors referred
• Referral and family approach documentation
• Copy of the “designated requestor” training course outlines
• List of trained “designated requestors”

Help Available from the Tissue Services
The Northwest Tissue Services works collaboratively with many regional hospitals to help ensure COP compliance and assist in the implementation of effective donation processes. Tissue Services staff aid in review and redrafting of donation policies and documentation forms regarding referral of every patient death, and documentation of family approach and outcome. Sample policies and documentation forms are also available for modeling.

“To assist staff at the time of death, we recommended that hospitals include donor referral documentation in a tool that already has to be filled out, rather than having a special form,” said Senior Hospital Relations Specialist Jan Hendrix. “We 
actually recommend that donor referral be included as the number one item so that if the person is a candidate for donation we have sufficient time to facilitate the process.”

Successful Inspection for Benefis
Benefis Healthcare in Great Falls was commended by HCFA for their strong donor referral program, which includes consolidated documentation.

“We developed an expirations check list that has been a really helpful tool for us. It includes specific things such as time of death, departments that need notification, and a variety of process-oriented checks,” said Vickie Hatzenbeller, RN, critical care manager and organ procurement program coordinator for Benefis. “The check list includes notification of the procurement agency. It becomes a permanent part of the record, so that it is the tool that our coordinators can use when they review records.”

Tissue Services Reports Can Aid Hospital QC
To review reporting systems and prepare for surveys, many regional hospitals have also taken advantage of referral outcome reports the Tissue Services can provide on a monthly or quarterly basis. The reports offer immediate reference of all the potential donor referrals for comparison against hospital death records to evaluate compliance. In addition to conducting “designated requestor” education for hospital staff, the Tissue Services provides course curricula and participant lists to meet HCFA and JCAHO training documentation requirements.

For more information on ensuring COP compliance and assistance available from the Northwest Tissue Services, call (206) 292-1879 or 800-858-2282.