The Omnibus Budget Reconciliation Act of 1987 mandated that hospitals must identify potential organ and tissue donors, notify an organ procurement organization of the potential donor, and inform family members regarding the opportunity to donate organs and tissues. Although the Joint Commission on Accreditation of Healthcare Organizations requires that hospitals comply with this statute, no standard for documenting compliance exists. A continuous quality improvement process was developed at one institution to define a policy, educate staff, and document and monitor compliance. The number of referrals to the organ procurement organization and the number of organ and tissue donors were found to increase. These observations suggest that implementation of a continuous quality improvement process that ensures compliance with organ procurement regulations might increase the number of organ and tissue donors.

The Omnibus Budget Reconciliation Act of 1987 mandated that hospitals must identify potential organ and tissue donors, notify an organ procurement organization of the potential donor, and inform family members regarding the opportunity to donate organs and tissues. Although the Joint Commission on Accreditation of Healthcare Organizations requires that hospitals comply with this statute, no standard for documenting compliance exists. A continuous quality improvement process was developed at one institution to define a policy, educate staff, and document and monitor compliance. The number of referrals to the organ procurement organization and the number of organ and tissue donors were found to increase. These observations suggest that implementation of a continuous quality improvement process that ensures compliance with organ procurement regulations might increase the number of organ and tissue donors.