This measure calculates the authorization rate for organ donation (defined as authorizations per 100 approaches) among referred potential organ donors or their next of kin within the Organ Procurement Organization’s (OPO’s) donation service area (DSA) in a calendar year.
Measure Specs
General Information
This measure calculates the Authorization Rate for organ donation (defined as authorizations per 100 approaches) among referred potential organ donors or their next of kin within the Organ Procurement Organization’s (OPO’s) donation service area (DSA) in a calendar year. We will refer to this measure as the Authorization Rate measure in this report. The goal of this measure is to provide OPOs with data about the rate of authorizations which can be used to better understand how effective their process is. Each organ donation is initially triggered by contact from the donor hospital as they identify a potential donor (a referral). OPO staff determine medical suitability for donation and, if appropriate, conduct an approach conversation with the referred potential organ donor or their next of kin to discuss the possibility of organ donation. It is critical to ensure that families are given the time, information, and support needed to make informed decisions. While donations must occur within specific medical timeframes for organs to remain viable for transplant, highly skilled OPO professionals are trained to approach these discussions with compassion and respect during moments of profound loss (AOPO, 2026).
Obtaining authorization for organ donation requires delicate and nuanced conversations that involve multiple factors. Emotions, timing, trust, communication, knowledge, and social and cultural implications all influence the authorization outcome. Siminoff et al. (2024) highlighted the importance of clinician training related to donor authorization conversations, due to the need for both technical expertise and strong relational communication skills. The authors noted that families who interact with clinicians with poor communication skills are more likely to perceive the patient’s care as poor, experience negative arousal, have inhibited grief processes, and report post-traumatic stress. Witjes et al. (2019) found that Authorization Rates for organ donation are higher when donation conversations are conducted by trained donation practitioners who guide families in making well-considered decisions.
The proposed Authorization Rate measure will help OPOs identify the effectiveness of approaches to referred donors by quantifying the outcome (authorizations) of approach conversations. OPOs can use this information to identify ways to improve their authorization processes. For example, OPOs can further evaluate their authorization outcomes by donor registration status (registered and non-registered) and by type of potential organ donor—Donation after Brain Death (DBD) or Donation after Circulatory Death (DCD)—allowing for the development of more targeted interventions within these groups.
Although OPOs currently track Authorization Rates, there is no standardized approach for this metric. The 2022 consensus study report by the National Academies of Sciences, Engineering, and Medicine (NASEM) noted the importance of using standardized measures to understand system variations and make meaningful performance comparisons. A standardized Authorization Rate measure would enhance transparency, facilitate benchmarking, and encourage the sharing of best practices. Efforts at improving Authorization Rates will help yield more donated organs and improve the quality of life for patients awaiting life-saving transplants.
References:
Association of Organ Procurement Organizations (AOPO). (2026, March 13). AOPO Statement on CMS Guidance Reinforcing Safeguards [Press Release]. AOPO Statement on CMS Guidance Reinforcing Safeguards - AOPO.
National Academies of Sciences, Engineering, and Medicine. (2022). Realizing the promise of equity in the organ transplantation system. Washington, DC: The National Academies Press. https://doi.org/10.17226/26364.
Siminoff, L. A., Alolod, G. P., McGregor, H., et al. (2024). Developing online communication training to request donation for vascularized composite allotransplantation (VCA): Improving performance to match new US organ donation targets. BMC Med Educ, 24, 77. https://doi.org/10.1186/s12909-024-05026-9.
Witjes, M., Jansen, N. E., van Dongen, J., Herold, I. H. F., Otterspoor, L., Haase-Kromwijk, B. J. J. M., van der Hoeven, J. G., & Abdo, W. F. (2020, September). Appointing nurses trained in organ donation to improve family consent rates. Nurs Crit Care, 25(5), 299–304. doi:10.1111/nicc.12462. Epub 2019 Jul 11. PMID: 31294520; PMCID: PMC7507830.
Once a referral and an approach to a referral are recorded in the OPO’s EDR system, OPO staff record the authorization status as a result of the approach. This includes a record of authorization through written FPA (donor designation), agreement by the next of kin of a donor to continue with FPA, or agreement by the next of kin on behalf of the donor.
The data for the numerator and denominator of the Approach Rate measure were gathered at the OPO test sites. Of our six OPO test sites, four used LifeLogics/TrueNorth EDR and two used iTransplant/InVita Health EDR. Both systems permit data capture via an application programming interface (API) linked to hospital Electronic Health Records (EHRs)—where available and in coordination with donor hospitals—for the input of patient data, including demographic and clinical data. Each OPO performs standardized quality assurance (QA) completeness checks of each donor case file in their EDR.
Prior to measure testing, we discussed the nature of the variables with OPOs to understand the data elements and workflows that generated the data points. We learned that OPOs were not systematically coding demographic values in the same way, such as collecting age instead of date of birth, or collecting multiple race categories that differ from the census categories. We did not find differences in the authorization variable itself, although some OPOs capture additional authorization detail. Through reviews of the OPO data, their dictionaries, the logic behind calculated fields, and—in some cases—additional data submissions, we learned how each OPO captured and reported their data. We clarified the measure specifications and definitions and engaged in discussions with each OPO to ensure that we obtained and analyzed the necessary data. Other clarifications included alignment on how missing data were handled. However, overall, we found that it was relatively straightforward to harmonize the data when we had clarifications on the data dictionary and field names.
Numerator
The numerator is the number of authorizations from referred potential donors in the OPO’s DSA in a calendar year.
The numerator for the Authorization Rate measure uses data shared directly by six OPOs. The numerator is the number of authorizations from referred potential donors in the OPO’s DSA in the calendar year. Authorization is defined as written first-person authorization (FPA) (donor designation), agreement by the next of kin (or by Uniform Anatomical Gift Act (UAGA) hierarchy) of a donor to continue with FPA for organ donation, or agreement by the next of kin on behalf of a donor to donate organs. An approach must also have occurred for authorization to occur.
Referrals are attributed to the calendar year (time between 12:00 a.m. on January 1 of a calendar year and 11:59 p.m. on December 31 of that same year) based on the referral date.
OPOs capture the ventilator status in their Electronic Donor Record (EDR) at the time of referral from the donor hospital.
Please refer to Attachment B for a list of definitions and acronyms associated with this measure submission.
Denominator
The denominator is the number of approaches made to referrals or their next of kin for organ donation in the OPO’s DSA in a calendar year.
The denominator for the Authorization Rate measure is the number of approaches made to referrals or their next of kin for organ donation in the OPO’s DSA in a calendar year.
An approach is defined as any type of conversation in person, over the telephone, or via telehealth with the intent to make donation a possibility after preliminary suitability has been determined by the OPO staff. The patient must have been referred to the OPO for an approach to occur.
Preliminary suitability situations include those in which the patient appears to meet DBD criteria but is not formally declared, the patient is declared to be brain dead and appears to be a suitable donor (at least one organ), or the OPO has determined that the patient is a suitable DCD candidate and has talked to the family about organ donation.
The approach definition does not change by outcome or rule-out circumstances (e.g., family declines, patient expiration, medical examiner denial, or other rule-out status). An approach does not include courtesy calls where a family has requested information about donation but the OPO had already chosen not to investigate further or pursue donation.
Exclusions
An approach must have occurred for the referral to be eligible for inclusion. Additionally, only ventilated referrals are used, and the patient’s age must be between 0 and 80 years old. Note that prior measures used 75 years as the age cut-off; however, literature shows that organs from donors up to age 80 can be effectively used in many transplant situations, which is why we have updated the age cut-off (Aubert et al., 2019). If data on “age” are missing, those observations are also excluded.
Reference:
Aubert, O., Reese, P. P., Audry, B., et al. (2019). Disparities in acceptance of deceased donor kidneys between the United States and France and estimated effects of increased US acceptance. JAMA Intern Med, 179(10), 1365–1374. doi:10.1001/jamainternmed.2019.2322.
Not all referrals result in actual approaches to a potential donor, as many factors need to be aligned for an approach to be warranted. Therefore, approaches are a subset of all referrals. Only referrals that led to an approach are used for the Authorization Rate denominator; the Approached variable is used in the calculation. In addition, only ventilated referrals with patients aged 0 to 80 years old are included.
Measure Calculation
To calculate the numerator for the measure, begin with the set of referrals for an OPO in a calendar year and filter the data to include only referrals where the patient was ventilated and aged 0 to 80 years old. Next, filter these referrals to referrals in which an approach occurred, then filter these referrals to only include referrals in which authorization was obtained. Count the number of unique referrals from this subset; this is the number of authorizations.
To calculate the denominator for the measure, begin with the set of referrals for an OPO in a calendar year and filter the data to include only referrals where the patient was ventilated and aged 0 to 80 years old. Next, filter to referrals in which an approach occurred. Count the number of unique referrals from this subset; this is the number of approaches.
To calculate the measure, divide the numerator (the number of authorizations for the OPO in the calendar year) by the denominator (the number of approaches for the OPO in the calendar year) to determine the Authorization Rate. This value is multiplied by 100, as the rate is expressed as X per 100 approaches. In addition to calculating the overall measure score, we stratified by demographic information for gender, race, and age.
Please refer to Exhibit 2: Measure Score Calculation Diagram in Attachment B for additional details.
We stratified this measure by race, gender/sex, and age.
We stratified by race to better understand whether different populations are served disproportionately relative to the proportions of potential donors in the DSA. Due to the nature of the data shared by OPOs, we compare “Non-Hispanic White” and “Non-White” populations. People of Hispanic ethnicity are included in the “Non-White” category because some OPOs coded “Hispanic” as a mutually exclusive “race” category.
We stratified by gender/sex to evaluate whether the authorizations and referrals received by the OPO reflect the gender/sex proportions of deaths in the population in the OPO’s DSA.
Finally, we stratified this measure by age. Stratification by age permits evaluation of the population breakdown of the authorizations and referrals received by the OPO as compared to the proportions of potential donors in the OPO’s DSA.
Additional stratification information is covered in Section 5.4.
There is no minimum sample size.
Supplemental Attachment
Point of Contact
Not applicable.
Steve Miller
McLean, VA
United States
Lisa Newton
Econometrica Inc.
Bethesda , MD
United States
Importance
Evidence
To validate the importance of the Authorization Rate measure and ensure accurate and comprehensive information when developing the measure, we performed an environmental scan of literature about the organ donation and transplant ecosystem (Rahman et al., 2025). We reviewed relevant literature for any measures or data sources that had already been explored and had potential as candidate measures. Based on this review, no appropriate measures were identified, and the team continued exploring alternative evidence for measures and amplified importance.
A thorough review of existing measures in the CMS Measures Inventory Tool (CMIT) also indicated that there were no measures comparable to the one proposed for endorsement (CMIT, n.d.). Therefore, we continued identifying potential measures using the CMS Blueprint Measure Lifecycle as a validated measure development framework.
The CMS Blueprint Measure Lifecycle was used to guide our work due to its rigorous and established approach to measure development and validation (CMS, n.d.). Econometrica operationalized the Blueprint by systematically integrating the conceptualization, specification, testing, implementation, measure use, evaluation, and maintenance phases into the project plan.
To better understand OPO operations, identify considerations for measure development, and reinforce measure importance, we conducted 7 site visits to U.S. OPOs, including organizations with Donor Care Units, totaling 45 individual interviews with OPO leadership, directors, managers, and other essential OPO frontline staff. Econometrica conducted a qualitative analysis of all interviews that informed the development of the ecosystem map and logic model (Rahman et al., 2026a).
We convened four meetings with a Technical Expert Panel (TEP) (Rahman et al., 2026b) and assembled an OPO stakeholder group (Rahman et al., 2026c) to gather targeted, informed feedback over five sessions (June 2025 to February 2026). The purpose of the TEP was to provide expert guidance on project strategy, measure development, and recommendations for new measures. The OPO stakeholder group served to engage OPOs in informing and testing measures and supporting the development of a shared logic model. In Fall 2025, our team solicited feedback from OPO stakeholders on a list of structural, process, and outcome measure candidates. This activity narrowed the list of measure candidates, with the Authorization Rate measure receiving a high percentage of agreement for advancement to the testing phase (Rahman et al., 2026c). During OPO Stakeholder Meeting 3, Econometrica continued in-depth discussions with stakeholders, further solidifying the final measures selected for the testing phase, including Authorization Rate (Rahman et al., 2026c).
We also conducted a qualitative study to explore the perspectives of donor families, transplant recipients, and OPO stakeholders to better understand the emotional, practical, and systemic aspects of organ donation and transplantation (Arellano et al., 2025). Although we did not identify findings with direct implications for the Authorization Rate measure, the importance of developing appropriate measures was emphasized.
In collaborative sessions with our TEP and OPO stakeholder group, and in accordance with the CMS Blueprint Measure Lifecyle, we identified measure selection criteria to guide the development and testing of quality measures (Rahman et al., 2026b; Rahman et al., 2026c; CMS, n.d.). These criteria were refined and prioritized to evaluate whether a measure was regarded as meaningful, actionable, and feasible. Our TEP and OPO stakeholders also emphasized that measures under consideration should improve upon current CMS measures and be rigorously developed, evidence-based, replicable, and verifiable. In addition to these standards, our TEP and OPO stakeholders recognized the need for flexibility in new measures to reflect the evolving science and medicine of organ donation. They identified that new measures should be aligned across the transplantation system (i.e., hospitals, OPOs, and transplant centers), oriented toward optimizing transplant outcomes, developed inclusively, and assessed for the potential to promote unethical behavior (induce individuals or organizations to seek out organs that will not be used). During our OPO site visits, we heard similar feedback among sites about the delicate nature of the approach conversation and how tracking is significant in understanding authorization decisions. This evidence is consistent with findings identified by Siminoff et al. (2024) and Valikodath et al. (2023), respectively. We took these guiding criteria into account as we developed and tested the Authorization Rate measure.
Measuring Authorization Rates provides OPOs with valuable insight into their performance, helping identify specific areas where improvement is needed. Identifying gaps and areas for improvement in the authorization process helps OPOs develop targeted interventions for quality improvement. Such gaps are described in a 2023 study by Valikodath et al., where researchers utilized the donor conversion rate to understand the relationship between donor registration rates and next-of-kin authorization. Using a multivariate model, the researchers found that increases in the number of deceased organ donors over time are largely due to organ donor registration and that there continues to be a high degree of variability in next-of-kin consent rates, independent of population demographics. In addition, U.S. consent rates lag in comparison to many European nations, which have an opt-out model, in contrast to the opt-in model used in the United States. Despite this, the authors found that there remain opportunities to optimize next-of-kin Authorization Rates. They recommended standardized training and educational initiatives related to registration and consent as viable performance improvement strategies.
OPO stakeholders highlighted the importance of the unique variables and challenges that impact authorization decisions, particularly in regard to the DCD pathway (Rahman et al., 2026c). The timing and sensitivity surrounding authorization conversations with families was noted. Since the potential donor is not brain dead, these conversations may need to occur over a longer period of time. The need to cultivate rapport, provide adequate education, and offer ongoing support with potential DCD donor families was emphasized as an important component. The importance of tracking the differences in authorization related to first-person DCD, registered, and non-registered donors was also identified as essential in understanding the variance in authorization patterns within an OPO’s DSA. One OPO identified first-person registration as a major driver of authorization, with an Authorization Rate average of 88 to 100 percent for registered donors, versus 25 to 55 percent for unregistered donors. This OPO noted that a state where the registry is well-supported with a high density of registered donors will render better Authorization Rates.
During site visits, OPOs noted the importance of community and family engagement to disseminate the donation message (Rahman et al., 2026a). OPOs engage and educate the community about organ donation through conversations with donor families and transplant recipients, media involvement, community events, and outreach efforts with community organizations, religious organizations, businesses, schools, etc. Engagement is critical for providing education and factual information to correct public misconceptions about organ donation, improve donor registration and family authorization, build public trust, and address cultural or religious myths and taboos regarding donation and transplantation.
OPOs also discussed the importance of donor registration programs to engage the community and increase the donor pool. These efforts included participating in Donate Life programs, partnering with Departments of Motor Vehicles, and reviewing non-registered populations to identify where resources and efforts can be focused. By engaging communities routinely, OPOs aim to build trust and cultural sensitivity before a potential case is approached for donation.
These findings collectively indicate the importance of the Authorization Rate measure in advancing the mission of OPOs to provide a compassionate and vital link between donors and patients awaiting lifesaving organ transplants (AOPO, 2026).
References:
Arellano, O., Rahman, M., O’Connor, J., & Rajakannan, T. (2025). Perspectives and experiences in organ donation and transplantation: A qualitative study [Internal document]. Econometrica, Inc., Bethesda, MD.
Association of Organ Procurement Organizations. OPO services. Retrieved April 6, 2026, from https://aopo.org/opo-services/.
Centers for Medicare and Medicaid Services. (n.d.). Centers for Medicare and Medicaid Services Measures Inventory Tool (CMIT). https://cmit.cms.gov/cmit#1/.
Centers for Medicare and Medicaid Services (CMS) Measures Management System. (n.d.) Blueprint Measure Lifecycle. https://mmshub.cms.gov/blueprint-measure-lifecycle-overview.
Rahman, M., Arellano, O., Lind, C., Newton, L., O’Connor, J., Paraboschi, J., & Rizvi, S. (2025, June 20). OPO measurement literature review report [Internal document]. Econometrica, Inc., Bethesda, MD.
Rahman, M., Arellano, O., Lind, C., Newton, L., O’Connor, J., & Paraboschi, J. (2026a, April 7). OPO site visit final report [Internal document]. Econometrica, Inc., Bethesda, MD.
Rahman, M., Arellano, O., & O’Connor, J. (2026b). Organ Procurement Organization (OPO) performance measurement technical expert panel (TEP) meetings 1–4 summary overview [Internal document]. Econometrica, Inc., Bethesda, MD.
Rahman, M., Arellano, O., & O’Connor, J. (2026c). Organ Procurement Organization (OPO) stakeholder group meetings 1–5 summary overview [Internal document]. Econometrica, Inc., Bethesda, MD.
Siminoff, L. A., Alolod, G. P., McGregor, H., et al. (2024). Developing online communication training to request donation for vascularized composite allotransplantation (VCA): Improving performance to match new US organ donation targets. BMC Med Educ, 24, 77. https://doi.org/10.1186/s12909-024-05026-9.
Valikodath, N., Lambert, A. N., Butler, A., Lebovitz, D. J., Chapman, G., Xu, M., Slaughter, J. C., Menachem, J. N., & Godown, J. (2023). The impact of donor consent mechanism on organ procurement organization performance in the United States. The Journal of Heart and Lung Transplantation, 42(5), 627–636. https://doi.org/10.1016/j.healun.2022.12.023. PMID: 36868968.
Measure Impact
The proposed Authorization Rate measure will provide OPOs with a standardized mechanism to measure authorization rates, with the desired outcome of increasing the availability of organs for donation. As noted previously, OPOs already collect and monitor authorization data as part of routine practice, but there is no standardized approach to tracking. During measure testing, we found that OPOs can collect and provide these data with limited burden. OPOs track authorization through multiple mechanisms, including interactive dashboards, time-based data scorecards, and working groups (Rahman et al., 2026a). As an intermediate outcome measure, the Authorization Rate measure can alert OPOs when further investigation of authorization causality is needed. If an OPO is underperforming on this metric, they can investigate the reason(s) behind the decline in authorization.
For example, evaluating Authorization Rates by registration status may provide insight into areas to increase donations, such as donations authorized within diverse populations and by legal next of kin. Other variables to explore may include approach conversation repetition and cultural or racial influence. The literature showed that Black and American Indian/Alaska Native individuals donate at lower rates than White individuals, which may be attributed to how sensitively these groups are approached about organ donation. Kernodle et al. (2021) found that, among Black families, those who declined donation were more likely to report feeling pressured and to have received less thorough discussions compared to Black families who authorized donation. Furthermore, Bodenheimer et al. (2021) found that donation authorization was higher when coordinators and donor families shared the same racial background, and although the effect of racial mismatch decreased after accounting for coordinator training and experience, the findings highlighted the need for better education and communication to address race-associated perceptions in the donation process.
The OPO relationship with donor hospitals is another critical factor that influences authorization. During our site visits, OPOs indicated that when hospitals support donation conversations, Authorization Rates are higher for non-registered donors (Rahman et al., 2026a). Conversely, hospitals that delay donation conversations and are late on referrals experience a decrease in authorization. By measuring authorization, OPOs can approach partner hospitals with real-time data to help address barriers and discuss remediation to improve donation efforts.
If implemented, we anticipate that measuring Authorization Rates will lead to the short-term outcome of an increase in the number of donation authorizations. Intermediate outcomes include identification and resolution of process gaps and improved effectiveness in the OPO authorization process. Ultimately, all of these efforts align to promote the long-term outcome of more donated organs being offered to transplant centers to improve the quality of life for patients awaiting life-saving transplants.
References:
Bodenheimer, H. C., Jr., Okun, J. M., Tajik, W., Obadia, J., Icitovic, N., Friedmann, P., Marquez, E., & Goldstein, M. J. (2012). The impact of race on organ donation authorization discussed in the context of liver transplantation. Trans Am Clin Climatol Assoc, 123, 64–77, discussion 77–8. PMID: 23303969; PMCID: PMC3540608.
Kernodle, A. B., Zhang, W., Motter, J. D., Doby, B., Liyanage, L., Garonzik-Wang, J., Jackson, K. R., Boyarsky, B. J., Massie, A. B., Purnell, T. S., & Segev, D. L. (2021, April 1). Examination of racial and ethnic differences in deceased organ donation ratio over time in the US. JAMA Surg, 156(4), e207083. doi: 10.1001/jamasurg.2020.7083. Epub 2021 Apr 14. PMID: 33566079; PMCID: PMC7876622.
Rahman, M., Arellano, O., Lind, C., Newton, L., O’Connor, J., & Paraboschi, J. (2026a, April 7). OPO site visit final report [Internal document]. Econometrica, Inc., Bethesda, MD.
A standardized metric for measuring OPO Authorization Rates does not currently exist. NASEM (2022) called for the creation of standardized performance measures, based on a consensus-driven process with limited reporting burden on health professionals or patients. As noted earlier, although OPOs may internally track Authorization Rates, the metrics are not standardized nor endorsed by the CMS Consensus-Based Entity (CBE). The proposed Authorization Rate measure, developed through the validated and rigorous CMS Blueprint Framework, offers a solution for OPOs to accurately track performance authorization for organ donation.
CMS currently uses two measures, Donation Rate and Organ Transplantation Rate, to measure OPO performance. OPO stakeholders have indicated that the current CMS measures, specifically denominators for measures, do not capture donor potential. Across the 2020 CMS rule-making public comment period, during our 2025 site visit interviews, and in our discussions with OPO stakeholders (2025–2026), we repeatedly heard concerns about these metrics (CMS Final Rule, 2020; Rahman et al., 2026a; Rahman et al., 2026c). One such concern is that the measures do not fall under the OPO scope of control. This was mentioned repeatedly by stakeholders. In the OPO Site Visit Report: “Several OPOs expressed concern about performance measures tying directly to activities within the control of the OPO itself” (Rahman et al., 2026a).
The CMS measures, although valuable, have limitations and do not provide the specificity and nuance required by OPOs to address the complexity of the authorization process for organ donation. As noted by the TEP, there is “agreement that there are many systematic problems in the (CMS) metrics, such as clear statistical fallacies” (Rahman et al., 2026b).
References:
Medicare and Medicaid Programs; Organ Procurement Organizations Conditions for Coverage: Revisions to the Outcome Measure Requirements for Organ Procurement Organizations. Final Rule. Published in the Federal Register on December 2, 2020, as 85 Fed. Reg. 77898. Federal Register: Medicare and Medicaid Programs; Organ Procurement Organizations Conditions for Coverage: Revisions to the Outcome Measure Requirements for Organ Procurement Organizations.
National Academies of Sciences, Engineering, and Medicine. (2022). Realizing the promise of equity in the organ transplantation system. Washington, DC: The National Academies Press. https://doi.org/10.17226/26364.
Rahman, M., Arellano, O., Lind, C., Newton, L., O’Connor, J., & Paraboschi, J. (2026a, April 7). OPO site visit final report [Internal document]. Econometrica, Inc., Bethesda, MD.
Rahman, M., Arellano, O., & O’Connor, J. (2026c). Organ Procurement Organization (OPO) stakeholder group meetings 1–5 summary overview [Internal document]. Econometrica, Inc., Bethesda, MD.
There was significant agreement among OPOs that the conversion of potential donors to donors (i.e., Authorization Rate) should be considered a key measurement area. Because authorization data are routinely collected, this measure is not only feasible but also supports OPOs in converting approaches to authorizations. The Authorization Rate measure is meaningful to the target population of patients and families of organ donation by increasing the accountability of OPOs to improve their processes for obtaining donation authorization.
As detailed in Section 2.2, we conducted numerous meetings, OPO site visits, and interviews with OPO stakeholders, donor family members, and transplant recipients, validating that the target population views the proposed Authorization Rate measure as meaningful (Arellano et al., 2025; Rahman et al., 2026a; Rahman et al., 2026c). In one interview, a donor family member noted that the ICU nurse caring for their loved one may have been inconvenienced by the extra work related to donation and that their palliative care doctor was unreceptive to donation. Additionally, once the family agreed to donation, they were required to complete extensive paperwork to authorize the donation process, which took time away from their loved one at the end of life. The family indicated that the donor hospital would have benefited from better training on how to discuss and support donation and emphasized the importance of measures that drive performance improvement. This feedback demonstrates that a hospital culture supportive of organ donation (Gibson et al., 2023) and clinician training related to donor authorization conversations (Siminoff et al., 2024) directly impact the authorization process and donor conversion rates.
During our conversations with families of organ donors, organ donation and transplantation were described as profoundly emotional experiences for both donor families and transplant recipients. For donor families, the process was often traumatic, particularly when donation followed the unexpected death of a family member and required rapid decisions under strict time constraints. Despite these challenges, many families reported strong internal support and positive interactions with OPOs (Arellano et al., 2025).
These findings collectively highlight the meaningfulness of the Authorization Rate measure to the target population and its use as a key metric for providing information that can inform care decisions.
References:
Arellano, O., Rahman, M., O’Connor, J., & Rajakannan, T. (2025). Perspectives and experiences in organ donation and transplantation: A qualitative study [Internal document]. Econometrica, Inc., Bethesda, MD.
Gibson, J. E., Campbell, T., Gibson, K., Kottemann, K., Krause, M. A., & Pack, L. (2023, June 15). Collaborative approach to organ donation in a level II trauma center. AACN Adv Crit Care, 34(2), 88–94. doi: 10.4037/aacnacc2023552.
Rahman, M., Arellano, O., Lind, C., Newton, L., O’Connor, J., & Paraboschi, J. (2026a, April 7). OPO site visit final report [Internal document]. Econometrica, Inc., Bethesda, MD.
Rahman, M., Arellano, O., & O’Connor, J. (2026c). Organ Procurement Organization (OPO) stakeholder group meetings 1–5 summary overview [Internal document]. Econometrica, Inc., Bethesda, MD.
Siminoff, L. A., Alolod, G. P., McGregor, H., et al. (2024). Developing online communication training to request donation for vascularized composite allotransplantation (VCA): Improving performance to match new US organ donation targets. BMC Med Educ, 24, 77. https://doi.org/10.1186/s12909-024-05026-9.
Performance Gap
The measure is being submitted for initial endorsement.
A measure of Authorization Rates provides essential information to OPOs to support quality improvement efforts directed at increasing authorizations for their approaches.
The data source is the OPO EHR. The data are presented by OPO for our six test site OPOs:
- OPO 1 provided data from 1/1/2021 through 12/31/2024.
- OPO 2 provided data from 1/1/2021 through 12/31/2024.
- OPO 3 provided data from 1/1/2022 through 12/31/2024.
- OPO 4 provided data from 1/1/2021 through 12/31/2024.
- OPO 5 provided data from 1/1/2021 through 12/31/2024.
- OPO 6 provided data from 1/1/2021 through 12/31/2024.
The Authorization Rates per 100 for our 6 test site OPOs are presented in Exhibit 3: Authorization Rates by OPO in Attachment B.
The Authorization Rates per 100 for our 6 test site OPOs are presented in Exhibit 3: Authorization Rates by OPO in Attachment B.
Care Gaps
Closing Care Gaps
This domain is optional for the Spring 2026 cycle.
Feasibility
Feasibility
All OPOs track their data electronically in EDRs. All data elements for the Authorization Rate measure are available in structured fields. During measure testing, some standardization of data elements was necessary to allow comparisons across OPOs.
OPOs use a combination of real-time data validation to catch missing data at the point of entry and conduct QA checks on a routine basis, often during monthly reviews. OPOs indicated that missing data are infrequent, identified through routine QA checks, and completed after following up with the coordinator or staff member familiar with that stage of the OPO activity. OPOs noted that donor records that lead to an organ donation are the most complete, as they have moved through each step of the donation workflow. In contrast, potential donors that do not result in a donation may have less complete records if the donation was authorized and not recovered, there was no authorization, or the referral was medically ruled out and otherwise did not proceed through the referral-approach-authorization-management-recovery pathway. This type of missing data limits the OPO’s ability to understand patterns, evaluate missed opportunities, and assess process performance at key decision points.
While these issues do not impede Authorization Rate measure calculations, they can limit the OPO’s internal visibility into possible operational improvements. All of this underscores the importance of identifying and resolving missing, incongruent, irregular, or incomplete data issues in a methodical, predictable, and timely manner.
Our test sites indicated that there will be no additional cost or burden imposed by this measure implementation as defined. Most OPOs noted that there will be minimal to no impact on clinician/provider workflow. One OPO indicated that implementation of the measure could encourage clinicians to be more intentional in how they speak to potential donor families and improve the family experience. Some OPOs expressed that there is a lack of standardized data requiring additional resources for data QA, which can be addressed with standardized templates.
The data are collected by OPOs as part of their routine care and captured in alignment with the Health Insurance Portability and Accountability Act privacy regulations in secure systems. There are no patient confidentiality concerns. For measure testing, the data analysis did not depend on any confidential patient information beyond age (or birthdate). Therefore, unique case IDs were used for each patient record. When our team received the data, no patient names were included. All of our measures are calculated based on patient populations large enough that it would be almost impossible to identify an individual.
All data elements used in the measure are collected routinely by OPOs. For some data items, additional coding or details from the OPO were required before the final measure could be constructed. Thus, while initially there were some challenges in constructing some of the variables needed for the measures, with a clearer understanding of measure requirements and definitions, these variables are routinely constructed in OPOs’ current data management processes.
As noted in Section 2.2, we used our extensive collaboration with OPOs, the TEP, and site visits to ensure that an Authorization Rate measure provided meaningful information to OPOs about their efforts to obtain authorization for donation following their approach conversations (Rahman et al., 2026a; Rahman et al., 2026b). Further, these collaborations ensured that the data elements were captured in EDRs and that many OPOs were already tracking these data points for internal performance benchmarking and improvement efforts, further demonstrating the feasibility of this measure.
We refined our initial definition of an authorization to reflect that the authority to agree to a donation is guided by the UAGA hierarchy (Verheijde et al., 2006). Our research and conversations with OPO staff and the TEP revealed the role of UAGA in aligning permissions for donation regardless of state laws regarding organ donation. We added this guidance to the definition of an authorization in the measure. We confirmed definitions and the variables used for authorizations with each OPO in order to calculate the measure rate consistently.
References:
Rahman, M., Arellano, O., Lind, C., Newton, L., O’Connor, J., & Paraboschi, J. (2026a, April 7). OPO site visit final report [Internal document]. Econometrica, Inc., Bethesda, MD.
Rahman, M., Arellano, O., & O’Connor, J. (2026b). Organ Procurement Organization (OPO) performance measurement technical expert panel (TEP) meetings 1–4 summary overview [Internal document]. Econometrica, Inc., Bethesda, MD.
Verheijde, J. L., Rady, M. Y., & McGregor, J. L. (2007, September 12). The United States revised uniform anatomical gift act (2006): New challenges to balancing patient rights and physician responsibilities. Philos Ethics Humanit Med, 2(19). doi: 10.1186/1747-5341-2-19. PMID: 17850664; PMCID: PMC2001294.
Proprietary Information
Scientific Acceptability
Testing Data
The OPO test sites provided data for testing, which were exported from their EDRs into Excel workbooks. As noted in Section 1.25 Data Source Details, we received testing data from six OPO test sites. Of these, four sites used LifeLogics/TrueNorth EDR and two sites used iTransplant/InVita Health EDR for donor record management. The data were quantitative, providing patient profile and demographic information for patients referred by a donor hospital to the OPO. The data included information on the referral date, approach conversation date and outcome, authorization outcome, and donation result. Gender, age, and race were also used for stratification.
All data is for a calendar year (1/1 through 12/31):
- OPO 1: 2021–2024.
- OPO 2: 2021–2024.
- OPO 3: 2022–2024.
- OPO 4: 2021–2024.
- OPO 5: 2021–2024.
- OPO 6: 2021–2024.
The reliability testing and stratification used the same data that were used to construct this measure. No specific exclusions were made.
There are 56 OPOs currently meeting the Conditions for Coverage under CMS regulations as of 2023 (CMS, 2020b). CMS categorizes OPOs by population size of their DSA. Six of the 56 OPOs volunteered to participate in measure testing by submitting anonymized patient data, data dictionaries, and definitions and by participating in surveys and discussions about their submitted data, definitions, data capture processes, and data quality checks.
Of the six test sites that contributed data, one was in the “less than 2.9 million” size, one was in the “2.9–5 million” size, one was in the “5–7.2 million” size, and three were in the “greater than 7.2 million” size (OPTN, 2025).
Our six test sites were from six states and included OPOs that were ranked as “underperforming” (three OPOs) and “passing” (three OPOs) under the current CMS performance tiers for the existing Donation Rate and Transplant measures (based on 2023 CMS data) (OPTN, 2025; CMS, 2025). Five of the 6 OPOs have DSA coverage in more than 1 state, bringing the total count of states in this analysis to 13 states.
Exhibit 4 in Attachment B includes the characteristics of the six test OPOs. The 6 sites are reasonably representative of the 56 OPOs.
References:
Centers for Medicare & Medicaid Services. (2020b). Medicare and Medicaid programs; organ procurement organizations conditions for coverage; revisions to the outcome measure requirements for organ procurement organizations. A rule by the Centers for Medicare & Medicaid Services. https://www.federalregister.gov/d/2020-26329/p-195.
Centers for Medicare & Medicaid Services (CMS). (2025, July). OPO public performance report. quality, certification & oversight reports. https://qcor.cms.gov/OPOs.
Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR). OPTN/SRTR 2023 Annual Data Report. U.S. Department of Health and Human Services, Health Resources and Services Administration; 2025. Accessed February 2026. https://srtr.transplant.hrsa.gov/annualdatareports.
Please refer to Exhibit 5 in Attachment B for the OPO demographic information.
Reliability
Authorization is a highly sensitive issue for OPOs. Authorization information is subject to audit for payment purposes and is essential to documenting that organ procurement was done appropriately and legally. Due to the high-cost, high-consequence nature of authorization, documentation of whether authorization took place (a binary variable found in the donor record) is highly reliable at (1) the patient or encounter level, (2) the hospital to OPO level, and (3) the entity level.
Person or Encounter Level
Authorization is a yes/no variable, with additional variables recording whether the source of authorization was first-person (some states allow the expression of intent of donation on a driver’s license or other registry to serve as documentation) or whether it was provided by the next of kin. Because donation should never be done without authorization and secondary verification of authorization, nearly all OPOs use a double-documentation system, where the staff member obtaining the authorization enters that data into the donor record and that authorization is supported by additional documentation, such as a copy of the registry record, a driver’s license, or a signed authorization by the next of kin.
As required in 42 CRF 486.342, OPOs must have a written protocol for organ donation decision-making. They must provide the family member or other person responsible for making the donation decision with a list of specific information and a physical copy of the signed consent form when it is completed. If the organ donor has provided first-person authorization and that is consistent with donation under state law and therefore no family authorization is needed, OPOs must also provide that information to the family and retain copies of this documentation. This information is all subject to review during CMS site surveys.
All OPOs we spoke with also reported conducting a quality assurance check on their records at least annually to ensure that the records are completed, and that all authorizations have all required documentation to match. In seeking reports that indicated the inter-rater reliability or match between the donor records and the authorization back-up documentation, OPOs provided screenshots demonstrating 100-percent record completion for donors, which are not provided here to protect the names of the donors.
While we are aware that some prior studies have found that OPO data cannot easily be harmonized across OPOs (Adam et al., 2026), we did not find this to be true. We found similar or identical fields for approach and authorization. This may be because OPOs have implemented an internal project called UNION that promotes the standardization of their data. The paper by Adam et al. (2026) uses older data from 2015 through 2021 while our measure testing used data from 2021 through 2024. Additionally, as OPOs roll out this authorization measure, OPO electronic donor record providers are participating in an activity to further standardize the capture of demographic data on donors and will use a self-auditing tool to validate their authorization data uniformly across all OPOs.
Accountable Entity Level
Reliability testing was conducted using the repeated split-sample methodology described by Nieser and Harris (2024), as recommended by the PQM Endorsement and Maintenance Guidebook (2025).
For each of the six OPOs and for each year in the range 2021–2024, the data used to compute the numerator (count of authorizations meeting all applicable inclusion and exclusion criteria, obtained from OPO data) and the denominator (count of approaches meeting all applicable inclusion and exclusion criteria, also obtained from OPO data) were repeatedly resampled to create pairs of half-sample datasets, with each record randomly assigned to one half-sample or the other. The number of repetitions was 200, which is the approximate size of the smallest OPO-year dataset used for reliability analysis. The Authorization Rate was then computed for each half-sample. This allowed the creation of a dataset containing 200 records for each OPO and year, with each record containing the OPO and year, and the rates for each of the two half-samples.
The data for each of the 200 sets of OPO-year pairs were then analyzed separately to obtain the correlation between the rates of the two randomly assigned half-samples. The measure of correlation used was the intraclass correlation coefficient (ICC) for a one-way random effects model—ICC(1)—obtained from the covariance estimates provided by a hierarchical generalized linear model. The ICC(1) provides a measure of the total proportion of total variance of the Authorization Rate that is explained by the OPO and year. (We do not currently have data from a sufficient number of OPOs to compute a statistically valid measure of correlation by OPO alone.) The average value of ICC(1) across the 200 repetitions, which is the measure of reliability, was then computed.
References:
Adam, H., Pollard, T., Suriyakumar, V., et al. (2026). Organ retrieval and collection of health information for donation: The ORCHID dataset. Scientific Data, 13, Article 120. https://doi.org/10.1038/s41597-025-06435-1.
Nieser, K. J., & Harris, H. S. (2024). Comparing methods for assessing the reliability of health care quality measures. Statistics in Medicine, 43(23).
Partnership for Quality Measurement, Endorsement and Maintenance Guidebook, National Consensus Development and Strategic Planning for Health Care Quality Measurement, October 2025, p.71.
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. (2026). 42 C.F.R. § 486.342: Condition: Requesting consent. https://www.ecfr.gov/current/title-42/part-486/section-486.342.
Person or Encounter Level
Please refer to Section 5.2.2 Methods of Reliability Testing.
Accountable Entity Level
The Authorization Rate reliability as estimated by the average ICC(1) value has a mean value of 0.9147, with a 95-percent confidence interval of [0.9106, 0.9187].
Person or Encounter Level
Please refer to Section 5.2.2 Methods of Reliability Testing.
Accountable Entity Level
The estimated Authorization Rate reliability is 0.9147, which surpasses the minimum reliability threshold of 0.6. Therefore, this measure meets the CBE requirements for reliability.
Please refer to Section 5.2.2 Methods of Reliability Testing and Section 5.2.3 Reliability Testing Results.
Please refer to Section 5.2.2 Methods of Reliability Testing and Section 5.2.3 Reliability Testing Results.
Validity
Authorization is a highly sensitive issue for OPOs. Authorization information is subject to audit for payment purposes and is essential to documenting that organ procurement was done appropriately and legally. Due to the high-cost, high-consequence nature of authorization, documentation of whether authorization took place (a structured, binary variable found in the donor record) is highly reliable and valid at (1) the patient or encounter level, (2) the hospital to OPO level, and (3) the entity level.
Person or Encounter Level
Authorization is a yes/no variable, with additional variables recording whether the source of authorization was first-person (some states allow the expression of intent of donation on a driver’s license or other registry to serve as documentation) or whether it was provided by the next of kin. Because donation should never be done without authorization and secondary verification of authorization, nearly all OPOs use a double-documentation system, where the staff member obtaining the authorization enters that data into the donor record and that authorization is supported by additional documentation, such as copy of the registry record, a driver’s license, or a signed authorization by the next of kin.
As required in 42 CRF 486.342, OPOs must have a written protocol for donation decision-making (authorization). They must provide the family member or other person responsible for making the donation decision with a list of specific information outlined in 42 CRF 486.342 and must provide a physical copy of the signed consent form to the family when it is completed. If the organ donor has provided first-person authorization, and that is consistent with donation under state law and therefore no family authorization is needed, OPOs must also provide that information to the family and the OPO retains copies of this documentation to ensure they are compliant with the regulation. This information and documentation is also subject to review during CMS site surveys.
All OPOs we spoke with also reported conducting a quality assurance check on their records at least annually to ensure that the records are completed and that all authorizations have all required documentation to match. In seeking reports that indicated the inter-rater reliability or match between the donor record and the authorization back-up documentation, OPOs provided screenshots demonstrating 100-percent record completion for donors; these are not included here to protect donor confidentiality. The records therefore have a high degree of face-validity.
Accountable Entity Level
We considered both face validity, which is the assumption that the measure reflects what it says it does, and criterion validity.
Face validity: The data used for this measure represents the only source of information on donation authorization—all such data are ultimately provided by OPOs. These are the only data that can be used to measure this concept. For this measure, the direct counts of authorizations were provided by the six participating OPOs, and they are not subjective or constructed. The denominator is the number of approaches. For these datasets, missing values were mostly not an issue.
Criterion validity: Criterion is the extent to which the measure relates to or predicts an outcome. Criterion validity includes both concurrent validity, which compares the measure in question to another outcome assessed at the same time such as from another data source, and predictive validity, which compares the measure to an outcome assessed at a later time.
To test concurrent validity, we compared it to other external data sources. Publicly available versions of the SRTR data provide the number of organ donors as opposed to the number of authorizations and therefore cannot be used for direct comparison with OPO data. However, given that the magnitude is similar and that authorization does not always lead to donation for a variety of reasons, SRTR provides evidence that OPOs are likely providing accurate authorization data since we observed that OPO authorization counts are always higher than the SRTR counts for organ disposition.
We also compared the approach data to the referral data to ensure that the approach numbers were less than referrals, as expected (see Table below). We queried OPOs to request information on the magnitude of the difference, and the OPOs provided an explanation regarding how they determine if an approach should be made from a referral. This added confidence that the OPO is capturing the expected approaches in their DSA in their referrals.
Table 1. Criterion Validity
OPO 1 | OPO 2 | OPO 3 | OPO 4 | OPO 5 | OPO 6 | |
|---|---|---|---|---|---|---|
| MCOD Deaths | 11,604 | 15,800.18 | 3,314 | 9,329 | 6,341 | 4,793.58 |
| Max Vent Referrals | 3,017.04 | 4,108.05 | 861.64 | 2,425.54 | 1,648.66 | 1,246.33 |
| Reported Referrals # by OPO | 18,734 | 19,199 | 7,131 | 12,887 | 13,511 | 8,634 |
| Approach # Reported by OPOs | 2,909 | 6,890 | 953 | 2,407 | 2,395 | 1,560 |
| Authorization # Reported by OPOs | 1,869 | 3,204 | 558 | 1,244 | 1,739 | 976 |
| Difference (Count) between Approach reported by OPOs and Authorization | 1,040 | 3,686 | 395 | 1,163 | 656 | 584 |
| Difference % | 44% | 73% | 52% | 64% | 32% | 46% |
Predictive Validity: We understand the gold standard to demonstrate validity is to determine the degree to which the performance on the measure predicts an outcome. For this measure, we chose donation rate as the outcome. Donation rate is an outcome, and the higher donations are, the more effective the organ procurement system is considered to be by CMS and the OPTN. We used simple regression to determine if authorization rate predicts donation rate. While a small N is a significant limitation of this analysis, we conducted it to ensure that all avenues for analysis were pursued.
Table 2. Authorization Rate vs. Donation Rate, R-Squared Value = 0.0355
OPO 1 | OPO 2 | OPO 3 | OPO 4 | OPO 5 | OPO 6 | |
| Authorization Rate | 64 | 47 | 59 | 52 | 73 | 63 |
| Donation Rate | 12 | 17 | 11 | 11 | 18 | 15 |
Reference:
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. (2026). 42 C.F.R. § 486.342: Condition: Requesting consent. https://www.ecfr.gov/current/title-42/part-486/section-486.342.
Person or Encounter Level
Please refer to Section 5.3.3 Methods of Validity Testing. We relied on OPO unpublished audits of their authorization records showing 99 to 100 percent authorization record completion. OPOs are implementing a uniform system of auditing for data validity moving forward. The audit tool is available upon request.
Accountable Entity Level
The comparison in Exhibit 6 in Attachment B shows the number of donations authorized by the OPO and the number of recovered organs recorded in SRTR. The numbers are consistently lower for the recovered organs than the number of authorizations. We also compared the authorization counts received directly from the OPO to what was reported in the SRTR file (these files were used in the development of other measures).
Please refer to Exhibit 6 in Attachment B.
Person or Encounter Level
Please refer to Section 5.3.3 Methods of Validity Testing.
Accountable Entity Level
As discussed in Section 5.3.4, the results are consistent with the expectations for how the measure should work. Logically, the count of authorized donors should be less than the count of donors who were approached (after a referral), and this is how the measure functions. It is a reasonable validation of the measure.
Please refer to Exhibit 6 in Attachment B for the results.
Risk Adjustment
Because this is an intermediate outcome measure, risk adjustment may obscure critical information. There is some debate in the literature about donation regarding the appropriateness of risk adjustment in general (Goldberg et al., 2020). We followed the Office of the Assistant Secretary for Planning and Evaluation’s recommendation not to risk-adjust process measures and extended that logic to this measure because of the risk of confounding factors. Risk adjustment of process measures is also not necessary if the measure is used purely for informational purposes and not used alone for certifying or decertifying an OPO. While the Authorization Rate is an intermediate outcome measure, we think the same considerations apply as for process measures.
Therefore, to better understand the underlying dynamics and to provide information without definitely deciding to risk adjust, we calculated stratified rates. The stratified rates allow us to understand how the OPOs differed across groups of interest and where there are some historical patterns of different donation rates (ASPE, 2020).
We stratified by age, race, and gender. We considered that different age concentrations for the different OPO DSAs could affect Authorization Rates. The goal was to test if and how age, race, and gender composition differed and how they could affect the measure outcomes. Specifically, areas with older ages may have higher death rates, but that may not translate directly to higher Authorization Rates. Stratifying by age allows us to observe if Authorization Rates differ by age. One issue for OPOs is obtaining full participation in the donation process for all races. We have stratified the rates by race to better understand if there are racial differences in donation rates and if minorities have lower Authorization Rates. For gender, generally men have higher death rates at younger ages. Observing the differences by gender will allow us to see if there are noticeable differences in authorizations by gender and understand if gender composition affects the measure (CMS, 2025; CMS, 2023; NQF, 2014; Vogel & Chen 2018).
References:
Centers for Medicare & Medicaid Services. (2023, August). Risk adjustment and risk stratification in quality measurement. Supplement material to the CMS Measures Management System (MMS) Hub. https://mmshub.cms.gov/sites/default/files/Risk-Adjustment-in-Quality-Measurement.pdf.
Centers for Medicare & Medicaid Services. (2025, May). Ways to account for risk. CMS Measures Management System (MMS). https://mmshub.cms.gov/measure-lifecycle/measure-specification/risk-adjustment/ways-to-account-for-risk.
Goldberg, D., Doby, B., & Lynch, R. (2020, August). Addressing critiques of the proposed CMS metric of organ procurement organ performance: More data isn’t better. Transplantation, 104, 8.
National Quality Forum. (2014, August). Risk adjustment for socioeconomic status or other sociodemographic factors. National Quality Forum. https://digitalassets.jointcommission.org/api/public/content/ed011a6479574761b11211d55eae0bc3?v=67b20abf.
Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. (2020). Second report to Congress on social risk factors and performance in Medicare’s Value-Based Purchasing Program. https://aspe.hhs.gov/sites/default/files/migrated_legacy_files/195191/Second-IMPACT-SES-Report-to-Congress.pdf.
Vogel, W. B., & Chen, G. J. (2018). An introduction to the why and how of risk adjustment. Biostatistics & Epidemiology, 4, 84–97. https://doi.org/10.1080/24709360.2018.1519990.
Please refer to Exhibit 7 in Attachment B.
The Authorization Rate measure was stratified by age, race, and gender. The distributions for those variables are shown in Exhibit 7.
We selected the stratification variables based on what OPOs, our TEP, and the literature indicated would impact the organ donation process.
In this section, we present Authorization Rates stratified by age, race, and gender. Please refer to Exhibits 8–13 in Attachment B for the interpretation of our results.
Use & Usability
Use
The Authorization Rate measure calculates the authorization rate for organ donation, or authorizations per 100 approaches, among referred potential donors or their next of kin within the Organ Procurement Organization’s (OPO’s) donation service area (DSA) in a calendar year. The goal of this measure is to provide OPOs with data about the rate of authorizations that can be used to better understand the effectiveness of their process.
The donor hospital triggers contact with the OPO as they identify a potential donor (a referral). OPO staff determine medical suitability for donation and, if appropriate, conduct an approach conversation with the referred potential organ donor or their next of kin to discuss the possibility of organ donation. While donations must occur within specific medical timeframes for organs to remain viable for transplant, highly skilled OPO professionals are trained to approach discussions with compassion and respect (AOPO, 2026). Clinician training on communication skills is crucial in this area (Siminoff et al., 2024); highly trained practitioners are more likely to have higher authorization rates (Witjes et al., 2019).
Risk adjustment for this measure can cause patterns or other information to be obscured due to confounding factors and it being an intermediate outcome measure. In lieu of risk adjustment, this measure is stratified by race, gender/sex, and age, in order to understand any differences in these categories. For race, this means a division into “Non-Hispanic White” and “Non-White” populations. (People of Hispanic ethnicity are included in the “Non-White” category because some OPOs coded “Hispanic” as a mutually exclusive “race” category.) Stratification by age permits evaluation of the population breakdown of the authorizations and referrals received by the OPO as compared to the proportions of potential donors in the OPO’s DSA. As men have higher death rates at younger ages, gender composition may affect this measure and stratifying for gender allows those insights (Vogel & Chen, 2018).
Ultimately, the Authorization Rate measure can be used to identify ways to improve authorization processes. Since it quantifies the outcome (i.e., authorizations) of approach conversations, OPOs can use this rate to, for example, break down outcomes by grouping such as donor registration status or type of organ donor (Donation after Brain Death (DBD) vs. Donation after Circulatory Death (DCD)) and consider more targeted approaches and interventions.
References:
Association of Organ Procurement Organizations (AOPO). (2026, March 13). AOPO Statement on CMS Guidance Reinforcing Safeguards [Press Release]. AOPO Statement on CMS Guidance Reinforcing Safeguards - AOPO.
Siminoff, L. A., Alolod, G. P., McGregor, H., et al. (2024). Developing online communication training to request donation for vascularized composite allotransplantation (VCA): Improving performance to match new US organ donation targets. BMC Med Educ, 24, 77. https://doi.org/10.1186/s12909-024-05026-9.
Vogel, W. B., & Chen, G. J. (2018). An introduction to the why and how of risk adjustment. Biostatistics & Epidemiology, 4, 84–97. https://doi.org/10.1080/24709360.2018.1519990.
Witjes, M., Jansen, N. E., van Dongen, J., Herold, I. H. F., Otterspoor, L., Haase-Kromwijk, B. J. J. M., van der Hoeven, J. G., & Abdo, W. F. (2020, September). Appointing nurses trained in organ donation to improve family consent rates. Nurs Crit Care, 25(5), 299–304. doi:10.1111/nicc.12462. Epub 2019 Jul 11. PMID: 31294520; PMCID: PMC7507830.
Usability
The literature and TEP and OPO stakeholder group feedback indicated that poor performance of the Authorization Rate measure can result from a lack of cultural sensitivity or ineffective communication skills used by OPO staff when conducting emotional conversations with families (Bodenheimer et al., 2012; Rahman et al., 2026b; Rahman et al., 2026c; Siminoff et al., 2024). Providing both initial and additional training to staff is a viable mechanism to overcome these variables. Additionally, OPOs described conducting case reviews to provide further insight and developing a targeted action plan when performance is suboptimal (Rahman et al., 2026a). Furthermore, stakeholders suggested strengthening collaboration with hospitals and other partners and improving public perception of donation to improve performance on this measure.
A robust internal quality improvement program can assist OPOs in identifying root causes and developing targeted strategies to improve their Authorization Rate metric. By using a Plan, Do, Study, Act framework, OPOs can implement small tests of change and alter authorization strategies for broader implementation. The following list of potential activities or tests of change is realistic and attainable for OPOs. Collectively, these activities are achievable within existing OPO structures and workflows, and they are expected to be implemented with minimal difficulty, as they largely build upon established practices, ongoing training frameworks, and existing partnerships.
- Strengthening collaboration with hospital staff and clinical partners.
- Enhancing community outreach and public education efforts.
- Implementing family readiness and engagement assessments.
- Conducting comprehensive case reviews for both authorized and not authorized outcomes.
- Providing initial and ongoing staff training.
References:
Bodenheimer, H. C., Jr., Okun, J. M., Tajik, W., Obadia, J., Icitovic, N., Friedmann, P., Marquez, E., & Goldstein, M. J. (2012). The impact of race on organ donation authorization discussed in the context of liver transplantation. Trans Am Clin Climatol Assoc, 123, 64–77, discussion 77–8. PMID: 23303969; PMCID: PMC3540608.
Rahman, M., Arellano, O., Lind, C., Newton, L., O’Connor, J., & Paraboschi, J. (2026a, April 7). OPO site visit final report [Internal document]. Econometrica, Inc., Bethesda, MD.
Rahman, M., Arellano, O., & O’Connor, J. (2026b). Organ Procurement Organization (OPO) performance measurement technical expert panel (TEP) meetings 1–4 summary overview [Internal document]. Econometrica, Inc., Bethesda, MD.
Rahman, M., Arellano, O., & O’Connor, J. (2026c). Organ Procurement Organization (OPO) stakeholder group meetings 1–5 summary overview [Internal document]. Econometrica, Inc., Bethesda, MD.
Siminoff, L. A., Alolod, G. P., McGregor, H., et al. (2024). Developing online communication training to request donation for vascularized composite allotransplantation (VCA): Improving performance to match new US organ donation targets. BMC Med Educ, 24, 77. https://doi.org/10.1186/s12909-024-05026-9.
The benefits of this measure being available for use and endorsed outweigh the potential unintended consequences associated with its use. However, there are two potential unintended consequences we identified through discussions with OPOs.
One potential unintended consequence is that hospitals may support families in not honoring (FPA), creating friction and resistance between the OPO and donor family that could result in poor performance of the measure. However, this can be addressed through hospital staff training and education, relationship-building, and sufficient time for conversations with the family. It is imperative that obtaining authorization involves informed, voluntary decision-making for families making the decision for donation.
A second potential unintended consequence is that authorization may be perceived by the family as coercive (Siminoff et al., 2024). If OPO staff are overly focused on obtaining consent, it may create implicit pressure that could cause an unintentional shift in the conversation toward persuasion rather than support. This can be addressed by ensuring that OPO staff involved in authorization receive specialized training and education on communication skills and maintain demonstrated competence in authorization conversations. Courses on authorization practices such as those provided by the North American Transplant Coordinators Organization help ensure that OPO staff approach authorization in a skilled and consistent manner.
Overall, there was consensus among the OPO test sites that the benefits of implementing an endorsed Authorization Rate measure far outweigh any unintended consequences, which can be mitigated through the strategies described above.
Reference:
Siminoff, L. A., Alolod, G. P., McGregor, H., et al. (2024). Developing online communication training to request donation for vascularized composite allotransplantation (VCA): Improving performance to match new US organ donation targets. BMC Med Educ, 24, 77. https://doi.org/10.1186/s12909-024-05026-9.
Comments
Staff Preliminary Assessment
CBE #5603 Staff Assessment
Importance
Strengths:
- A clear logic model for the organ donation process is provided, depicting the relationships between inputs (e.g., demand for organs, access to medical facilities), donation activities (e.g., receipt and management of referrals), and desired outcomes (e.g., more organs transplanted). This model demonstrates how the measure's implementation will lead to the anticipated outputs.
- If implemented, the developer argued the measure’s anticipated impact on important outcomes, such donation authorizations, would be positive. The developer argued that because the measure would provide Organ Procurement Organizations (OPOs) with a standardized means to assess their success in attaining authorizations among potential donors, it would enable them to identify groups with lower authorization rates and to develop interventions that increase authorization rates for those groups.
- The measure is supported by a comprehensive evidence review, including a National Academies of Sciences, Engineering, and Medicine (NASEM) study, a scientific literature review, seven site visits conducted with OPOs, and consultation with the technical expert panel (TEP). This work demonstrates a clear net benefit of creating measures to assess the processes that precede organ donation, including Authorization Rate, represent a critical step in the process of organ donations. The measure developer argues that implementing this measure will allow OPOs to monitor their success in attaining authorizations using a standardized approach, which could in turn increase in the number of organs available for transplant.
- The developer described a sufficient search process. They did not identify any similar measures or measures. Instead, existing measures focus on Donation Rate and Transplantation Rate, which are affected by many factors outside an OPO’s control.
- Description of patient input supports the conclusion that Authorization Rate is meaningful with at least moderate certainty. Patient input was obtained through 7 OPO site visits totaling 45 interviews with OPO employees and a qualitative study conducted with 16 participants including donor families, transplant recipients, and OPO stakeholders.
Limitations:
- The committee should consider whether the stratification scheme described in section 1.19 allows OPOs to make meaningful and appropriate comparisons. For example, the measure developer noted that Authorization Rates are lower among Black and American Indian/Alaska Native individuals than people of other races/ethnicities and suggests the measure could support efforts to increase Authorization Rates among these groups. However, the proposed stratification scheme only provides data on Non-Hispanic White vs. “Non-White” population groups.
Rationale:
- This new measure meets all criteria for 'Met' for importance due to the significant problem it addresses, its robust evidence base, a plausible performance gap, justifiable advantages over existing measures, and a well-articulated logic model, making it essential for addressing Authorization Rate among OPOs.
- There is at least moderate confidence that the business case is adequate, i.e., that implementing a standardized measure of Authorization Rate will improve organ donation process monitoring, ultimately leading to more viable organs becoming available to organ transplant centers.
Closing Care Gaps
The developer did not address this optional domain.
Feasibility Assessment
Strengths:
- All required data elements are routinely collected by OPOs and all variables are constructed routinely in OPO’s current data management processes.
- The developer described how, while there were initially challenges with constructing some variables needed for the measure, those challenges were resolved by creating clearer definitions for these variables. For example, the initial definition of an authorization was revised to reflect that the authority to agree to a donation is guided by the Uniform Anatomical Gift Act hierarchy.
- The developer described the costs and burden associated with data collection and data entry, validation, and analysis. They indicated there is little to no additional burden for OPOs to implement the measures as defined.
- Test sites indicate the data are already being collected and tracked by OPOs. Some of this data is collected manually because some referrals are placed by telephone. There is also manual labor involved in records reviews. However, OPOs are already collecting these data and conducting these reviews. Implementing the measure will not result in any additional burden for OPOs.
- The measure is calculated using unique case IDs for each patient record. The measure developer asserts that because the measure is calculated based on a large population, it would be almost impossible to identify an individual.
- There are no fees, licensing, or other requirements to use any aspect of the measure (e.g., value/code set, risk model, programming code, algorithm).
Limitations:
- Test sites utilized two different Electronic Donor Resources (EDRs). The application could be strengthened by discussion about the feasibility of calculating the measure in additional EDRs.
Rationale:
- This new measure meets all criteria for 'Met' for feasibility due to its well-documented feasibility assessment, clear and implementable data collection strategy, clear description of adjustments made to specifications, and transparent handling of patient confidentiality, burden, licensing, and fees. These factors collectively ensure that the measure can be implemented effectively and sustainably in a real-world healthcare setting.
Scientific Acceptability
Strengths:
- Data used for reliability testing were sourced from six OPOs which offered to provide data for reliability testing for each year in the period 2021 to 2024. One of the OPOs provided data for years 2022 to 2024.
- The developer performed the required reliability testing for this new measure by referencing evidence from OPOs which demonstrated 100% record completion for donors, with most OPOs using a double-documentation system where staff record the authorization and then the authorization is supported by additional documentation. The developer stated that all OPOs they spoke with conduct quality assurance checks for proper documentation at least annually.
Limitations:
- Note that accountable entity-level reliability testing is not required for initial endorsement, and is not considered in the rating.
Rationale:
- This new measure is rated as 'Met' for reliability because the developer provided the required evidence for this measure to demonstrate sufficient reliability at the data element-level.
Strengths:
- The developer stated that all OPOs provided evidence of a 100% completion rate for authorizations for donation (the numerator), and that most OPOs use a double-documentation system where information entered into the record by a staff member is accompanied by documentation such as a signed authorization from next of kin or a copy of a driver's license declaring the donor's permission to use their organs.
Limitations:
- As there is no external "gold" standard to compare with authorizations documented by OPOs, the principal risks to validity of the numerator are non-standardized processes across OPOs for documenting authorizations and the use of unstructured fields to capture data. The developer acknowledges the lack of a standardized process across OPOs, but it would be helpful for the developer to provide one or more representative examples of data entry tools used to collect authorizations.
- Regarding the validity of data elements in the denominator, this measure shares most of those same data elements with CBE 5602 (approaches), and the limitations of data element validity for CBE 5602 should be considered here as well.
- Note that accountable entity level validity testing is not required for initial endorsement, and is not considered in the rating.
- The developer applied stratification to measure results based on age, gender, and race. However, it is unclear in the submission how the risk factors were selected and if the factors vary in prevalence across measured entities, warranting stratification for meaningful entity comparisons. The analytical results provided address equity and descriptive reporting, but do not demonstrate that stratification improves measure validity or fairness of comparisons across entities.
Rationale:
- This new measure is rated as ‘Not Met But Addressable’ for validity because the validity testing results partially support an inference of validity for the measure, suggesting that the measure somewhat accurately reflects performance on quality and can distinguish good from poor performance to a limited extent. There are several opportunities for the developer to provide additional information that could improve the assessment of data element validity.
- Stratification was applied to manage differences due to patient characteristics, but the developer did not demonstrate how the patient characteristics were selected or that they impact measure score comparisons across entities.
Use and Usability
Strengths:
- The measure is not currently in use, but the developer described the measure as appropriate for in internal quality assurance and performance improvement (QAPI) activities, quality improvement initiatives with external benchmarking, public reporting, and regulatory and accreditation programs.
- The developer provided a summary of how accountable entities can use the measure results to improve performance. To increase Authorization Rates OPOs can strengthen collaboration with hospital staff and clinical partners, enhance community outreach and public education efforts, implement family readiness and engagement assessments, conduct case reviews for both authorized and not authorized outcomes, and provide ongoing staff training.
- A potential unintended consequence the measure developer identified is donor families perceiving authorization requests as coercive. The developer stated that this could be addressed by ensuring OPO staff involved in obtaining authorization receive specialized training and education on communication skills and maintain demonstrated competence in authorization conversations.
Limitations:
- None identified.
Rationale:
- This new measure is rated ‘Met’ for use and usability because there is a clear plan for use in at least one accountability application and the measure provides actionable information for improvement. The developer reported that entities can address potential unintended consequences through educating OPO staff and hospital employees to ensure approach conversations are handled appropriately.
Committee Independent Review
Important intermediate outcome metric in organ donor process
Importance
Clearly demonstrates importance through review of literature and engagement with diverse stakeholders including OPOs and families. Demonstrated that no measure currently exists to accurately track performance authorization for organ donation.
Closing Care Gaps
Not required
Feasibility Assessment
All data elements for the Authorization Rate measure are available in structured fields. During measure testing, some standardization of data elements was necessary to allow comparisons across OPOs. Test sites indicated that there will be no additional cost or burden imposed by this measure implementation as defined. Most OPOs noted that there will be minimal to no impact on clinician/provider workflow.
Scientific Acceptability
The Authorization Rate reliability has a mean value of 0.9147, with a 95-percent confidence interval of [0.9106, 0.9187], above the 0.60 threshold. Unpublished audits of OPO authorization records showing 99 to 100 percent authorization record completion.
While most metrics of validity were met, there are similar questions about risk stratification. Namely, the developers discuss disparities identified in the literature regarding cultural sensitivity, particularly among Black/African American patients, but their risk stratification grossly lumps groups by Hispanic ethnicity
Use and Usability
Providers clear and measurable QI initiatives to support the measure use, free measure with no proprietary or licensing constraints. Considered potential unintended consequences with mitigation strategies.
Concerns similar to measure 5602.
Importance
General Info “This measure calculates the Authorization Rate for organ donation (defined as authorizations per 100 approaches) among referred potential organ donors or their next of kin within the Organ Procurement Organization’s (OPO’s) donation service area (DSA) in a calendar year.”Note exclusions age 80 although there is no age limit for donors. “A thorough review of existing measures in the CMS Measures Inventory Tool (CMIT) also indicated that there were no measures comparable to the one proposed for endorsement” “The CMS Blueprint Measure Lifecycle was used to guide our work due to its rigorous and established approach to measure development and validation…” “These findings collectively indicate the importance of the Authorization Rate measure in advancing the mission of OPOs to provide a compassionate and vital link between donors and patients awaiting lifesaving organ transplants.” Impact: “The proposed Authorization Rate measure will provide OPOs with a standardized mechanism to measure authorization rates, with the desired outcome of increasing the availability of organs for donation.”
Closing Care Gaps
optional
Feasibility Assessment
“All OPOs track their data electronically in EDRs. All data elements for the Authorization Rate measure are available in structured fields.” “All data elements used in the measure are collected routinely by OPOs.”
Scientific Acceptability
“Due to the high-cost, high-consequence nature of authorization, documentation of whether authorization took place (a binary variable found in the donor record) is highly reliable at (1) the patient or encounter level, (2) the hospital to OPO level, and (3) the entity level.”
“Due to the high-cost, high-consequence nature of authorization, documentation of whether authorization took place (a structured, binary variable found in the donor record) is highly reliable and valid at (1) the patient or encounter level, (2) the hospital to OPO level, and (3) the entity level.”
Risk adjustment. – “Because this is an intermediate outcome measure, risk adjustment may obscure critical information.”
Use and Usability
Use not in use. Future use: public reporting , accreditation, quality improvement
Usability- “poor performance of the Authorization Rate measure can result from a lack of cultural sensitivity or ineffective communication skills used by OPO staff”-suggest training.
Summary
If not met but addressable issues are resolved-accept. Note: Iowa Donor Network supports
Authorization Rate for Organ Donation Among Approached (#5603)
Importance
The importance of the measure is adequately described.
Closing Care Gaps
Addresses a measure that is not currently available.
Feasibility Assessment
Data routinely collected for administrative purposes although standardization of the data elements may need careful work to help the measure's value as a useful indicator of performance by entities.
Scientific Acceptability
About 200 half samples were generated, intraclass correlation produced but no estimates was shared in the narrative. The applicant indicated the lack of data to test for reliability.
The validity test used resulted in a very low R-squared (0.03). Such low number on the R-squared estimate may cast serious doubt on the validity of the measure.
Use and Usability
Such a measure may be important in shining light on awareness and active engagement of organ donation entities in general. However, the measure doesn't appear ready public dissemination at the moment.
Summary
This measure represents a serious effort to illuminate the challenges surrounding organ donation in the United States. However, based on its current limitations, it does not yet appear ready for public use.
The measure would benefit from standardized data inputs and a thoughtful approach to risk-adjustment, despite concerns some have raised about applying risk-adjustment to process measures. Several factors, including social and environmental conditions, could meaningfully influence performance on this measure. In particular, cultural attitudes toward organ donation vary widely across communities, and these differences could substantially affect results unless they are explicitly accounted for through risk adjustment.
I support.
Importance
Closing Care Gaps
Feasibility Assessment
Scientific Acceptability
Use and Usability
Summary
I am in support of this measure.
Need more information
Importance
Although I see the importance of improving access to organ donations, I struggle to see the argument presented on how this measure will support such improvement. I would like more information regarding why this measure is not something already being measured by OPO as a sort of KPI. How will this measure increase organ donations? I do appreciate the denominator selected, that would take out some of my other concerns I have had in the prior similar measures.
Closing Care Gaps
Feasibility Assessment
Agree with Batelle.
Scientific Acceptability
Agree with Batelle.
Agree with Batelle.
Use and Usability
My struggle is related to this measure’s use. In my mind this should be something already measured by OPOs. Otherwise, how do they ensure their services are needed and they are performing at their highest level? Also, the stratification by race is minimal and I struggle to understand how this will support improving the cultural sensitivity of the staff conducting these interviews, as identified.
Summary
This measure in my mind should be something already implemented in OPOs as a KPI. Otherwise, how are OPOs ensuring their service is appropriate? The stratification by race also concerns me if the ultimate goal is to improve cultural sensitivity, it should include additional categories outside of white non-hispanic and non-white.
Looking forward to further discussion.
(No subject)
Importance
Based upon the strong support of the OPO network in the public comments, reflects that this measure would show an important process step in the organ donation process. A useful framework highlights the step from potential donor to referred donor to authorized donor to actual donor to transplanted organs. Having a series of process measures would allow health systems and OPOs to more accurately identify where performance issues exist and then develop plans to improve.
Closing Care Gaps
Optional
Feasibility Assessment
Scientific Acceptability
Use and Usability
With potential addition of 4 process metrics (5601, 5602, 5603, 5604) need to be cognizant of the cumulative burden of measuring all of these measures and for local teams to implement improvements across all 4 measures.
Additionally, this metric may be more likely to put pressure on the OPO from converting a patient from a referral to a donor. Would like thoughts on why this measure is needed in addition to the referral metric.
(No subject)
Importance
Closing Care Gaps
Feasibility Assessment
Scientific Acceptability
Agree with staff comments.
Data from OPOs failing under current CMS tier system not included which might inform discussion of validity. See comments on referral.
Use and Usability
Agree with staff comments.
Organ Donation Auth Rate
Importance
Clear logic model that describes the relationship between access to medical facilities, demand for organs, donation activities, and outcomes. Comprehensive lit review. Intends to improve organ donation process monitoring.
Closing Care Gaps
Developer did not address
Feasibility Assessment
Routinely collected data in current processes; Little to no additional burden for collection; No barrier to use (no licensing fee). Developer may want to expand discussion for calculation in additional EDRs.
Scientific Acceptability
Agree with Battelle Comments
Agree with Battelle Comments
Use and Usability
This measure does not currently exist in accountability programs but has a plan for QAPI use.
Summary
Implementation of this measure will improve moniring of the organ donation process and has a path for inclusion in QAPI activities. Encourage developer to strengthen scientific validity for endorsement.
CBE #5603: Authorization Rate for Organ Donation
Importance
Closing Care Gaps
Optional
Feasibility Assessment
All data elements used in the measure are collected routinely by OPOs. OPOs must have a written protocol for donation decision-making (authorization).
Scientific Acceptability
Strong reliability results
More clarity is needed. I can't follow what type of validity testing they performed in comparison to my understanding of the types of validity testing conducted for PMs (e.g., face validity).
Use and Usability
Not in use but planned use is described.
Summary
Overall, I think this a good measure. I need clarity on the validity testing and can see the unintended consequences that were described.
(No subject)
Importance
Feasibility Assessment
Scientific Acceptability
agree with concerns about unstructured authorization documentation, although suspect this likely does not impact measure results
Public Comments
Comment in Support of CBE ID 5603
Please see attached.
Response to Public Comment
Thank you for sharing your personal experience with organ donation. Your thoughtful comments support the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to share your perspective.
Public Comment CBE ID: 5603
Please see attached.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
NEDS Public Comment Letter CBE IDs: 5601 -5604
Please see attached
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
AOPO Supports the Authorization Rate Measure
The Partnership for Quality Measurement
P.O. Box 1532
Brunswick, GA 31521
RE: CBE IDs: 5601, 5602, 5603, 5604
Dear Partnership for Quality Measurement (PQM) Team:
The Association of Organ Procurement Organizations (AOPO) appreciates the opportunity to provide comments on the following measures:
BACKGROUND
AOPO is the national trade association representing 47 of the nation’s organ procurement organizations (OPOs). OPOs are federally designated, non-profit organizations responsible for facilitating deceased organ donation in partnership with donor hospitals, donor families, transplant centers, and other stakeholders across the donation and transplantation system. OPOs serve every community in the United States and play a critical role in helping save and improve lives through organ donation and transplantation.
DISCUSSION
AOPO strongly supports endorsement of CBE IDs 5601, 5602, 5603, and 5604 because they provide a more accurate, actionable, and accountable framework for evaluating organ donation performance than the measures currently used by CMS. These measures are critical to strengthening the nation's organ donation system and ensuring that every donation opportunity is maximized.
Meaningful improvement in the organ donation system depends on performance measures that accurately assess the responsibilities of each stakeholder. Effective measurement should evaluate the activities organ procurement organizations directly control, rather than relying solely on end-stage outcomes influenced by multiple stakeholders. When metrics fail to reflect actual performance, they can obscure opportunities for improvement, misdirect accountability, and ultimately affect patients awaiting lifesaving transplants.
Current Performance Measures Do Not Fully Measure OPO Performance
The two current CMS metrics—donation and transplant rate—do not fully reflect the work performed by OPOs. In particular, the current transplant rate reflects the performance of the broader system, including transplant centers, acceptance practices, transportation and other factors beyond an OPO’s control. This makes it difficult to fairly evaluate performance or identify where improvements are truly needed. As a result, the current framework risks unintended consequences for patients and system stability.
Endorsement Is Critical to Protecting System Stability and Patient Access
Under existing CMS regulations, nearly two thirds of OPOs could face decertification or competition this year. Based on current data, OPOs serving up to 72 percent of the U.S. population will be impacted by the end of 2026. Such widespread disruption across the donation system poses significant risks to a highly coordinated and time-sensitive donation system. The focus should be on improving performance while maintaining continuity of care for patients and donor families.
Organ donation relies on seamless collaboration among hospitals, donor families, OPOs, transplant centers, and transportation partners. Instability in any part of this process can jeopardize donation opportunities and delay transplantation for patients in need. Endorsing measures that more accurately assess OPO performance is essential to ensuring accountability while preserving continuity of care and maintaining public confidence in the system.
The Proposed Measures Are Scientifically Rigorous and Broadly Supported
AOPO, in partnership with 53 OPOs and Econometrica, Inc., launched a national effort to develop better performance metrics identified as the four measures mentioned above. These measures are the result of a rigorous, multi-stakeholder development process that included independent measure development experts, technical expert panel input, stakeholder interviews, site visits, literature review, and testing aligned with CMS measure development standards. As a result, these measures are scientifically sound, objective, and well-positioned to support national quality improvement efforts.
The development process also generated extraordinary collaboration across the OPO community. Ninety eight percent of OPOs participated in the measure development process and committed to advancing a common framework for quality improvement and accountability. This level of engagement demonstrates broad stakeholder confidence in the measures and a collective commitment to improving outcomes for donor families, transplant candidates, and recipients.
The Measures Provide Actionable Insights Throughout the Donation Process
A key strength of these measures is that they evaluate the full donation pathway, including referral, family approach, authorization, and donation. Together, they provide a comprehensive picture of the activities OPOs perform every day to facilitate organ donation.
Unlike outcome measures alone, these metrics identify where barriers exist within the donation process, enabling targeted quality improvement efforts. They support stronger hospital partnerships, improved family authorization practices, and more effective identification of donation opportunities. Most importantly, they provide actionable information that can be used to improve performance at each step of the donation process.
Endorsement Will Advance Accountability, Transparency, and More Lives Saved
Endorsing these four measures would establish a performance framework that is fairer, more transparent, and more useful for driving improvement. Accurate measurement strengthens accountability by evaluating what OPOs actually do, while also creating opportunities for collaboration and continuous quality improvement across the donation system.
Ultimately, endorsement is about more than measurement. These metrics will help maximize donation opportunities, improve coordination among stakeholders, strengthen public trust, and increase the number of organs available for transplantation. Better measurement leads to better performance, and better performance means more lives saved.
CONCLUSION
AOPO appreciates the opportunity to provide comments on the proposed measures—CBE IDs 5601, 5602, 5603, and 5604—for endorsement. We strongly support their endorsement and believe they represent a significant advancement in the measurement of OPO performance.
These measures provide a scientifically rigorous, transparent, and actionable framework that better reflects the work performed by OPOs and supports continuous quality improvement across the donation system. Endorsement by PQM would help advance a more meaningful approach to performance measurement – one that strengthens accountability, promotes collaboration, supports system stability, and ultimately helps save more lives through organ donation and transplantation.
As an organization committed to advancing strategies that increase the number of lives saved through organ donation and transplantation, AOPO offers these comments in support of that mission.
Sincerely,
Allison J. Erickson
AOPO President
Chief Administrative Officer, New England Donor Services (NEDS)
On behalf of:
The Association of Organ Procurement Organizations (AOPO)
McLean, Virginia
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
Comments in Support of the Measurement Proposal
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
The Federation of American…
The Federation of American Hospitals (FAH) supports the goal of these measures to increase referrals of and access to potential organ donors; however, it is crucial that safe outcomes and improved patient experience be maintained. In addition, the process of identifying and approaching potential donors and their families must be done respectfully and there is a real risk of unintended negative consequences with each of these four measures when used for accountability purposes. As a result, we believe that each measure must be well specified, demonstrated to be feasible, and produce reliable and valid results prior to endorsement. Perhaps most importantly, robust input from patients and families is needed to ensure that the process is respectful of their perspectives and decisions and that the measures are designed to facilitate these discussions.
The FAH believes that additional refinements and testing may be needed to address the following concerns:
The FAH asks that the committee carefully consider these items during their review of this measure.
Response to Public Comment
Thank you for your comments and for taking the time to share your concerns. We appreciate the support of the Federation of American Hospitals (FAH) in the goal of the measures and understand FAH, as the association that represents for-profit hospitals, may be concerned about the costs of these measures to hospitals. We first want to clarify that these are measures of Organ Procurement Organizations (OPOs), not hospitals. While some OPOs are hospital-based, the activities reflected in these measures are already statutorily required of OPOs and, therefore, should not result in any additional costs to OPOs. Where the measures will promote increased engagement with donor hospitals and transplant centers, those costs should be overcome by the benefits of participation in payment for donor care and lifesaving transplants. Additionally, we agree that safe outcomes and improved patient experience should be maintained, and OPOs seek to identify and approach donor families in ways that are respectful.
We entirely agree that robust input from patients and families is essential, which is why the 53 OPOs that worked to develop these measures engaged a Technical Expert Panel with transplant recipient and donor family representation and conducted interviews with transplant recipients and donor families. In addition, some of the OPO representatives in the process are also donor family members or parents or transplant recipients themselves.
Regarding your comment about the calendar year, we did display only the aggregated years of data in the tables in this report. We did this primarily because donation is a rare event, and when broken down further by year and Donation Service Area (DSA), race, gender, and age, we ran the risk of publishing a number that could allow for the identification of the OPOs in the pilot study or, more problematically, the actual donor patients. This would have violated the data use agreements in place with the pilot sites and could have caused significant harm to donor families. However, we did conduct the analysis suggested by year to understand the results. We included the years 2021–2024 to ensure that we were able to capture years that included the COVID-19 pandemic, which substantially impacted death rates and causes of death, as well as the years during which the opioid epidemic peaked. Opioid usage is also correlated with increased deaths by causes consistent with organ donation. We looked at means, medians, modes, and ranges to ensure that the measure is meaningful, including for OPOs with small DSAs.
Regarding reliability, we encourage FAH to review the detailed explanation of reliability provided in the measure and for the data provided. The Partnership for Quality Measurement (PQM) provides measure developers and stewards alternatives to conducting expensive interrater reliability studies, including submissions of reports and audit documentation to demonstrate reliability. To ensure the measure is implemented across OPOs consistently, a self-audit tool has been developed for OPOs to use to sample their data quarterly, validate it, and collect their data quality rate. These self-audits will not only serve to ensure data validity and reliability but will also help OPOs identify the root causes of data inaccuracies or errors to promote continuous quality improvement in their data.
Please see attached document…
Please see attached document.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
Versiti Public Comment CBE ID: 5603 Authorization Rate
Public comment from Versiti Blood Health regarding measure 5603 is attached.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
Public Comment CBE ID: 5601 Rate of Hospital Referrals
Please see attached comment.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
CORE Public Comment
Please see attached document.
Response to Public Comment
Thank you for your comments and for taking the time to share your concerns. We appreciate the opportunity to clarify this issue. Donors who are authorized who later become medically unsuitable would be counted as authorized in this measure. Authorization rate is one indicator of performance and not intended to be used to adversely affect Organ Procurement Organizations (OPOs). The Association of Organ Procurement Organizations (AOPO) has issued a statement regarding appropriate use of measure data. Regarding your comment on family-driven conversations, you are asking about the approach measure. A family-driven conversation would not be considered an approach, as it does not meet the definition of an approach. The detailed measure guidance issued to OPOs does cover this question, as would the technical assistance opportunities offered to OPOs. We encourage you to bring further questions to the technical assistance mailbox.
Comment in Support of the AOPO Performance Measurement Proposal
Thank you for the opportunity to provide comments on CBE ID: 5603 Authorization Rate for Organ Donation Among Approached, Referred Potential Organ Donors in the Organ Procurement Organization’s Donation Service Area in a Calendar Year (Authorization Rate) currently under review through the Partnership for Quality Measurement (PQM) endorsement process.
Obtaining authorization for organ donation requires thoughtful, nuanced conversations that are influenced by many factors, including emotional readiness, timing, trust, communication, knowledge, and social and cultural considerations. CMS appropriately requires that these critical discussions be conducted by trained, designated requestors. Organ Procurement Organizations (OPOs) are responsible for ensuring that approaches to a potential donor patient’s next-of-kin are carried out with the utmost respect, sensitivity, and professionalism. Evidence consistently shows that authorization rates are higher when donation conversations are led by trained donation professionals who are equipped to guide families through complex decisions in a compassionate and informed manner. Strengthening this process can ultimately increase the number of organs available for transplantation.
The proposed Authorization Rate measure will provide OPOs with meaningful insight into the effectiveness of their approach conversations by quantifying authorization outcomes. This metric will enable OPOs to identify opportunities for improvement, enhance communication practices, and strengthen processes that support families in making informed decisions about donation.
Currently, CMS regulations evaluate OPO performance primarily through donation and transplantation rates. These measures are important, yet they do not fully reflect the role of OPOs within the donation ecosystem. In particular, the transplant rate is influenced by the performance of the broader system—including transplant centers, allocation, and logistics—making it an imprecise measure of OPO-specific performance. Additionally, the current framework establishes a forced distribution model in which OPOs are comparatively ranked, placing organizations at risk of decertification based on relative performance rather than objective standards. This zero-sum approach—unlike any other Medicare program—introduces unnecessary instability into the nation’s organ donation and transplantation system and may ultimately place patients at risk.
True accountability and meaningful improvement require accurate, role-specific measurement. Oversight needs to reflect what OPOs directly control and influence—not just downstream outcomes. Strong, well-designed metrics enable better decision-making, clearer accountability, improved system coordination, and increased public trust. This proposed measure directly assesses a core OPO responsibility.
The measure is grounded in science, developed using CMS-aligned methodologies, and independently validated in partnership with Econometrica. This rigorous, data-driven approach ensures objectivity, reliability, and practical applicability. Endorsement and adoption of this measure will enable OPO leaders to better identify opportunities for process improvement, enhance performance, and maximize donation potential. Importantly, it will also strengthen transparency and reinforce public confidence in the donation system.
Most critically, aligning performance measurement with actual OPO responsibilities will reduce the risk of disruption caused by the current methodology and support a more stable, effective system—one that is better positioned to save lives through organ donation and transplantation.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
Public Comment CBE ID: 5603 Authorization Rate
Mid-South Transplant Foundation Public Comment on CBE ID: 5603 Authorization Rate. Please see attached.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
Lifeline of Ohio (OHLP) Public Comment
See attached comment
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
MORA comment on CBE ID:5603
Thank you for this opportunity to submit our support for this important project.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
HonorBridge Public Comment, CBE 5603
See attached
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
PQM Public Comment CBE ID5603
Public comment from Iowa Donor Network attached regarding measure 5603.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
DNAZ PQM Public Comment
Public comment from DNAZ regarding measure 5603 is attached.
DNAZ PQM Public Comment 7.1.26
Public comment from NFH regarding measure 5603 is attached.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
Comments in Support of the AOPO Performance Measurement Proposal
I appreciate the opportunity to provide comments on CBE ID: 5603 Authorization Rate for Organ Donation Among Approached, Referred Potential Organ Donors in the Organ Procurement Organization’s Donation Service Area in a Calendar Year (Authorization Rate) currently under review through the Partnership for Quality Measurement (PQM) endorsement process.
Obtaining authorization for organ donation requires thoughtful, nuanced conversations that are influenced by many factors, including emotional readiness, timing, trust, communication, knowledge, and social and cultural considerations. CMS appropriately requires that these critical discussions be conducted by trained, designated requestors. Organ Procurement Organizations (OPOs) are responsible for ensuring that approaches to a potential donor patient’s next-of-kin are carried out with the utmost respect, sensitivity, and professionalism. Evidence consistently shows that authorization rates are higher when donation conversations are led by trained donation professionals who are equipped to guide families through complex decisions in a compassionate and informed manner. Strengthening this process can ultimately increase the number of organs available for transplantation.
The proposed Authorization Rate measure will provide OPOs with meaningful insight into the effectiveness of their approach conversations by quantifying authorization outcomes. This metric will enable OPOs to identify opportunities for improvement, enhance communication practices, and strengthen processes that support families in making informed decisions about donation.
Under current CMS regulations, OPO performance is evaluated primarily through donation and transplantation rates. While important, these measures do not fully reflect the role of organ procurement organizations within the donation ecosystem. In particular, the transplant rate is influenced by the performance of the broader system—including transplant centers, allocation, and logistics—making it an imprecise measure of OPO-specific performance.
Additionally, the current framework establishes a forced distribution model in which OPOs are comparatively ranked, placing organizations at risk of decertification based on relative performance rather than objective standards. This zero-sum approach—unlike any other Medicare program—introduces unnecessary instability into the nation’s organ donation and transplantation system and may ultimately place patients at risk.
True accountability and meaningful improvement require accurate, role-specific measurement. Oversight should reflect what OPOs directly control and influence—not just downstream outcomes. Strong, well-designed metrics enable better decision-making, clearer accountability, improved system coordination, and increased public trust.
This proposed measure directly assesses a core OPO responsibility.
The measure is grounded in science, developed using CMS-aligned methodologies, and independently validated in partnership with Econometrica, an independent third-party research organization. This rigorous, data-driven approach ensures objectivity, reliability, and practical applicability.
Endorsement and adoption of this measure will enable OPO leaders to better identify opportunities for process improvement, enhance performance, and maximize donation potential. Importantly, it will also strengthen transparency and reinforce public confidence in the donation system.
Most critically, aligning performance measurement with actual OPO responsibilities will reduce the risk of disruption caused by the current methodology and support a more stable, effective system—one that is better positioned to save lives through organ donation and transplantation.
Thank you for the opportunity to comment and for your consideration of these important measures.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
Authorization Rate
By endorsing and adopting this measure, OPO leaders will be better equipped to identify improvement opportunities, enhance performance, and realize the full potential for organ donation. Just as importantly, the measure will increase transparency, strengthen accountability, and build greater public confidence in the donation system.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
Comments in Support of the AOPO Performance Measurement Proposal
Thank you for the opportunity to comment.
Obtaining authorization for organ donation requires thoughtful, nuanced conversations that are influenced by many factors, including emotional readiness, timing, trust, communication, knowledge, and social and cultural considerations. CMS appropriately requires that these critical discussions be conducted by trained, designated requestors. Organ Procurement Organizations (OPOs) are responsible for ensuring that approaches to a potential donor patient’s next-of-kin are carried out with the utmost respect, sensitivity, and professionalism. Evidence consistently shows that authorization rates are higher when donation conversations are led by trained donation professionals who are equipped to guide families through complex decisions in a compassionate and informed manner. Strengthening this process can ultimately increase the number of organs available for transplantation.
The proposed Authorization Rate measure will provide OPOs with meaningful insight into the effectiveness of their approach conversations by quantifying authorization outcomes. This metric will enable OPOs to identify opportunities for improvement, enhance communication practices, and strengthen processes that support families in making informed decisions about donation.
Thank you for the opportunity to comment and for your consideration of these important measures.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
The Partnership for Quality…
The Partnership for Quality Measurement
P.O. Box 1532
Brunswick, GA 31521
Dear Partnership for Quality Measurement (PQM) Team:
I appreciate the opportunity to provide comments on CBE ID: 5603 Authorization Rate for Organ Donation Among Approached, Referred Potential Organ Donors in the Organ Procurement Organization’s Donation Service Area in a Calendar Year.
Meaningful improvement in the organ donation system requires strong, accurate metrics that reflect the work and responsibilities of each stakeholder—not simply the final outcome. The current CMS donation and transplant rate measures do not fully capture the role of OPOs, and the transplant rate is influenced by the entire system, including transplant centers and logistics. This makes it difficult to fairly evaluate performance, identify where improvement is needed, and protect stability for patients and donor families. With nearly half of OPOs potentially facing decertification or competition this year—and OPOs serving up to 72 percent of the U.S. population potentially impacted by the end of 2026—the risk of widespread disruption is significant.
To address these concerns, AOPO partnered with 53 OPOs and Econometrica, Inc. to develop four measures that more accurately evaluate the work OPOs perform throughout the donation process—from referral and family approach through authorization and donation. Developed through a rigorous, multi-stakeholder process consistent with CMS standards, these measures provide greater transparency and allow organizations to identify specific opportunities for targeted improvement. Stronger, more actionable metrics will support accountability, continuity of care, and ultimately better outcomes for patients waiting for a lifesaving transplant.
At Iowa Donor Network, we use data-driven quality improvement efforts to strengthen hospital partnerships, improve family authorization practices, and maximize donation opportunities. The proposed measures—including referral rates, approach data, authorization rates, and hospital engagement—provide actionable information that supports continuous improvement throughout the donation process.
We review this data not only at an organizational level, but directly with our team members to help identify opportunities, reinforce best practices, and improve performance. Through my work on the AOPO Impact Committee, similar data is also used to identify successful practices and share them across the organ procurement community, supporting improvement beyond our own organization.
These accurate metrics will help ensure that every donation opportunity is maximized. They support better coordination across the system, so organs reach patients faster, and they strengthen transparency and public trust, which is essential for donation. Ultimately, better measurement means more transplants and more lives saved.
I appreciate the opportunity to provide comments on this proposed measure for endorsement. At Iowa Donor Network, we are committed to advancing thoughtful, data-driven strategies that strengthen the donation system and increase the number of lives saved through organ donation and transplantation. I offer these comments in support of that shared mission.
Sincerely,
Angie Capps
Director of Inspire the Gift, Iowa Donor Network
Member, AOPO Impact Committee
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
Gift of Life Donor Program Comment on CBE 5601-5604
Gift of Life Donor Program Comment on CBE 5601-5604
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
Comments in Support of the AOPO Performance Measurement Proposal
I appreciate the opportunity to provide comments on CBE ID: 5603 Authorization Rate for Organ Donation Among Approached, Referred Potential Organ Donors in the Organ Procurement Organization’s Donation Service Area in a Calendar Year (Authorization Rate) currently under review through the Partnership for Quality Measurement (PQM) endorsement process.
Obtaining authorization for organ donation requires thoughtful, nuanced conversations that are influenced by many factors, including emotional readiness, timing, trust, communication, knowledge, and social and cultural considerations. CMS appropriately requires that these critical discussions be conducted by trained, designated requestors. Organ Procurement Organizations (OPOs) are responsible for ensuring that approaches to a potential donor patient’s next-of-kin are carried out with the utmost respect, sensitivity, and professionalism. Evidence consistently shows that authorization rates are higher when donation conversations are led by trained donation professionals who are equipped to guide families through complex decisions in a compassionate and informed manner. Strengthening this process can ultimately increase the number of organs available for transplantation.
The proposed Authorization Rate measure will provide OPOs with meaningful insight into the effectiveness of their approach conversations by quantifying authorization outcomes. This metric will enable OPOs to identify opportunities for improvement, enhance communication practices, and strengthen processes that support families in making informed decisions about donation.
Under current CMS regulations, OPO performance is evaluated primarily through donation and transplantation rates. While important, these measures do not fully reflect the role of organ procurement organizations within the donation ecosystem. In particular, the transplant rate is influenced by the performance of the broader system—including transplant centers, allocation, and logistics—making it an imprecise measure of OPO-specific performance.
Additionally, the current framework establishes a forced distribution model in which OPOs are comparatively ranked, placing organizations at risk of decertification based on relative performance rather than objective standards. This zero-sum approach—unlike any other Medicare program—introduces unnecessary instability into the nation’s organ donation and transplantation system and may ultimately place patients at risk.
True accountability and meaningful improvement require accurate, role-specific measurement. Oversight should reflect what OPOs directly control and influence—not just downstream outcomes. Strong, well-designed metrics enable better decision-making, clearer accountability, improved system coordination, and increased public trust.
This proposed measure directly assesses a core OPO responsibility.
The measure is grounded in science, developed using CMS-aligned methodologies, and independently validated in partnership with Econometrica, an independent third-party research organization. This rigorous, data-driven approach ensures objectivity, reliability, and practical applicability.
Endorsement and adoption of this measure will enable OPO leaders to better identify opportunities for process improvement, enhance performance, and maximize donation potential. Importantly, it will also strengthen transparency and reinforce public confidence in the donation system.
Most critically, aligning performance measurement with actual OPO responsibilities will reduce the risk of disruption caused by the current methodology and support a more stable, effective system—one that is better positioned to save lives through organ donation and transplantation.
Thank you for the opportunity to comment and for your consideration of these important measures.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
5603 Public Comment
Public comment from NFH regarding measure 5603 is attached.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
Comments in Support of the AOPO Performance Measurement Proposal
Subject: Comments in Support of the AOPO Performance Measurement Proposal
I appreciate the opportunity to provide comments on CBE ID: 5603 Authorization Rate for Organ Donation Among Approached, Referred Potential Organ Donors in the Organ Procurement Organization’s Donation Service Area in a Calendar Year (Authorization Rate) currently under review through the Partnership for Quality Measurement (PQM) endorsement process.
Obtaining authorization for organ donation requires thoughtful, nuanced conversations that are influenced by many factors, including emotional readiness, timing, trust, communication, knowledge, and social and cultural considerations. CMS appropriately requires that these critical discussions be conducted by trained, designated requestors. Organ Procurement Organizations (OPOs) are responsible for ensuring that approaches to a potential donor patient’s next-of-kin are carried out with the utmost respect, sensitivity, and professionalism. Evidence consistently shows that authorization rates are higher when donation conversations are led by trained donation professionals who are equipped to guide families through complex decisions in a compassionate and informed manner. Strengthening this process can ultimately increase the number of organs available for transplantation.
The proposed Authorization Rate measure will provide OPOs with meaningful insight into the effectiveness of their approach conversations by quantifying authorization outcomes. This metric will enable OPOs to identify opportunities for improvement, enhance communication practices, and strengthen processes that support families in making informed decisions about donation.
Under current CMS regulations, OPO performance is evaluated primarily through donation and transplantation rates. While important, these measures do not fully reflect the role of organ procurement organizations within the donation ecosystem. In particular, the transplant rate is influenced by the performance of the broader system—including transplant centers, allocation, and logistics—making it an imprecise measure of OPO-specific performance.
Additionally, the current framework establishes a forced distribution model in which OPOs are comparatively ranked, placing organizations at risk of decertification based on relative performance rather than objective standards. This zero-sum approach—unlike any other Medicare program—introduces unnecessary instability into the nation’s organ donation and transplantation system and may ultimately place patients at risk.
True accountability and meaningful improvement require accurate, role-specific measurement. Oversight should reflect what OPOs directly control and influence—not just downstream outcomes. Strong, well-designed metrics enable better decision-making, clearer accountability, improved system coordination, and increased public trust.
In my more than 20 years working for health systems and physician practices I have never witnessed the use of untested and unmodified measures that do as little to assess the performance of an organization as the current CMS measures do. True accountability and meaningful improvement require accurate, role-specific measurement. Oversight should reflect what OPOs directly control and influence—not just downstream outcomes. Strong, well-designed metrics enable better decision-making, clearer accountability, improved system coordination, and increased public trust.
This proposed measure directly assesses a core OPO responsibility. The measure is grounded in science, developed using CMS-aligned methodologies, and independently validated in partnership with Econometrica, an independent third-party research organization. This rigorous, data-driven approach ensures objectivity, reliability, and practical applicability.
Endorsement and adoption of this measure will enable OPO leaders to better identify opportunities for process improvement, enhance performance, and maximize donation potential. Importantly, it will also strengthen transparency and reinforce public confidence in the donation system.
Most critically, aligning performance measurement with actual OPO responsibilities will reduce the risk of disruption caused by the current methodology and support a more stable, effective system—one that is better positioned to save lives through organ donation and transplantation.
Thank you for the opportunity to comment and for your consideration of these important measures.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
In Support of Authorization Rate Measure
I appreciate the opportunity to provide comments on CBE ID: 5603 Authorization Rate for Organ Donation Among Approached, Referred Potential Organ Donors in the Organ Procurement Organization’s Donation Service Area in a Calendar Year (Authorization Rate) currently under review through the Partnership for Quality Measurement (PQM) endorsement process.
Obtaining authorization for organ donation requires thoughtful, nuanced conversations that are influenced by many factors, including emotional readiness, timing, trust, communication, knowledge, and social and cultural considerations. CMS appropriately requires that these critical discussions be conducted by trained, designated requestors. Organ Procurement Organizations (OPOs) are responsible for ensuring that approaches to a potential donor patient’s next-of-kin are carried out with the utmost respect, sensitivity, and professionalism. Evidence consistently shows that authorization rates are higher when donation conversations are led by trained donation professionals who are equipped to guide families through complex decisions in a compassionate and informed manner. Strengthening this process can ultimately increase the number of organs available for transplantation.
The proposed Authorization Rate measure will provide OPOs with meaningful insight into the effectiveness of their approach conversations by quantifying authorization outcomes. This metric will enable OPOs to identify opportunities for improvement, enhance communication practices, and strengthen processes that support families in making informed decisions about donation.
Under current CMS regulations, OPO performance is evaluated primarily through donation and transplantation rates. While important, these measures do not fully reflect the role of organ procurement organizations within the donation ecosystem. In particular, the transplant rate is influenced by the performance of the broader system—including transplant centers, allocation, and logistics—making it an imprecise measure of OPO-specific performance.
Additionally, the current framework establishes a forced distribution model in which OPOs are comparatively ranked, placing organizations at risk of decertification based on relative performance rather than objective standards. This zero-sum approach—unlike any other Medicare program—introduces unnecessary instability into the nation’s organ donation and transplantation system and may ultimately place patients at risk.
True accountability and meaningful improvement require accurate, role-specific measurement. Oversight should reflect what OPOs directly control and influence—not just downstream outcomes. Strong, well-designed metrics enable better decision-making, clearer accountability, improved system coordination, and increased public trust.
This proposed measure directly assesses a core OPO responsibility.
The measure is grounded in science, developed using CMS-aligned methodologies, and independently validated in partnership with Econometrica, an independent third-party research organization. This rigorous, data-driven approach ensures objectivity, reliability, and practical applicability.
Endorsement and adoption of this measure will enable OPO leaders to better identify opportunities for process improvement, enhance performance, and maximize donation potential. Importantly, it will also strengthen transparency and reinforce public confidence in the donation system.
Most critically, aligning performance measurement with actual OPO responsibilities will reduce the risk of disruption caused by the current methodology and support a more stable, effective system—one that is better positioned to save lives through organ donation and transplantation.
Thank you for the opportunity to comment and for your consideration of these important measures.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.
Comment in Support of the AOPO Performance Measurement Proposal
I appreciate the opportunity to provide comments on CBE ID: 5603 Authorization Rate for Organ Donation Among Approached, Referred Potential Organ Donors in the Organ Procurement Organization’s Donation Service Area in a Calendar Year (Authorization Rate) currently under review through the Partnership for Quality Measurement (PQM) endorsement process.
Obtaining authorization for organ donation requires thoughtful, nuanced conversations that are influenced by many factors, including emotional readiness, timing, trust, communication, knowledge, and social and cultural considerations. CMS appropriately requires that these critical discussions be conducted by trained, designated requestors. Organ Procurement Organizations (OPOs) are responsible for ensuring that approaches to a potential donor patient’s next-of-kin are carried out with the utmost respect, sensitivity, and professionalism. Evidence consistently shows that authorization rates are higher when donation conversations are led by trained donation professionals who are equipped to guide families through complex decisions in a compassionate and informed manner. Strengthening this process can ultimately increase the number of organs available for transplantation.
The proposed Authorization Rate measure will provide OPOs with meaningful insight into the effectiveness of their approach conversations by quantifying authorization outcomes. This metric will enable OPOs to identify opportunities for improvement, enhance communication practices, and strengthen processes that support families in making informed decisions about donation.
Under current CMS regulations, OPO performance is evaluated primarily through donation and transplantation rates. While important, these measures do not fully reflect the role of organ procurement organizations within the donation ecosystem. In particular, the transplant rate is influenced by the performance of the broader system—including transplant centers, allocation, and logistics—making it an imprecise measure of OPO-specific performance.
Additionally, the current framework establishes a forced distribution model in which OPOs are comparatively ranked, placing organizations at risk of decertification based on relative performance rather than objective standards. This zero-sum approach—unlike any other Medicare program—introduces unnecessary instability into the nation’s organ donation and transplantation system and may ultimately place patients at risk.
True accountability and meaningful improvement require accurate, role-specific measurement. Oversight should reflect what OPOs directly control and influence—not just downstream outcomes. Strong, well-designed metrics enable better decision-making, clearer accountability, improved system coordination, and increased public trust.
This proposed measure directly assesses a core OPO responsibility.
The measure is grounded in science, developed using CMS-aligned methodologies, and independently validated in partnership with Econometrica, an independent third-party research organization. This rigorous, data-driven approach ensures objectivity, reliability, and practical applicability.
Endorsement and adoption of this measure will enable OPO leaders to better identify opportunities for process improvement, enhance performance, and maximize donation potential. Importantly, it will also strengthen transparency and reinforce public confidence in the donation system.
Most critically, aligning performance measurement with actual OPO responsibilities will reduce the risk of disruption caused by the current methodology and support a more stable, effective system—one that is better positioned to save lives through organ donation and transplantation.
Thank you for the opportunity to comment and for your consideration of these important measures.
Response to Public Comment
Thank you for responding in support of the endorsement of this measure. Your thoughtful comments provide additional context to the value of endorsed metrics that reflect OPO performance. We appreciate you taking the time to respond.