Self-Assessment Tool and Clinical Audits: A Way to Manage Organ Donation and Transplantation in Hospital Settings

The self-assessment tool (SAT) of hospital management in donation and transplantation is a systematic instrument that allows reaching a situation status on Procurement and Transplantation with emphasis on the management and cultural change of Health Personnel in each care center. The SAT allows reflection on institutionalization, achievements, and the cultural change generated by donation and transplantation in Health Personnel. It also allows the evaluation of the culture of hospital donation and the formulation of plans and goals for the future. The SAT evaluates 5 components (Logistics, Education, Communication, Donation Culture, and Results Evaluation) with 30 questions and reflects the core aspects of the hospital donation process. The answers to the SAT are numbered and based on the total score. We can classify the management and its results as insufficient, basic, intermediate, and advanced. The SAT was applied in 8 hospitals whose donation results are externally audited, and their results were compared with the result of the self-assessment. The SAT was useful in supporting and guiding the work of the intra-hospital transplant coordinator; it allows the classification of the hospital, taking into account the main aspects of donation and transplant management and, based on this, generating a package of measures for improvement.