Each hospital in this state shall enter into agreements or affiliations with procurement organizations for coordination of procurement and use of anatomical gifts. Each hospital must have a protocol that ensures its maintenance of an effective donation system in order to maximize organ, tissue, and eye donation. The protocol must:
(1) be available to the public during the hospital’s normal business hours;
(2) establish a procedure for the timely notification to an organ procurement organization of individuals whose death is imminent or who have died in the hospital;
(3) establish procedures to ensure potential donors are declared dead by an appropriate practitioner in an acceptable time frame;
(4) establish procedures to ensure that hospital staff and organ procurement organization staff maintain appropriate medical treatment of potential donors while necessary testing and placement of potential donated organs, tissues, and eyes take place;
(5) ensure that all families are provided the opportunity to donate organs, tissues, and eyes, including vascular organs procured from asystolic donors;
(6) provide that the hospital use appropriately trained persons from an organ procurement organization, tissue bank, or eye bank to make inquiries relating to donations;
(7) provide for documentation of the inquiry and of its disposition in the decedent‘s medical records;
(8) require an organ procurement organization, tissue bank, or eye bank that makes inquiries relating to donations to develop a protocol for making those inquiries;
(9) encourage sensitivity to families’ beliefs and circumstances in all discussions relating to the donations;
(10) provide that the organ procurement organization determines medical suitability for organ donation and, in the absence of alternative arrangements by the hospital, the organ procurement organization determines medical suitability for tissue and eye donation, using the definition of potential tissue and eye donor and the notification protocol developed in consultation with the tissue and eye banks identified by the hospital for this purpose;
(11) ensure that the hospital works cooperatively with the designated organ procurement organization, tissue bank, and eye bank in educating staff on donation issues;
(12) ensure that the hospital works with the designated organ procurement organization, tissue bank, and eye bank in reviewing death records; and
(13) provide for monitoring of donation system effectiveness, including rates of donation, protocols, and policies, as part of the hospital’s quality improvement program.