The coordination of donation activities has been conceived and structured on three different, but interrelated levels: national, regional and hospital. The national level is represented by ONT and the regional level by 17 regional transplant coordination offices, one per autonomous region. These first two levels, both being dependent on the national and regional health-care authorities respectively, act as an interface between the technical and the political strata and in full support of the effective realization of the process of donation from the deceased. Any national decision on donation and transplantation activities is made in agreement with the National Transplant Committee of the Health Interterritorial Council, composed of ONT as chair and the 17 regional coordinators. The hospital level of coordination is represented by a network of hospitals officially authorized for handling procurement activities, in direct charge of developing the deceased donation process in an efficient way. This network evolved from less than 20 hospitals in 1989 to 118 in 1992, a rapid evolution which reflects the important efforts performed by the system and the political support received already in its very first years. The network has kept increasing with 181 hospitals being involved in 2012.

A transplant coordination team is appointed at each procurement hospital, constituting a team that is responsible for developing a proactive donor detection program and effectively converting potential into actual donors. The transplant coordinators (TCs) in Spain, particularly the leaders of the transplant coordination teams, have a unique profile conceived to facilitate the early identification and referral of possible or potential organ donors, the critical phase of the process of deceased donation. TCs are in-house professionals, part of the staff of the procurement hospital that is involved, rather than having professionals that are located outside of the hospitals and that would have to be contacted upon the identification of a potential donor. TCs are nominated by and report to the medical board of the hospital, hence not being dependent on the head of the transplantation teams. Most of the TCs are part-time dedicated to donation activities, which allows them to be appointed even at hospitals with a low deceased donor potential. The part-time dedication also permits these professionals to leave the coordination tasks and return to and be fully dedicated to their original activities when appropriate. Notably, the majority of the leaders of the transplant coordination teams in Spain are critical care physicians.TCs thus develop their daily activity directly at those units where 12.4 % of deaths occur in persons with a clinical condition consistent with brain death .⁹

The Quality Assurance Program in the Deceased Donation Process has become an essential tool in the consolidation of the system.¹⁰ So far focused on DBD, the program aims at assessing and monitoring the potential of deceased organ donation, evaluating performance and identifying key areas for improvement in the realization of the deceased donation process. Already in place for more than 10 years, the program is based on a continuous and systematic review of the clinical charts of all patients dying at critical care units in the procurement hospitals. The program includes an internal audit performed by TCs locally that allows the building up of specific performance reference indicators. This activity is complemented by external audits carried out by expert TCs belonging to a region different to the one to which the evaluated hospital belongs. External audits are performed under the request of regional TCs and provide a unique opportunity for sharing practices and experiences and thus identifying possible actions for improvement in the form of recommendations targeted at the transplant coordination team and the hospital managers.