TABLE 3.

Key areas highlighted by the gap analysis in which significant shortfalls in the Greek organ donation and transplantation program were identified.

Framework domain	Key features	Details
Enabling Elements: Government: Political Support, Funding, and Long-Term Commitment	Funding	Lack of financial stability and long-term sustainability
	Government commitment	Lack of strategic planning and continuity
Enabling Elements: Government: Key Legislation	Diagnosis of brain death	Transplant legislation has defined brain death. This gives the false impression of conflicts of interest. There are no clear provisions regarding the performance of diagnostic tests or the role of ancillary testing
	Modes of donation	Pediatric live donation (LD) is prohibited. There are no provisions for adult or pediatric controlled or uncontrolled donation after circulatory death (cDCD/uDCD), withdrawal of life-saving treatment (WLST), “no-touch” time, or directed or non-directed altruistic donation
	Consent policy	An opt-in consent system is in effect
Enabling Elements: Building and Maintaining Public Support and Trust in the System	Creating public trust	There are high levels of public distrust in the system
	Periodic surveys and educational campaigns for the general public	Public awareness of organ donation is limited
	Communication strategies	There are no targeted national communication strategies
Structural Elements: National Transplant Organization	Leadership capacity	The National Transplant Organization (NTO) has no authority to enact reforms in the system
	Organizational structure	The current organizational structure does not correspond with the responsibilities defined by national legislation
	Organizational resources	The program is short-staffed and under-resourced
	National and international responsibilities	The responsibilities defined by legislation follow international best practices. However, the organization’s national responsibilities are not met and few international collaborations have been established
Structural Elements: Infrastructure	Workforce	The numbers of transplant surgeons, physicians, and anesthetists are below the European average
	Facilities	There are five transplant centers in Greece. One new transplant center is currently under construction. The goal is to accommodate additional pediatric and adult transplant services. The capacity of the operative theaters and access to imaging, endoscopy, pathology, and histocompatibility services are below the European standard at all five of the existing transplant centers
Structural Elements: Reimbursement of Staff and Facilities	Mechanisms of reimbursement	The KEN-DRG diagnosis-related group reimbursement system covers transplantation activities but not activities related to donation (e.g., maintenance of donors in the intensive care unit, organ retrieval, among other activities). There is no provision for reimbursement of organ donor coordinators for work specifically related to donation
	Incentives	Donation activities represent a considerable financial burden to participating hospitals
Structural Elements: Registries, Databases and Information Technology (IT)	Registries and waiting lists	There are no living donation (LD) registries
	IT and data protection	Critical donor data are not easily accessed by the different parties involved due to the absence of a functional IT system
Structural Elements: Quality Standards and Continual Quality Improvement	Maintaining quality standards	While quality standards for authorization and licensing of transplant units are clearly defined in national legislation, there is no evidence of regular inspection of transplant facilities, equipment, or personnel. There are no quality standards provided to guide donation, pre-transplant, or post-transplant care. A few quality indicators are monitored annually by the NTO.
	Driving quality improvement	Although performance data comparing transplant centers are published every 3 years, there are no nationally agreed-upon procedures designed to facilitate improvement. No evidence of quality improvement interventions was found
Operational Elements: Prevention	Primary prevention	There are no public health programs designed to prevent heart, lung, liver, and kidney disease
	Secondary prevention	There are no screening programs targeting populations at high risk of developing heart, lung, liver, and/or kidney disease
Operational Elements: Deceased Donation	Donation coordination	Although the qualifications, training, duties, and responsibilities of organ donation coordinators (ODCs) are defined by national legislation, there is no legislative provision for protected time to perform duties or any form of financial reimbursement. Most of the ODC posts in Greece remain unfilled
	Donor evaluation and management	There are no nationally agreed-upon guidelines for the evaluation and management of deceased donors
	Organ retrieval, preservation, and transport	There are no nationally agreed-upon protocols for organ retrieval, preservation, or transport
Operational Elements: Live Donation (LD)	Promoting LD	Although there are legislative provisions that address reimbursement of living donors for costs incurred, there are currently no policies that promote living donation
	Assessment of living donors	There are no nationally agreed-upon guidelines for the evaluation and management of living donors
Operational Elements: Transplantation	Referral and assessment for transplant	There are no nationally agreed-upon criteria or standardized processes to guide patient referrals and assessments for suitability for transplant. There are also no nationally agreed-upon criteria for listing decisions
	Transplant coordination	Only seven transplant recipient coordinators, all of whom are all based at the NTO headquarters, are responsible for the coordination of all transplant procedures throughout the entire country. Because of staff shortages, this service is not available on all days or at all times
	Surgery and perioperative care	The lack of physical and human resources hinders timely access to operating theaters. There are no standardized national peri-operative care protocols
	Access to post-transplant care	Patients in transplant units are followed-up routinely by multidisciplinary transplant teams. Some patients need to travel long distances for routine check-ups. There is no provision for shared-care protocols nor any infrastructure to support telemedicine
Operational Elements: Post-Transplant Follow-Up	National follow-up guidelines	National follow-up guidelines are lacking
	National outcomes monitoring	While short-term (1 year) graft and patient survival rates are monitored by the NTO, mid-term and long-term outcomes are not monitored
Training and Research: Research and Development	Research outputs	Minimal research is performed. Participation in international research efforts remains poor
	Research facilities and funding	There are no official research funding bodies. Access to research facilities (e.g., experimental laboratories, experimental surgery facilities) remains limited
Training and Research: Teaching, Training, and Professional Development	Continuous professional development for nurses and intensivists	Organ donation is not included as a core training module for intensivists or their support staff
	Continuous professional development for organ donation coordinators	Although the NTO has developed a sophisticated curriculum for training coordinators in cooperation with the Transplant Procurement Management-Donation and Transplantation Institute (TPM-DTI), this program is no longer operational
	Continuous professional development for physicians and transplant surgeons	There are no dedicated training programs for transplant surgeons or physicians
Professional Organizations and Scientific Societies	Engagement	Professional organizations and scientific societies are not involved in the development of national transplantation policy