Spain’s ONT: System Enablement, Not Defaults

Confidence: High. Primary reviews document the long-run system transformation and outcomes.

Fit narrative (Problem → Behavior → Solution → Product)

• Problem Market Fit: Families face difficult consent decisions; hospitals lacked consistent identification/coordination.
• Behavior Market Fit: Coordinated consent conversations and rapid ICU workflows enable donation behaviors.
• Solution Market Fit: Three-tier coordinator system, training, and protocols reduce friction at the bedside.
• Product Market Fit: Donation rates reach world-leading levels and persist over decades.

Behavior metrics (window/denominator stated)

• Window: ~1989–2023; Denominator: per-million population (pmp).
• Outcome: ~25 pmp → ~49 pmp (Spain); sustained leadership.
• Mechanism: Family conversations, coordinator coverage, DCD use, expanded criteria.

Solution enablement (environment/process)

• Coordinators in each hospital; regional/national coordination.
• Training for rapid identification and family engagement.
• Transparent data/reporting; cultural education; ICU pathways.

Limitations/confounders

• Cross-country differences; legal frameworks differ but infrastructure is the key driver.

Sources

• See review: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8128443/
• Evidence Ledger: BS-0004.

BSM vs Spain ONT (system design)

BSM Component	Spain ONT System Element	How it Enables Behavior
Abilities	Trained in‑hospital coordinators	Equip clinicians to identify donors and hold consent conversations
Motivations	Cultural education and respectful family engagement	Aligns values and reduces anxiety at decision point
Social Environment	Coordinator network; family support protocols	Normalizes donation process; provides social support
Physical Environment	ICU pathways; rapid identification workflows	Removes logistical friction in critical hours
Perception/Beliefs	Transparent reporting and communications	Builds trust in the system and process integrity