Constant monitoring is paramount in order to detect the criticalities and improve the results of the deceased donation process. Concomitant with the institution of a regional transplantation service authority--Organizzazione Toscana Trapianti--in 2003, Tuscany adopted a program of quality assurance of the deceased donation process by compulsory reporting of all encephalic deaths from local intensive care units to the regional transplant office in Florence. The indicators we adopted were the efficiency of deceased donor (DD) identification, expressed as the ratio of encephalic deaths (ED) to total deaths with encephalic lesions (EL) (ie, ED/EL); the efficiency of DD reporting, expressed as the ratio of reported potential DD (RPDD) to total ED (ie, RPDD/ED); the efficacy of the DD process, as the ratio between actual DD (ADD) to total ED (ie, ADD/ED); the conversion rate; the percent of opposition to donation; and the incidence of DD maintenance failures. Data were collected prospectively, stratified by regional hospital consortia (Aziende Sanitarie Locali) and compared with international benchmarks. In the period 2003-2006 the mean efficiency of DD identification was 48.3%+/-4.4% (range 42.6%-53.2%); the mean efficiency of DD reporting was 95.2%+/-2.5% (range 92.5%-98.5%); the mean efficacy of the deceased donation process was 51.8%+/-2.4% (range 48.6%-54.4%); the mean conversion rate was 59.6%+/-2.2% (range 57.6%-62.7%); the mean opposition rate was 31.9%+/-1.1% (range 30.6%-33.2%); and the incidence of DD maintenance failure was 5%+/-2.9% (range 2.2%-8.7%). The breakdown analysis revealed wide interhospital variability in terms of efficiency of DD identification (from a low of 25% to a high of 80%); efficacy of the donation process (from a low of 22% to a high of 79%); and conversion rate (from a low of 29% to a high of 79%). Our results highlight that the donation process gets started in about 50% of eligible cases. Further strategies are favored to address this critical area.