The regulatory framework for transplantation in the United States is governed by the Organ Procurement and Transplant Network (OPTN), a federally established process that is managed by an independent contractor. A component of the guidance of the OPTN is that transplant centers and organ procurement organizations (OPOs) will be subject to transparent and recurring analysis of their individual performance. With a continued disparity between the supply and the demand of transplantable organs, the systems established to evaluate performance must critically assess where opportunities for improvement exist.