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Standard Seven: The blood standard quality improvement cycle

Standard Seven: The blood standard quality improvement cycle. Philippa Kirkpatrick. Standard 1 Governance for Safety and Quality in Health Service Organisations. Standard 2 Partnering with Consumers. Standard 3 Healthcare Associated Infections. Standard 10 Preventing Falls and

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Standard Seven: The blood standard quality improvement cycle

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  1. Standard Seven:The blood standard quality improvement cycle Philippa Kirkpatrick

  2. Standard 1 Governance for Safety and Quality in Health Service Organisations Standard 2 Partnering with Consumers Standard 3 Healthcare Associated Infections Standard 10 Preventing Falls and Harm from Falls Standard 4 Medication Safety Standard 9 Recognising and Responding to Clinical Deterioration in Acute Health Care Standard 5 Patient Identification and Procedure Matching Standard 8 Preventing and Managing Pressure Injuries Standard 7 Blood and Blood Products Standard 7 Blood and Blood Products Standard 6 Clinical Handover The NSQHS Standards

  3. Why a blood standard? Inherent risks Ingrained in the culture of medical practice Inappropriate transfusions Product wastage

  4. Scope - activities The Blood Standard covers Use of blood and blood products The prescribing practice and clinical use of blood and blood products, and whether or not those products are prescribed and used appropriately Management of blood and blood products Handling, transport, storage (including inventory management) of blood and blood products Administration of blood and blood products The process used to deliver the product to the patient.

  5. Scope Currently covered by Standard 7 • Fresh blood products eg • Red cells • Platelets • Plasma • Cryoprecipitate • Serum eye drops • Plasma derived products eg • IVIg • RhD immunoglobulin • Clotting factors • Albumin Recombinant clotting factors Classes of products funded under National Blood Arrangements Not currently covered by Standard 7 • Monoclonal antibodies • Vaccines • Other recombinant products Haematopoietic progenitor cells • Plasma derived products eg • Tisseel • Artiss • C1-INH • Fibrinogen Classes of products not funded under National Blood Arrangements Blood Biological Medicine

  6. Standard 7 overview • 4 criterion • 23 actions One overall improvement program

  7. Criterion OneGovernance and systems

  8. Transfusion quality improvement system (Action 7.4.1) Improve documentation (7.5.3) Reduce wastage (7.8.2) Reduce management risks (7.2.2) Improve quality and use of policies (7.1.3) Improve documentation of consent (7.11.1) Reduce adverse event risks (7.3.1) Reduce administration risks (7.6.2) Improve provision of patient information (7.10.1) Reduce systems risks (7.2.2)

  9. Transfusion governance group (Action 7.4.1) What about in small organisations? Join with other hospitals or identify a group responsible for more than just transfusion practice (ensuring they have a clear remit to govern transfusion practice) • Oversight of the program • Review reports • Identify recurring issues • Root cause analysis of incidents • Develop or agree action plan • Evaluate effectiveness of actions

  10. Policies, procedures and protocols (Action 7.1.1) • You should have policies, procedures and protocols that reflect best practice, and national evidence based guidelines where they are available. • Your policies, procedures and protocols should cover the spectrum of: • Use of blood and blood products • Management of blood and blood products • Administration of blood and blood products

  11. Quality improvement cycle Transfusion Quality Improvement System Identify what you will do - develop or identify policies, procedures or protocols Implement the policies Plan Do Act Check Take action to improve uptake and improve their quality Monitor their use AND monitor their quality

  12. Criterion TwoDocumenting patient information

  13. The patient clinical record (Action 7.5.1) • A best possible history of blood product usage and relevant clinical and product information is documented in the patient clinical record • This action builds on Action 1.9.1 by identifying the information relevant to transfusion of blood and blood products that should be documented

  14. Documentation requirements • Product identification • Provision of information • Patient consent or refusal • Indications • Special product requirements • Known patient transfusion history • Compatibility label or report • Type of product • Volume of product • Date and time of commencement • Date and time of completion • Observations • Patient response including any adverse events

  15. Patient documentation case study What actions are required to demonstrate compliance with the Standard? (note that this case study is presented not to demonstrate particular actions that are required to achieve accreditation, but to demonstrate that the purpose of Standard 7 is to improve safety and quality based on an assessment of risk).

  16. Case Study Hospital One • Transfusion governance group has reviewed findings and developed and implemented an action plan Outcome: the action plan is matched with the level of compliance. • Reviewed policy • Implemented training of all staff • Identified staff associated with non-compliance and communicated directly with them • Made changes to the IT system to facilitate inclusion of all information (prompts) • Increased frequency of audit on the hospital audit plan • Initiated more regular spot checks of fate of product against patient records

  17. Case StudyHospital One • Audit report does not have a management response or action plan • They posted on the intranet a reminder to document transfusion in the patient clinical record • They have not undertaken any other follow up and the next audit is scheduled for one year away • Outcome: the action plan is not matched with the level of compliance. The health service organisation needs to demonstrate additional work prior to accreditation.

  18. Case StudyHospital Two • They posted on the intranet a reminder to document transfusion in the patient clinical record • They have not undertaken any other follow up and the next audit is scheduled for one year away Outcome: the action plan is matched with the level of compliance.

  19. Managing adverse events • Recognise and respond to adverse events • Document adverse events in the patient clinical record • Take action to reduce the risk of adverse events as part of your transfusion quality improvement system

  20. Complexities of incident reporting National reportParticipate in national haemovigilance reporting 7.3.3 State reportParticipate in state haemovigilance reporting 7.3.3 Executive reportReview of incident analysis by highest governance level 7.3.2 Local reportReport in local incident system and review by Transfusion Governance Group 7.3.1 External reportReport to pathology provider, or product manufacturer 7.6.3 Patient recordDocument in patient clinical record 7.6.1

  21. Criterion ThreeManaging blood and blood product safety

  22. Management of blood and blood products • Blood must be stored and handled appropriately to prevent risk to patients. • Systems should be implemented to reduce risks associated with receipt, storage, collection, and transport (Action 7.7.1 and 7.7.2) • Wastage of blood should be minimised (Action 7.8.1 and 7.8.2)

  23. Responsibility where services are outsourced • Many health service organisations receive blood from an outsourced pathology • It remains the health service organisation’s responsibility to demonstrate compliance with the Standard

  24. Criterion FourCommunicating with patients and carers http://www.questacon.edu.au/enlighten/

  25. Communication (Actions 7.9.1, 7.9.2 and 7.10.1) • Develop or identify resources to inform patients and their carers about the alternatives, risk and benefits of transfusion (Action 7.9.1) • Provide this information to patients and their carers in a format that is understood and meaningful (7.10.1) • Allow patients and carers to partner in decisions on their care based on the communication on the alternatives, risks and benefits of transfusion (Action 7.9.2)

  26. Consent (Action 7.11.1) • Have a documented consent policy • Ensure written and documented consent meets local policy • Ensure the consent is actually informed – link with 7.9 and 7.10 • Assess compliance with the consent policy, and take actions to increase compliance

  27. When you are developing your consent policy consider…. Is the consent specific to transfusion? What do you do when a patient is unable to consent? How long does the consent last? Who is documenting the consent?

  28. The Standard Seven quality improvement cycle YOU CAN DO IT!

  29. Available resources Clinical practice guidelines National Blood Authority www.blood.gov.au/guidelines • Patient Blood Management Guidelines Module 1: Critical Bleeding Massive Transfusion Module 2: Perioperative Module 3: Medical Module 4: Critical Care Module 5: Obstetric Module 6: Paediatric/Neonates • Guidelines on the Prophylactic Use of Rh D Immunoglobulin (anti-D) in Obstetrics • Criteria for the Clinical Use of Intravenous Immunoglobulin (second edition) NHMRC guidelines portal www.nhmrc.gov.au/guidelines • Factor VIII and FIX Guidelines • Warfarin Reversal Consensus Guidelines Australian and New Zealand Society of Blood Transfusion (ANZSBT) guidelines and publications www.anzsbt.org.au/publications/

  30. Available resources Product information and product management • 10 Tips to Help Manage you Blood Product Inventoryhttp://www.nba.gov.au/supply/10-tips.pdf • Managing blood and blood product inventory – Guidelines for Australian Health Providers http://www.nba.gov.au/supply/inventory-guidelines.pdf • Australian Red Cross Blood Service Blood Component Information Circular http://www.transfusion.com.au/sites/default/files/BCI%202012.pdf • The Australian Red Cross Blood Service blood components and products web site http://www.transfusion.com.au/blood_products • BloodSafe eLearning Australia module on Transporting Blood https://www.bloodsafelearning.org.au/ • ANZSBT Guidelines for the Administration of Blood Products http://www.anzsbt.org.au/publications/ • ANZSBT Guidelines for Pre-Transfusion Laboratory Practice http://www.anzsbt.org.au/publications/ • National Pathology Accreditation Advisory Council (NPAAC) Requirements for Transfusion Laboratory Practice http://www.anzsbt.org.au/news/documents/07NPAACReqforTLP.pdf • Australian Standard for Medical Refrigeration Equipment – For the Storage of Blood and Blood Products (AS3864) http://infostore.saiglobal.com/store/Details.aspx?ProductID=1600490 • NBA BloodNet http://www.blood.gov.au/bloodnet/ • NBA BloodPortalhttps://portal.blood.gov.au/ • Flippin’ Blood http://www.transfusion.com.au/sites/default/files/Flippin%20Blood%20ONLINE.pdf

  31. Available resources Adverse event recognition and reporting • See Jurisdictional programs • NBA Haemovigilance Reports 2008 http://www.blood.gov.au/haemovigilance/ • National Haemovigilance Data Dictionary http://www.blood.gov.au/haemovigilance/ • Flippin’ Blood http://www.transfusion.com.au/sites/default/files/Flippin%20Blood%20ONLINE.pdf • ANZSBT Guidelines for the Administration of Blood Products(http://www.anzsbt.org.au/publications/) Patient information and consent • See Jurisdictional programs • The Australian Red Cross Blood Service – Information for Patients www.mytransfusion.com.au Jurisdictional Programs • New South Wales – Blood Watch http://www.cec.health.nsw.gov.au/programs/blood-watch • Queensland iBlood Management Program http://www.health.qld.gov.au/qhcss/qbmp/ • South Australia – BloodSafehttp://www.health.sa.gov.au/bloodsafe/ • Victoria – Blood Matters http://www.health.vic.gov.au/bloodmatters/ • Western Australia Patient Blood Management Program http://www.health.wa.gov.au/bloodmanagement

  32. Images created by PresenterMedia For any queries about this presentation, email: blood.standard@blood.gov.au

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