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Decorating from the inside out – Impact of Accreditation on the quality of our transfusion service

Decorating from the inside out – Impact of Accreditation on the quality of our transfusion service. Ankit Mathur Rotary Bangalore ttk Blood Bank Bangalore Medical Services Trust. BMST. BMST was established in the year 1984 Rotary Bangalore –TTK blood bank, Regional Blood Transfusion Center

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Decorating from the inside out – Impact of Accreditation on the quality of our transfusion service

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  1. Decorating from theinside out – Impact of Accreditation on the quality of our transfusionservice AnkitMathur Rotary Bangalore ttkBlood Bank Bangalore Medical Services Trust

  2. BMST BMST was established in the year 1984 Rotary Bangalore –TTK blood bank, Regional Blood Transfusion Center Day care Blood Transfusion center HLA Laboratory Community Services Department BMST Tissue Bank: Bones & amniotic membrane

  3. Journey of Accreditation Basic Quality Management system was in place NABH accreditation: 2009 NABH Application : 2011 Achieved : 2011 Technical & Management clauses

  4. Management clauses Regular training, training documentation Competency evaluation Equipment management Quality indicators & analysis Internal audit & ORM Document control & change control Incidence reporting & evaluation Feedback from stakeholders

  5. Quality Manual & Policy QM & QP was in place Organogram & ethics code Awareness among staff was not there Repeated training sessions Display in each department IN PRACTICE

  6. Training & Competency evaluation Regular training sessions Good attendance Effectiveness analysis: pre & post training questions Regular competency evaluation: unknown sample for testing by different people Skill Matrix

  7. Quality indicators QI were not in place Set for each lab: blood donation, component sep, TTI & XM-issue lab as well as HLA lab Analysis of QI: monthly

  8. QI: blood components Number of units not comply with quality standards Cryo precipitate Started analyzing each step & experimenting Modification in procedure: thawing & centrifugation Coagulation lab for QC testing Finally Cryo is meeting quality standard

  9. Internal Audit Vertical & horizontal audit Single unit audit IA: once in 6 months Management Review Meeting Regular Operational Review Meeting (ORM) : monthly: performance check list ORM: useful which give overview of whole blood bank operation

  10. Document control & Change control Document control log & its maintenance Recommendation of change Reason of change in doc/ procedure/ equipment or other Discussed in ORM Documentation of change control & approval from QM Document control log

  11. Change control document 14

  12. Feed back from stakeholders Suggestion Box Blood donors & BDC organizer Patient’s relatives Blood storage center’s in charge Physicians & surgeons/ other hospitals All feedbacks are discussed in ORM & action taken

  13. Error reporting & CAPA Incidence reporting & evaluation Incidence form available at each lab Staff is trained for reporting Incidences are analyzed by TM & QM Classified as adverse event, event with no harm & near miss event Corrective & preventive action

  14. Incidence reporting system: study Classified: Identification & classification of events in transfusion medicine, HS Kaplan; Transfusion vol 38, 1998

  15. Analysis of Near Misses Understanding about incidence reporting improved More NM: more opportunities of evaluate the system

  16. Conclusion Accreditation didn’t solve all the problems It guided us correct way how to solve Quality is Infinity Accreditation not the end goal Maintaining QMS is always a challenge

  17. Thank you

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