Collaboration between blood services and hospitals

1. Collaboration between blood services and hospitals Gent, November 17, 2006 Jukka Rautonen Tiina Mäki

2. Contents of the bag, i.e., ”technical quality” Conventional focus of blood service management Donor recruitment Donor selection Aseptic collection Screening tests Risk Production process Adequate storage+transp. • All improvements cost money • What about the cost of stock-outs, delays,... Usage pattern

3. Purchasing Logistics "New" issues to consider Donor recruitment Donor selection Aseptic collection Screening tests Risk Production process Adequate storage+transp. Forecasting Usage pattern

4. ILLUSTRATIVE Security and safety of the steps Screening tests Production process Donor selection Security Aseptic collection Adequate storage and transp. Donor recr. Usage pattern

5. Purchasing Logistics Forecasting Some neglected areas • Savings potential >10% of purchasing costs • Influence the standards • Create alliances with key suppliers • Savings potential >10% of total supply chain costs • Do not re-invent the wheel • Do not accept the present day constraints • Create alliances with key customers • Required for adequate SCM • Finding the right tools may prove to be difficult • Value judgements are tricky

6. Maximize technical quality Everything else is secondary Improving quality is expensive Functional quality matters! Make informed trade-offs In many cases, improving quality saves money Re-design the value chain together with your customers Purchasing Logistics Helping customers Service marketing Managing a blood service From conventional wisdom... … to modern thinking... … by acquiring a new skill set Financial skills IT HRD

7. Choosing the approach High Collaborative approach addressing the entire value chain Strategic importance of category/ supplier Strategic sourcing focusing on supply and demand side levers Mutual willingness to participate is a prerequisite for collaboration Incremental value Vs. effort to capture value Medium • Level of criticalness for own business, e.g. total cost impact and operational impact • Value and growth potential of joint business • Supplier strength and market share Rapid sourcing focusing on supply side levers Low Low Medium High • Multiple dimensions driving high value chain complexity, e.g. tough requirements on delivery times, large variety of products • The nature of the opportunities make these difficult to address by one function/ player alone Complexity of value chain/ benefits capture Source: Booz Allen

8. Blood Service view Blood bags High Collaborative approach addressing the entire value chain Strategic importance of category/ supplier Strategic sourcing focusing on supply and demand side levers Mutual willingness to participate is a prerequisite for collaboration Incremental value Vs. effort to capture value Medium • Level of criticalness for own business, e.g. total cost impact and operational impact • Value and growth potential of joint business • Supplier strength and market share Rapid sourcing focusing on supply side levers Office supplies Low Low Medium High • Multiple dimensions driving high value chain complexity, e.g. tough requirements on delivery times, large variety of products • The nature of the opportunities make these difficult to address by one function/ player alone Complexity of value chain/ benefits capture

9. Hospital view Platelets RBC High Collaborative approach addressing the entire value chain FFP Strategic importance of category/ supplier Strategic sourcing focusing on supply and demand side levers Mutual willingness to participate is a prerequisite for collaboration Incremental value Vs. effort to capture value Medium • Level of criticalness for own business, e.g. total cost impact and operational impact • Value and growth potential of joint business • Supplier strength and market share Rapid sourcing focusing on supply side levers Office supplies Low Low Medium High • Multiple dimensions driving high value chain complexity, e.g. tough requirements on delivery times, large variety of products • The nature of the opportunities make these difficult to address by one function/ player alone Complexity of value chain/ benefits capture

10. Cost of blood to a hospital FRC Blood Service Hospitals M€ 24% total 76% of total 12.8 52.3 39.5 Source: Disguised data from a joint project by FRCBS and several hospital districts

11. Cost of outpatient blood transfusion Supplies 19 % Other 46 % Variable labor cost 17 % Fixed labor cost Crémieux et al. Cost of outpatient blood transfusion in cancer patients. J Clin Oncol 2000;18:2755-2761 18 %

12. Goals of the "Ketju" SCM programme • Cost efficient and reliable supply chain of blood products controlled by FRCBS • Compatibleinformation systems between FRCBS and hospitals • Inventory levels in different stages of the supply chain and traceabilityof blood products, taking into account the information security and privacy issues • Deliveries that match demand: FRCBS manages the inventories also in hospitals and delivers blood according to the need – blood product availability secured • Cost efficient, optimized, and consistent internal operations in hospitals related to the management of blood products

13. Improved distribution 24/7 Today In the future On-call hours Office hours

14. Original three-year plan

15. Two pilot projects were completed

16. Rigorous project management was used

17. Roll-out – current status • Central hospitals • (8-10,000 RBC/year) • Order placement and fulfilment practices • University hospitals • (15-40,000 RBC/year) • Consolidated warehousing (by FRC) within hospital premises • VMI? Outsourced blood bank? 1b 1b 1a 1a 2 2

18. Key lessons learned • Costs are decreasing and quality is increasing! • Must use top level SCM expertise • Outsourcing (parts of) logistics may be necessary • Hospitals have been extremely positive – current bottleneck is our own resources • Need to tailor the partnership agenda • IT systems are the biggest challenge – how to make three (or more) systems talk with each other. This will introduce at least a 1-2 year delay to the program • Probably must modify our own organisational structure

19. Use of red cells in primary hip replacement operations in Finnish hospitals (2002) over 7-fold difference ??? Red cell units/patient

20. What was done since 2002: • a database was created of transfusions in Finland • ~70% of Finnish blood product use is currently in the database • data is updated 2x/year

21. All major (university-linked) hospitals are included + 5 other central hospitals, more coming

22. What data are collected from where? • Only existing hospital databases are utilized • administrative registers • laboratory databases • hospital blood bank registers • FRC Blood Service database (Progesa) The data collected: • surgical operations • main diagnoses • selected laboratory results • the blood products given • The patient identification information (unique social security number is coded)

23. Selection of the patients included in the database • Included are • patients who have blood orders • AND patients undergone surgical operations • AND patients with selected diagnosis (hematological, pregnancy or childbirth, trauma)

24. Reports published in web (by BS) Benchmarking meetings (arranged by BS; doctors, nurses) Optimal Use of Blood, what do we do with all that data? Publications, theses Hospitals' own analysts (trained by BS) Recommendations, guidelines?

25. Standard reports available in internet • published on Blood Service home page (www.bts.redcross.fi) (some examples in english as well) Patient group comparisons between hospitals Overall information on blood usage Transurethral prostathectomy, percentage of patients receiving red cells

26. Benchmarking days • Personnel teams (doctors, nurses) treating, e.g., hip operations or cardiac surgery or childbirths etc. from different hospitals are invited • The groups look for differences in their practices with a background list, most important differences are named • The actions to be taken are agreed • A follow-up session is organized 1.5 years later

27. An example of a background list from heart surgery meeting Preoperative tests (blood counts etc), how controlled? Treatment of preoperative anaemia Amount of blood reserved for routine coronary surgery Hb-triggers for red cell transfusion (preop., periop., postop.) B-Trom triggers for platelet transfusion FFP-transfusion triggers Operative techniques Anesthesia-techniques, hypothermia Use of blood savers/washers How to reverse warfarin-treatment? Use of haemosthatic medication Laboratory follow-up Hospital guidelines on transfusion Patient's opinion (refuse/demand) on transfusion Patient discharge criteria

28. Use of the database by hospitals • Hospitals are given an internet-connection to their own data • One person / hospital is trained to use the analysis-tool (Ecomed) • She/he can further analyse hospital's own data own reports for personnel recommendations publications, thesis etc

29. What happened in the "high use" hospital • Routine blood order for hip replacement was reduced to 2 units of RBC • Preoperative iron was recommended • Restrictive fluid consumption preoperatively

30. Mean use of red cells in primary hip replacementHOW DOES IT LOOK LIKE NOW? Difference reduced to 2.4 fold

31. Where does all the blood go anyway?Use of blood according to the main diagnosis Diseases of the circulatory system B Malignant diseases of the blood B Injury and poisoning Other neoplasms Diseases of the digestive system B Other B=Benchmarking day organized

32. Use of blood according to the surgical operation Musculoskeletal system B Digestive system and spleen B Heart and thoracic vessels B Peripheral vessels Other thoracal operations Urinary systems, male genitals, retroperitoneal other (gynecology etc) B B=Benchmarking day organized

33. Sex and age of transfused patients A benchmarking day of blood use in elderly is under consideration

34. Should recommendations be given? • IDEA: Experts from hospitals gather, discuss, write and publish recommendations • FRC Blood Service could bring the experts together, but we would avoid making clinical recommendations • Under consideration

35. Challenges • Taking the project inside the hospitals • (Surgeons etc.) • How to study the clinical OPTIMUM? • How to avoid overreacting and too restrictive attitudes towards blood use?