Standard Seven: The blood standard quality improvement cycle - PowerPoint PPT Presentation

Standard Seven: The blood standard quality improvement cycle Philippa Kirkpatrick

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

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

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.

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

Standard 7 overview 4 criterion 23 actions One overall improvement program

Criterion One Governance and systems

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

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

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

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

Criterion Two Documenting patient information

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

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

Patient documentation case study Hospital One Hospital Two Has policy Yes Yes Documentation 50% of records 95% of records completeness are complete are complete audit results Documentation 5% of units fate <0.01% of units sample results not documented fate not documented 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).

Case Study Hospital One Transfusion governance group has reviewed findings and developed and implemented an action plan 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 Outcome: the action plan is matched with the level of compliance.

Case Study Hospital 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.

Case Study Hospital 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.

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

Complexities of incident reporting National report 7.3.3 Participate in national haemovigilance reporting State report 7.3.3 Participate in state haemovigilance reporting Executive report Review of incident analysis by highest 7.3.2 governance level Local report Report in local incident system and review by 7.3.1 Transfusion Governance Group External report 7.6.3 Report to pathology provider, or product manufacturer Patient record 7.6.1 Document in patient clinical record

Criterion Three Managing blood and blood product safety

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)

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 You use blood Review reports and Have a contract that provided by a seek implementation includes standards contracted pathology of strategies to and reporting provider rectify problems

Criterion Four Communicating with patients and carers http://www.questacon.edu.au/enlighten/

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)

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

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

The Standard Seven quality improvement cycle YOU CAN DO IT!