creating a meaningful self-assessment program for your

Creating a Meaningful Self-Assessment Program for

Your Transfusion Service

Sheri Goertzen, MT(ASCP)BB, CLS(CA), CQA(ASQ)

Valley Children’s Healthcare

sgoertzen@valleychildrens.org

Oct. 19, 2021

Objectives

1) Review accreditation requirements for an internal assessment program.

2) Identify various internal audits that best measure performance.

3) Utilize strategies for creating audit tools that are easy to use and encourage the development of your staff’s quality detective skills.

4) Discuss helpful tips on how to strengthen and maintain your internal assessment program.

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Faculty Disclosure

Sheri Goertzen, MT(ASCP)BB, CLS, CQA(ASQ):

• I have no relevant financial relationships to

disclose for this presentation.

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In compliance with ACCME policy,

AABB requires the following

disclosures to the session audience

Where to begin?

• Highest Quality

• Regulatory Requirements

• Accreditation Requirements

• Assess the Operations and

Quality Systems

• Scheduled and conducted

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Self-Assessment Program Design

Required Ongoing Monitors… 8.2 Utilization Review

Transfusing facilities shall have a peer-review program that monitors and addresses

transfusion practices for all categories of blood and blood components. The following

shall be monitored:

1) Ordering practices.

2) Patient Identification.

3) Sample collection and labeling.

4) Infectious and noninfectious adverse events.

5) Near-miss events.

6) Usage and discard.

7) Appropriateness of use, including group O RBCs and AB plasma.

8) Blood Administration policies.

9) The ability of services to meet patient needs.

10) Compliance with peer-review recommendations.

11) Clinically relevant laboratory results. 6

Suggested Ongoing Monitors…• Turnaround Times

• Uncrossmatched Blood Requests (Physician Signature)

• MTP Activations

• Product Recalls, Lookbacks

• Incident Reporting, BPDRs

• Informed Consent

• Blood Warmer use

• Blood Administration Policy Compliance– Required Documentation, Vitals, Completion within 4 hours

• Outpatient or Home Transfusion

• Therapeutic Apheresis (Plasma Exchange, WBC Depletion)

• Therapeutic Phlebotomy

• Surgical Normovolemic Hemodilution

• Cell-Saver Procedures

• Bloodless Medicine (Successful Transfusion Avoidance)

• RBC Exchange Program for Sickle Cell Patients

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Select Your Monitors & Audits

• Define ongoing monitors vs. scheduled focus audits

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Recruit Your Auditors/Assessors

• Std. 1.2 Quality System

– A quality system shall be defined, documented,

implemented, and maintained. All personnel shall be

trained in its application.

• Teaches process improvement

• Brings new perspective

• Fosters “ownership” of department operations

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Auditor Training

• Can use a formal or home-grown method of training

– Enroll auditors in an education course

– Develop an On-Line module and Post-Test

– Provide reading material, lecture

• Main objective is to teach auditors to go “in search of”

factual evidence of conformance or nonconformance

• No bias is allowed!!!

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Create Your

Schedule!

• Split into manageable

pieces

• 2 year plan

• Organized using:

– AABB Assessment Tool

– Focus Audits

– Tracer Audits

– Bedside Audits

– CAP Checklist Tool

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Stick to Your

Schedule!

• Post the schedule in the

department

• Encourage staff to sign up

as volunteer assessors

• Include these audits in your

quality reports

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Within the 2 Year Cycle…

• Ongoing Monthly and Quarterly Monitors

• AABB Assessment Tool

• CAP TM & All Common Checklists

• Bedside Audits – From Issue through 15 min. Vitals

• Tracer Audits

• Add’l select Focus Audits, as needed

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Inspection Binder

• File completed sections of the annotated AABB assessment tool and the annotated CAP checklist in a binder.

• Add copies of your licenses, registrations, contracts, agreements, etc.

• You’re maintaining an “Inspection Ready Binder” for your next unannounced inspection

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Creating Audit Tools

• Volunteer assessors

• Include details for the auditor of what exactly needs

to be present in order to be acceptable.

• Include acceptability criteria for each item on your

tool. Removes “guesswork” for your auditor.

• Standardize & Simplify

– Use check boxes and scoring keys

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AABB Tool

Scoring, Review, Corrective Action

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CAP

Checklist

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Creating Audit Plan

• Determine purpose, scope,

criteria, documents needed

• Determine schedule,

auditors, resources needed

• Determine reviewers of the

report

• Obtain medical director

approval in advance

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Sample of a Quality Audit Plan

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Transfusion Tracer Audit

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Transfusion Reaction

Tracer Audit

• Start with a transfusion

reaction

• Trace backward

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Bedside Audit

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Document Review

• Split all documents into a 24

month review schedule.

• Enlist help with performing

new or biennial document

review.

• Provide a review tool which

guides the reviewer on all of

the items that need

checking.

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Reporting Strategies

• Remember your audience when preparing your self-assessment program reports.– Transfusion Committee? Department of Pathology?

Patient Safety Committee?

• Track & Trend?– Set Targets/Goals/Thresholds whenever possible to

measure performance

• Details of outliers important? Yes or No?

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Reporting Strategies

• Graph vs. Spreadsheet vs. Chart vs. Dashboard

– Report data as % Acceptable or % Non-acceptable?

– Select a reporting format that provides the most useful data

for your audience.

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0123456

Series 1 Series 2 Series 3

1st Qtr 2nd Qtr

Dashboard Format

• Lots of data on one page

• Able to report data covering:1) Ordering practices.

2) Patient Identification.

3) Sample collection and labeling.

4) Infectious and noninfectious adverse events.

5) Near-miss events.

6) Usage and discard.

7) Appropriateness of use, including group O RBCs and AB plasma.

8) Blood Administration policies.

9) The ability of services to meet patient needs.

10) Compliance with peer-review recommendations.

11) Clinically relevant laboratory results.

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Practical Approach… It Can Be Done!!!

• Don’t re-invent the wheel!!!– Use tools that are available: e.g. AABB, CAP, CLSI

• Organizing ahead of time is KEY– Try planning 2 years in advance

– Spread it out over 24 months

• Staying on schedule is ESSENTIAL– Its hard to catch up once you fall behind!

• Recruiting helpers is VITAL– You can’t do this alone… it’s a team project!

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Useful Resources

AABB Guide to The Quality Assessment of Transfusion, T. Nichols, et al. 2020-2021 Transfusion Medicine Section Coordinating Committee, AABB: 2021.

AABB Guide to Patient Blood Management and Blood Utilization, R. Gammon, et al. 2020 Transfusion Medicine Section Coordinating Committee, AABB: 2020.

Auditing in the Transfusion Service, S. Butch, T. Downs, AABB Press: 2012.

Guidelines for the Quality Assessment of Transfusion, AABB 2004-2005 Clinical Transfusion Medicine Committee, AABB: 2006.

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Thank you!

Contact info:

Sheri Goertzen, MT(ASCP)BB, CLS, CQA(ASQ)

sgoertzen@valleychildrens.org

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