Joint Commision Blood Performance Measures 2011

[BSIPHERD]

Joint Commission has published its new Performance Measures for Transfusion. Here is a link to their Implement Guide (OMG - It's 180 pages long). What does it mean for each of us? I guess we have to read it first! What have others done (or will do) to implement this?

http://www.jointcommission.org/assets/1/6/PBM_Implementation_Guide_20110624.pdf

[AMcCord]

Hadn't seen it yet (or heard about it), but then I'm usually the last to know about things like this. Thanks for posting the guide. Looks like fun! not.

[webersl]

Couldn't tell when we have to start reporting this.

[Eoin]

Hi Guys,

Knew they were coming (we are Joint Commission International Accredited). We capture most of these either at audit or as direct Performance Measures now, but a tighter framework obviously. Taken me best part of a day to read , copy codes etc and inwardly absorb - ah well, we all like extra work - don't we. We will look back and laugh one day (I think the day I retire).

However on the bright side, more positive side, we have been using the measures for a couple of years now, and practice has definitely improved. We have a Failure Mode Effect Analysis to prove that risk has fallen (incorporated with a full blood tracking system within the hospital).

Cheers

Eoin

[Kashmira patel]

Thank You for posting the guide.

Kashmira

[carolyn swickard]

Thanks so much for the post - I have been wondering about these - when they would be ready and how to find them.

[Liz]

Hi Guys,

Knew they were coming (we are Joint Commission International Accredited). We capture most of these either at audit or as direct Performance Measures now, but a tighter framework obviously. Taken me best part of a day to read , copy codes etc and inwardly absorb - ah well, we all like extra work - don't we. We will look back and laugh one day (I think the day I retire).

However on the bright side, more positive side, we have been using the measures for a couple of years now, and practice has definitely improved. We have a Failure Mode Effect Analysis to prove that risk has fallen (incorporated with a full blood tracking system within the hospital).

Cheers

Eoin

Hello Eoin,

Can you elaborate of that: full blood tracking system

Eg: if a unit is spiked and for some reason not used and and in the rare case disposed of at the OR and the Blood Bank is not informed, how would you trace that?

thank you

[Norbert Ahrens]

There is an implemented full blood tracking in Germany for somewhat more than a decade, and it is realized by forms that have to be filled for every single unit by the physicians on the wards, emergency departments, OR and so on. These forms get sent back to the blood bank, where the usage gets documented electronically. Through the recent years we got a coverage of 98 to 100% of all units. Though laborious for the transfusing staff, this really helps to reduce wastage.

Best regards,

Norbert

[Liz]

Norbert, these are excellent results, you do have ownership of the blood. Can I see a form please, and does it have duplicates?

Thank you

[Norbert Ahrens]

The form is obviously in German. I tried to put it here:

https://www.sugarsync.com/pf/D751217_816712_6790689

It is printed on special paper with a horizontal perforation line. The upper part goes to the patient's documentation, and the lower part is returned to the blood back.

Yours,

Norbert

[Liz]

Hello Norbert, Can you tell me when the Blood Bank part is sent back, is it immediately at the end of transfusion?

Thank you very much. Yes it is in German and I am able to decipher it. This has given me a good idea for improvement. We have this information on a tag, an additional 4A form similar to yours will be better for tracking.

Thanks

Liz

[ANORRIS]

I am unable to open it. Can someone forward it to me? Does anyone have it in English?

[Norbert Ahrens]

The hosting site has some technical issues today. It should work, if you try it later.

The forms are returned on a daily basis. That does not mean that all are returned the same day, some take about a week.

Yours,

Norbert

[Liz]

Thanks Norbert.

[Liz]

Norbert,

How often do you count the forms that return and compare them to what was issued?

Thanks

Liz

[Norbert Ahrens]

We print listings of the remaining units occasionally, i.e. every few weeks for every department, and the responsible physician would investigate on the usage of the remaining units. These listings comprise usually one or two dozens of units. The retrieval is not among the favourite activities, but it is done.

Is your laboratory information system prepared for this type of documentation?

Yours,

Norbert

[Liz]

We can partly use the in-house made software and then the actual returned tags will be checked by hand.

Thank you for the tips.

Liz

[Eoin]

Hello Eoin,

Can you elaborate of that: full blood tracking system

Eg: if a unit is spiked and for some reason not used and and in the rare case disposed of at the OR and the Blood Bank is not informed, how would you trace that?

thank you

Liz,

We have Neoteric BloodTrack installed. Even emergency O Negs are traced to a patient. All they need is a barcoded (2D) armband. PDAs are used (User ID Scanned, Blood Unit No Scanned and then patient armband 2d barcoded) as soon as the blood is spiked and hung. Alerts come up on the manager system (monitored in lab, my office and Haemovigilance Office), so we know they are gone). Wireless comms picks up the PDA signal constantly and all info keeps coming down. All sorts of other alerts come up as well (outside 30 min removal from Issue Fridge rule). This would also give a warning to them on the PDA and would tell them not to use it. These alerts are customisable (quite a variety) as is how you set up the system to be used in the clinical setting. All packs come back to a special fridge where they are held for 48 hours as well, so we can follow unused packs there too. I did a FMEA Risk analysis on the whole process, and we have reduced risk by over 60% since its introduction. The Haemovigilance Officer keeps an eye on all vitals (incl times) and feeds back non-conformances immediately to clinical users in form of an educational letter pointing out the problem in their practice. This has seen N/Cs fall dramatically as well. Fairly well received on wards & departments, and we love it.

Cheers

Eoin

[Liz]

Eoin, thank you that is interesting, interesting , intertesting. I am going to write to the Hospital director and insist. He made me a remark once that I must have ownership of the blood units, ok so he will have to execute this plan. Thank you.

[JFRhamy]

The Patient Blood Management Performance Measures recently posted by The Joint Commission are voluntary implementation. We heard almost universally from our pilot sites that they found the tracking of the metrics to be beneficial so we made them available on the web site along with a guide on how to collect the data in a uniform way. It is entirely up to you if and how you implement these measurement tools.