Sort of new to this position and starting a comp review of CAP regs, our PPs and practices.

Could use some help with TRM.30866.  This has to deal with a Service Agreement between the BB and clinical areas.

Anybody care to share yours? 

Thanks

Ours is a simple policy that says we will provide testing and blood products to the clinical areas. 

Here's the related code of federal regulations: https://www.law.cornell.edu/cfr/text/42/493.1103

Ours has sections for the following:

Accreditation

Staffing - minimum staff available, on-call, etc.

Testing Menu - including tests that can be sent to reference lab

Turn Around Time -- refers to a different policy

Critical Values

Blood Suppliers - outlines what is available, how far away they are, etc.

Blood Inventory - available and available upon special request

Delays in Provision of Blood Products or Services - what might cause a delay, what we do if there is a delay in testing

Transportation of Blood Products - outlines how we issue blood, includes info about coolers

Blood Administration - refers to a housewide policy

Consultation - how to contact blood bank for consultation with pathologist or our blood supplier's medical director.

 

Thanks for the responses.  This will give me an outline of what I need.  Thanks again.

Mine has the blood products we offer and the TAT for the various order statuses (stat, routine, ASAP, etc)

On 2/5/2016 at 10:30 AM, Teristella said:

Ours has sections for the following:

Accreditation

Staffing - minimum staff available, on-call, etc.

Testing Menu - including tests that can be sent to reference lab

Turn Around Time -- refers to a different policy

Critical Values

Blood Suppliers - outlines what is available, how far away they are, etc.

Blood Inventory - available and available upon special request

Delays in Provision of Blood Products or Services - what might cause a delay, what we do if there is a delay in testing

Transportation of Blood Products - outlines how we issue blood, includes info about coolers

Blood Administration - refers to a housewide policy

Consultation - how to contact blood bank for consultation with pathologist or our blood supplier's medical director.

 

Nice inclusions. You got some I didn't think of - think I'll poach some of your ideas.

I remember noting that I should review my service agreement because that looked like a good list.

I wrote a policy that had the different types of orders the physicians might order and a brief description of each type, e.g. DAT, RBC request, CMV negative, Miscarriage workup,etc. How we expect the specimens to be labeled and signed. How they should be signed during a downtime when things fall apart and why specimens are rejected. I also included the amount of time until products or tests would be ready and I was very liberal with the time. I pretty much doubled the usual time so they would not hold the time against us. I included what forms are required to dispense blood products, who transports what to where, etc

I tried to cover anything that a nurse or physician would have a question about. I had the Lab Director and the CMO sign. It was posted online for all personnel to view.