Action 7.2

The health service organisation applies the quality improvement system from the Clinical Governance Standard when:

a. Monitoring the performance of the blood management system

b. Implementing strategies to improve blood management and associated processes

c. Reporting on the outcomes of blood management

Intent

Quality improvement systems are used to support blood management.

Reflective questions

How is the effectiveness of the blood management system continuously evaluated and improved?

How are the outcomes of improvement activities reported to the governing body, the workforce and consumers?

Key tasks

  • Review, measure, and assess the effectiveness and performance of, organisational and clinical strategies for blood management
  • Implement quality improvement strategies for blood management based on the outcomes of monitoring activities
  • Provide information on the outcomes of quality improvement activities to the governing body, the workforce, consumers and other organisations.

Strategies for improvement

Hospitals

The Clinical Governance Standard has specific actions relating to health service organisations’ quality improvement systems.

  • Action 1.8 – quality improvement systems
  • Action 1.9 – reporting
  • Action 1.11 – incident management and investigation systems

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for blood management.

Monitor effectiveness and performance

The blood management governance group should routinely identify recurring issues, monitor incidents and implement quality improvement strategies.

Use the organisation’s quality improvement systems to identify and prioritise the organisational and clinical strategies for blood management.

If clinical decisions result in a deviation from policies and procedures, record the deviation and the justification for the deviation, including any PBM strategies implemented. Ensure that the blood management governance group routinely reviews deviations to identify outliers. This will help identify where changes in clinical behaviour are appropriate, and where refinement of the policy, procedure or protocol is needed to reflect best practice.

If adverse patient outcomes are identified through incident monitoring (see Action 1.11), ensure that the blood management governance group assesses whether these incidents could be reduced by improving policies and procedures.

Investigate, audit or assess practices against national evidence-based guidelines. For example, to assess compliance with clinical practice guidelines, compare the use of products per procedure by unit/ clinician or surgeon to identify and analyse outliers.

Implement quality improvement strategies

Use established quality improvement systems to assess and reduce risks across the full range of transfusion practices.

Review these systems to ensure that they include requirements for:

  • Monitoring compliance with blood management policies and procedures
  • Monitoring compliance with comprehensive documentation of transfusion in the patient’s healthcare record
  • Improving systems to support more effective PBM
  • Reducing risks to individual patients from administration of blood or blood products
  • Reducing risks associated with receipt, storage, collection and transport of blood and blood products
  • Reducing wastage of blood and blood products
  • Monitoring compliance with informed consent policies for blood and blood products (see Actions 2.4 and 7.3).

Mitigate system-related transfusion risks based on the assessment of the likelihood and impact of the risk. Ensure that specific actions to manage identified risks include communicating issues to the workforce, educating clinicians on appropriate practice, and implementing change processes to improve clinical practice.

Report outcomes

Ensure that reporting and feedback mechanisms are in place for blood management that cover each of the following areas:

  • Pre-, intra- and post-operative/treatment PBM strategies, including identifying patients at risk of anaemia, iron deficiency, blood loss and bleeding
  • Use and management of blood and blood products in accordance with policies and procedures
  • Risk mitigation, education, and safety and quality improvement programs for the management and use of blood and blood products
  • Risk management processes for adverse events, incidents and near misses relating to transfusion practice
  • Policies, procedures and protocols for documenting details of the strategies in place to manage the patient’s own blood and transfusion details in the patient’s healthcare record
  • Availability of blood and blood products
  • Informed consent from patients.
Day Procedure Services

Applicability of actions

The actions in the Blood Management Standard will not be applicable for day procedure services that do not use blood or blood products. These services should provide evidence that they do not use, receive, store, collect or transport the blood or blood products governed under this standard.

Services using blood or blood products should refer to the information provided for hospitals for blood management.

MPS & Small Hospitals

The Clinical Governance Standard has specific actions relating to health service organisations’ quality improvement systems.

  • Action 1.8 – quality improvement systems
  • Action 1.9 – reporting
  • Action 1.11 – incident management and investigation systems

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for blood management.

Monitor effectiveness and performance

The blood management governance group should routinely identify recurring issues, monitor incidents and implement quality improvement strategies.

If clinical decisions result in a deviation from policies and procedures, record the deviation and the justification for the deviation, including any PBM strategies implemented.

If adverse patient outcomes are identified through incident monitoring (see Action 1.11), ensure that the blood management governance group assesses whether these incidents could be reduced by improving policies and procedures.

Investigate, audit or assess practices against national evidence-based guidelines.

Use established quality improvement systems to assess and reduce risks across all transfusion practices.

Ensure that specific actions to manage identified risks include communicating issues to the workforce, educating clinicians on appropriate practice, and implementing change processes to improve clinical practice.

Ensure that reporting and feedback mechanisms are in place for blood management outcomes.

Last updated 30th May, 2018 at 01:09am
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