Action 7.01

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

• Action 1.07 – policies and procedures
• Action 1.10 – risk management systems
• Actions 1.19, 1.20 and 1.21 – education and training

Health service organisations should:

• Use these and other established safety and quality systems to support the policies and procedures, risk management and training for blood management
• Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

Policies may be developed or adapted at different levels within the organisation. However, all policy documents should be incorporated into a single, coherent set to maximise the effectiveness of the policy development process.

Implement blood management governance structures

Health service organisations are expected to have a governance group responsible for blood management, with a formalised reporting structure to the organisation’s clinical governance and/or managers. The blood management governance group develops and oversees the safety and quality systems for blood management. This may include:

• Ensuring that members of the clinical workforce are trained in documentation requirements relating to transfusion, and receipt, storage, collection and transport of blood and blood products
• Developing strategies to improve and monitor compliance
• Increasing circulation of, or developing new, communiqués for clinicians involved in administering or prescribing blood and blood products to manage the risks identified.

Where any component of blood and blood product management is outsourced, the organisation is responsible for ensuring the safety and quality of those components. Ensure that there is a procedure in place to confirm and monitor the activities of the third party, and receive reports from the third party that would satisfy the requirements under this standard.

Implement policies and procedures

Ensure that there are organisational policies and procedures in place that cover:

• Preoperative anaemia and iron deficiency assessment and management pathways, or evidence through chart audit of a haemoglobin assessment
• Identification of patients at high risk of bleeding
• Use of appropriate diagnostic assays to assess cause of bleeding in a timely manner
• Use of decision support tools to support decision-making about bleeding management
• Cell salvage procedures (an autologous blood conservation technique for minimising blood loss)
• Use of all treatment options
• Management strategies that help minimise the likelihood of transfusion (including any PBM program)
• Support for transfusion alternatives and blood product refusal
• Pre-transfusion practice – strategies to optimise and conserve the patient’s own blood, identify patients at risk of bleeding, and pre-transfusion blood sampling and testing
• Pre-, intra- and post-treatment or intervention assessment and documentation of a patient’s haemoglobin, ferritin and iron studies
• Prescribing practice and clinical use of blood and blood products, and decisions to use blood and blood products, including any specific requirements (for example, irradiated products)
• Record taking and reporting, including completion of local blood request forms
• Administration of blood and blood products, including venous access; the use of equipment, concurrent fluids and medications; pre-administration identity check of patient and blood product; infusion rates; and observations and monitoring¹
• Identity checks at the time of pre-transfusion specimen collection, testing, product allocation, and collection of blood products from storage
• Management of blood and blood products – including receipt, storage, collection and transport, wastage, and contingency planning
• Informed patient consent relating to blood and blood products, and partnering with patients in their own care.

Policies, procedures and protocols should accord with national evidence-based guidelines. Where there are no national evidence-based guidelines, develop a local policy, procedure or protocol that communicates the appropriate practices, or rely on clinical judgement.

Manage risks

Use established risk management systems (see Action 1.10) to identify, monitor, manage and review risks associated with blood management. Develop processes to manage clinical risks for different populations served within the organisation, clinical and workplace risks for the workforce, and organisational risks.

Use information from measurement and quality improvement systems, adverse events, clinical outcomes and patient experience data to inform and update risk assessments and the risk management system. Consider the training the workforce may need to effectively use incident management and investigation systems to inform risk management, and to plan and implement quality improvement processes to mitigate these risks.

The administration of blood products involves a number of processes performed by multiple clinicians across different disciplines, which can increase the risk of human or system error. Identify risks associated with transfusion, especially risks relating to procedural errors, and redesign the system to reduce the potential for patient harm.

Risks associated with the administration of blood products may be reduced by avoiding the transfusion altogether, assessing the benefits of PBM strategies that optimise the patient’s own blood, and considering all treatment options. Assessing the impact and likelihood of risks relating to blood management and transfusion of blood and blood products will inform decisions about which, if any, blood management and transfusion-related risks to include in the organisation-wide risk management system.

Regularly and comprehensively review systems for effective and appropriate prescribing, sample collection, cross-matching, transport, storage and product administration to minimise the potential for error and patient harm.

Identify system weaknesses by:

• Regularly assessing risks relating to the systems in place for transfusion practice and clinical use of blood and blood products
• Regularly assessing blood-related incident reports, including near misses and root causes, using organisation-wide incident management and investigation systems, and strategies outlined in Action 7.07
• Developing and monitoring transfusion-related key performance indicators to identify and deal with blood-related risks.

Identify training requirements

Assess the competency and training needs of the workforce in line with the requirements of Action 1.19, 1.20 and 1.21. Perform a risk assessment to inform the training schedule and to set priorities for the members of the workforce who need training. Develop, or provide access to, training and education resources to meet the needs of the workforce regarding blood management.

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.

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

• Action 1.07 – policies and procedures
• Action 1.10 – risk management systems
• Actions 1.19, 1.20 and 1.21 – education and training

Health service organisations should:

• Use these and other established safety and quality systems to support the policies and procedures, risk management and training for blood management
• Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

Policies may be developed or adapted at different levels within the organisation. However, all policy documents should be incorporated into a single, coherent set to maximise the effectiveness of the policy development process.

Blood management governance

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established governance arrangements for blood management.

Small hospitals that are not part of a local health network or private hospital group should set up clinical governance for blood management to oversee the safety and quality systems for blood management. This may include:

• Ensuring that members of the clinical workforce are trained in documentation requirements relating to transfusion, and receipt, storage, collection and transport of blood and blood products
• Developing strategies to improve and monitor compliance
• Increasing circulation of, or developing new, communiqués for clinicians involved in administering or prescribing blood and blood products to manage the risks identified.

Implement policies and procedures

Depending on the risks and use of blood and blood products, policies and procedures may need to cover:

• Preoperative anaemia and iron deficiency assessment and management pathways, or evidence through chart audit of a haemoglobin assessment
• Identification of patients at high risk of bleeding
• Use of appropriate diagnostic assays to assess cause of bleeding in a timely manner
• Use of decision support tools to support decision-making about bleeding management
• Use of all treatment options
• Management strategies that help minimise the likelihood of transfusion (including any PBM program)
• Support for transfusion alternatives and blood product refusal
• Pre-transfusion practice – strategies to optimise and conserve the patient’s own blood, identify patients at risk of bleeding, and pre-transfusion blood sampling and testing
• Pre-, intra- and post-treatment or intervention assessment and documentation of a patient’s haemoglobin, ferritin and iron studies
• Prescribing practice and clinical use of blood and blood products, and decisions to use blood and blood products, including any specific requirements (for example, irradiated products)
• Record taking and reporting, including completion of local blood request forms
• Administration of blood and blood products, including venous access; the use of equipment, concurrent fluids and medicines; pre-administration identity check of patient and blood product; infusion rates; and observations and monitoring¹
• Identity checks at the time of pre-transfusion specimen collection, testing, product allocation, and collection of blood products from storage
• Management of blood and blood products – including receipt, storage, collection and transport, wastage, and contingency planning
• Informed patient consent relating to blood and blood products, and partnering with patients in their own care.

Manage risks

Use established risk management systems (see Action 1.10) to identify, monitor, manage and review risks associated with blood management.

The administration of blood products involves a number of processes performed by multiple clinicians across different disciplines, which can increase the risk of human or system error. Identify risks associated with transfusion, especially risks relating to procedural errors, and redesign the system to reduce the potential for patient harm.

Risks associated with the administration of blood products may be reduced by avoiding the transfusion altogether, assessing the benefits of PBM strategies that optimise the patient’s own blood, and considering all treatment options. Assessing the impact and likelihood of risks relating to blood management and transfusion of blood and blood products will inform decisions about which, if any, blood management and transfusion-related risks to include in the organisation-wide risk management system.

Identify training requirements

Assess the competency and training needs of the workforce in line with the requirements of Action 1.19, 1.20 and 1.21. Perform a risk assessment to inform the training schedule and to set priorities for the members of the workforce who need training. Develop, or provide access to, training and education resources to meet the needs of the workforce regarding blood management.