Regional
Quality - A Journey of the Blood Bank at JDW, National Referral Hospital
Blood Transfusion Service is a vital part of the health care service. In Bhutan, advancement in clinical practice and health care technology has enhanced better diagnosis that has lead to an increased need for blood transfusions, thereby necessitating implementation of measures to ensure quality blood and its products.
Solid and hematological malignancies, chronic kidney patients on regular dialysis, alcohol liver diseases and trauma from road accidents leading to acute blood loss are some examples of transfusion dependent patients constituting 60 to 70 % of blood needs for a 350 bedded National referral Hospital which the National Blood bank (NBB) caters to in the capital city Thimphu.
The NBB comprises of a transfusion specialist, a quality manager cum senior laboratory technologist and laboratory technicians and functions as a blood center. Since 2018, the hospital and the NBB embarked on a journey to become a quality managed organization and below mentioned are some steps taken towards its achievement. A quality management system (QMS) is defined as a formalized system that documents processes, procedures, and responsibilities for achieving quality policies and objectives. At NBB, the best approach adopted towards Quality Management System (QMS) was to use the existing internal resources and capacities and gradually build on them.
Steps taken:
1. The hospital executive management was briefed with the benefits of implementing a QMS and support was obtained; 2. Through periodic meetings and trainings, NBB staff was sensitized on quality work culture and active participation by all in the decision making process and change management; 3. Creation of a Quality Management Structure: 3.1. Quality policy was developed which states that ‘Quality is of paramount importance and we at the NBB are committed towards achievement of quality and to comply with the National Blood Safety Standards; 2013 so that our clients and users are satisfied’. 3.2. A part-time quality manager was appointed.
3.3. In-house quality awareness trainings conducted for staff and few also participated in ex-country trainings. Such opportunities helped better staff understanding of quality, their role in enhancing quality along entire blood chain and the consequences of poor quality. 3.4. Quality manual was developed by a team from NBB and the clinical laboratory through multiple consultations with technical experts. It included the essentials of the quality management system. 4. A review and analysis of all processes in various sections of NBB was done and baby steps to implement quality in each process and procedure initiated.
5. Existing documentation was also reviewed:-
- A format for writing standard operating procedures (SOPs) was designed; with combined effort and involvement of the hospital Quality Assurance and Standardization division(QASD),
- A list prepared of all the processes and procedures in use;
- Few staff trained in writing SOPs;
- SOPs validated and made available at work stations;
- Staff trained to use SOPs;
- Other NBB documents like reports, record forms, charts and logs were revised and put to use.
6. Environmental conditions such as air-conditioning of functional areas, space adequacy, and all critical equipment in the blood cold chain assessed, standardized and periodically monitored.
7. GMP requirements such as pest control, fire safety requirements, emergency exits,
bio-safety of staff and waste management guidelines are in place and followed.
8. Equipment maintenance and repair system has been introduced by the hospital bio-medical engineering division but needs further strengthening in terms of trained resource and finance.
9. Stock management of reagents and consumables, especially of critical reagents exist with FIFO policy and defined critical levels before stock outs.
10. Management of staff- Staff personal record requirements are enlisted but compliance to maintain up to date records is weak.
11. Internal Quality Control (IQC) is practiced in all sections of blood bank and logs maintained. NBB participates in External Quality Assessment programs for blood group serology and infectious disease screening with international organizations like the Pacific Paramedical Training Centre, New Zealand and the National Reference Laboratory, Australia with process of corrective actions incorporated with the IQA/EQA deviations. 12. Laboratory management committee conducts periodic management review meetings and minutes of these meetings are recorded and shared to all staff.. 13. Recently in 2023, a Hospital Transfusion Committee has been constituted to audit the clinical use and transfusion practices. A program of training the intern doctors and post-graduate residents on the national guidelines on appropriate use of blood is in place and SOPs on safe bedside transfusion practices followed by clinical ward nurses.
14. The importance of quality measurement is highly recognized by the hospital; hence 4 key performance indicators (KPIs) for the NBB derived from the Bhutan Healthcare Standards for Quality Assurance 2018 are monitored.
These are:
a. Percentage of blood component usage
b Percentage of transfusion reactions.
c. Percentage of wastage of blood and blood components.
d. Turn-around-time (TAT) for STAT blood orders.
The first 3 are to be submitted to QASD monthly, whereas the TAT is surveyed twice a year by QASD.
Challenges on-going
1. Blood transfusion is not yet recognized as a specialty and is under the department of laboratory services with shared human resource and budget ; 2. Resources in terms of trained and adequate technical man power working at blood transfusion services are inadequate; 3. Unreliable supply management systems; 4. Limited financial resources to bring in quality changes and improvement; 5. Insufficient supervision, monitoring and oversight. 6. Weak document control process. Conclusion
Quality is an ongoing journey. There is no fixed destination in this journey. It involves a commitment to ongoing improvement within the organisation and recognition that no system is ever perfect. There is always potential to improve.
Table 1: KPIs 2023
