Assessment against the National Standards
Health services should be accredited against the National Safety and Quality Health Service (NSQHS) Standards (National Standards) and those using blood and blood products need to meet the requirements of the Blood Management Standard. There are many resources available to help health services achieve accreditation against the National Standards.
- user guides
- accreditation workbooks
Of particular interest are:
The Blood Management Standard
The Blood Management Standard covers all elements of blood management and transfusion practice, which includes the principals and practices of Patient Blood Management (PBM).
The intention of the Blood Management standard is to identify risks, put in place strategies, ensure that a patient’s own blood is optimised and conserved, and that any blood or blood product transfusion is appropriate and safe. The Blood Management Standard draws on the principals of PBM and blood stewardship as set out in the .
There are three criteria and ten actions in the Blood Management Standard
Organisation-wide governance and quality systems ae used to ensure safe and high-quality care for patient’s own blood, and to ensure that blood product requirements are met. (ACSQHC; 2017)
This criterion is closely aligned with and should be read in conjunction with the Clinical Governance Standard and the Partnering with Consumers Standard. An organisation wide, systematic approach is required to meet the criterion.
Actions and their requirements in this criterion are:
- 7.1 Integrating clinical governance
- Implement blood management governance structures
- Implement policies and procedures
- Manage risks
- Identify training requirements
- 7.2 Applying quality improvement systems
- Monitor effectiveness and performance
- Implement quality improvement strategies
- Report outcomes
- 7.3 Partnering with consumers
- Shared decision making
- Implement informed consent
- Effective communication
The examples provided may assist health services to develop their own resources to support this criterion. Some of the resources have been developed by Blood Matters, while others are documents used in health services.
Integrating clinical governance 7.1
Implementing blood management governance structures
- this committee plays a significant role in the health service clinical governance and quality improvement to support blood management. This document includes responsibilities and suggestions for membership, agenda and executive engagement.
- an assessor’s guide to conducting blood product clinical competency for enrolled nurses. This should be used in conjunction with the EN transfusion competency template and local health service requirements.
- an example template that can be modified to suit local health service requirements, to assess enrolled nurses blood product transfusion clinical competency. This should be used in conjunction with the EN transfusion competency guide.
- the National Blood Authority has developed a National Blood Supply Contingency Plan to ensure a rapid response should there be threat to the safe and adequate supply of blood. It is expected that health services have an Emergency Blood Management Plan to ensure an appropriate response should the NBSCP be activated. The template is designed to be modified by health services to suit local requirements, while meeting the intention of the NBSCP.
Implement policies and procedures
- the Barwon Health procedure for dispatching (issuing) blood to the clinical area for use and the process for ensuring correct identification processes for both the patient and the product for patients who are transferred to Barwon Health with externally crossmatched blood products.
Risk management should be undertaken in conjunction with the Risk Management Team using the local Risk Management Framework and procedures.
Identifying training requirements
Applying quality improvement systems 7.2
This includes blood management quality performance indicators, quality and safety improvement, and quality surveillance.
- Blood Management/Transfusion Nurses and Safety officers are a key component of the quality improvement and risk management system for blood. This generic template provides a typical example of the specified requirements of such positions.
- Transfusion Trainers are a key component of the quality improvement and risk management system for blood in smaller organisations where only small amounts of blood are used. This generic template provides a typical example of the specified requirements of such positions.
- the handbook is aimed at providing Blood Management/Transfusion Nurses/Trainers and Quality Officers, to understand the context of blood and blood products in Australia, and provide structure and guidance to achieve best practice in blood management and transfusion practice.
Monitor effectiveness and performance
Quality improvements should be monitored and reported through the relevant governance committee, such as a Blood Management Committee or Executive Quality Committee.
- this report is aimed at informing health services blood management (or equivalent) committee with an overview of the activities of the Blood Matters Program and the overarching context of blood management in Victoria. These reports are produced twice yearly.
Implement quality improvement strategies
- the quality improvement summary is an example provided by the Royal Melbourne Hospital and is used as an easy way to promote improvements in a simple easy to follow way. A useful snapshot of improvements for accreditation.
- the Blood Matters audits contribute to health service requirement for monitoring performance and reporting results. The audit tools provide assessment against best practice guidelines, the data is analysed, benchmarked with peer health service and reported to individual health services. The audit reports are published with recommendations and discussion.
- appropriateness of red cell, platelet and FFP transfusions
- transfusion documentation
- cumulative phlebotomy loss
- a quick anaemia assessment.
Partnering with consumers (7.3)
Shared decision making
It is important that patients and carers are actively involved in their own care.
Treatment plans should be developed with patients and carers.
Consumer information should be provided about the risks and benefits of blood and blood product transfusion, the risks of not having a recommended transfusion, as well as alternatives that may be available or that can reduce the need for a transfusion.
Consumers should have an opportunity to ask questions and the provider of the information should ensure the recipient has understood the information. Information (written and verbal) for consumers needs to be in a format the consumer can understand.
Implementing informed consent
Consent and refusal of blood
Informed consent is defined by the Australian Health Practitioners Regulatory Authority (AHPRA) in the Code of conduct for registered health practitioners (2014) as: 'a person’s voluntary decision about their health care that is made with knowledge and understanding of the benefits and risks involved.'
- Millions of people receive blood transfusions each year, but many will not be fully aware of the risks. In this journal article Anne-Maree Farrell and Margaret Brazier argue for a formalised consent procedure for blood transfusion.
The law supports a person’s rights when it comes to medical treatment in Victoria in the following ways:
- a person has the right to refuse medical treatment in most circumstances
- the medical practitioner must usually seek the person’s consent prior to carrying out medical treatment
- a person’s capacity to consent is assumed unless there are indications otherwise
- a competent person can refuse treatment in relation to a current or future condition under the Medical Treatment Planning and Decisions Act 2016 by completing a valid instructional directive
- likewise, the person’s medical treatment decision maker can consent to or refuse treatment on their behalf if they no longer have the capacity to do so themselves.
The steps for health practitioners to follow when a patient does not have decision-making capacity to make their own medical treatment decision is set out in MTPD Act 2016.
The Jehovah’s Witness community is known to refuse blood transfusions and have a number of resources regarding management of patients without the use of allogenic blood. The covers clinical strategies for:
- avoiding blood transfusion in surgical patients
- avoiding blood transfusion in obstetrics and gynaecology
- managing acute gastrointestinal haemorrhage without blood transfusion
- avoiding blood transfusion in critically ill patients.
Many Victorian Jehovah’s Witness patient carry a 'no blood' card. It provides brief information on how to access their Advance Care Directive. An example of the Advance Care Directive and No Blood card are provided in the .
- A general guide to blood transfusion: Information for patients and families
- A general guide to iron and iron deficiency: Information for patients, families and carers
- Information for children.
, available in 18 translations. Languages available are English, Arabic, Burmese, Chinese, Croatian, Dari, Dinka, Greek, Hindi, Indonesian, Italian, Khmer, Persian, Polish, Punjabi, Swahili, Tamil, Turkish and Vietnamese. There is also information for children.
- 7.1 Integrating clinical governance
The clinical use of blood and blood products is appropriate, and strategies are used to reduce the risks associated with transfusion. (NSQHS Standards, Hospital guide 2017).
Overarching PBM/transfusion-related guidelines, policies and procedures are found in the clinical governance section (7.1).
In this section are resources to assist health services address the actions in this criterion, which are:
- 7.4 optimising and conserving patent’s own blood - information can be found in the section marked
- 7.5 documenting
- 7.6 prescribing and administering blood and blood products
- 7.7 and 7.8 reporting adverse events.
The examples of charts, checklists and forms relating to the administration of blood products are used to promote complete transfusion documentation. The resources are designed to assist health services to support processes for prescribing and clinical use of blood and blood products.
- a comprehensive form developed by Austin Health. It is an example of a form used for blood and blood product prescription and administration, consent documentation and adverse reaction reporting as well as providing guidance on blood administration safety, and the pre-transfusion checking requirements.
Prescribing and administering blood and blood products 7.6
Reporting and adverse events 7.7 and 7.8
(7.5, 7.7 and 7.8) - developed at RMH for reporting transfusion reactions to the Transfusion Laboratory and includes the order for subsequent blood testing. This form is now only used when the EMR is not available.
(7.6) - the blood component compatibility report used at St Vincent’s Health, contains details of the compatibility of the blood component (the form is blank), and on the reverse side it has the blood checking requirements and a summary of possible adverse reactions. This is an example of the form that is sent with the unit of blood, blood product.
Strategies are used to effectively manage the availability and safety of blood and blood products. (NSQHS Standards, guide for Hospitals, 2017)
In this section are resources to assist health services address the actions in this criterion, which are:
- 7.9 Storing, distributing and tracing blood and blood products
- 7.10 Availability of blood.
It is important that all health services have systems to safely and efficiently receive, store, collect, transport blood and blood products and to monitor their wastage and traceability.
Blood use and waste is recorded on the National Blood Authority’s BloodNet, which is currently available nationally.
The resources, tools, templates and examples are aimed at helping health services to develop strategies to effectively manage the availability and safety of blood and blood products.
Storing, distribution and tracing blood and blood products (7.9)
Victorian traceability requirements of blood and blood products replaces the Department of Health and Human Services Circular 32/2008 - traceability of transfused blood and blood products. This document outlines the health services legal responsibility to be able to trace all blood and blood products.
- - an example of a blood fridge maintenance record developed by BloodSafe SA, includes, daily, weekly and monthly checks. This includes temperature chart, alarm tests and battery backup checks.
- - The Lifeblood Health professionals webpage provides details on the storage requirements of blood components.
- (7.9, 7.10) - Developed by Eastern Health, this document provides information about what the 30 minute/4 hour rule is and what it means in clinical practice.
- (7.9, 7.10) - developed by Eastern Health providing instructions on the use of the Blood in Motion blood transportation system; what it does and when, why and how it’s used.
Availability of blood (7.10)
- (7.9) BloodNet is the NBA’s web-based system used by health services to order blood and blood products. The NBA offers supporting material for its use.
- (7.1, 7.10) - developed by Austin Health outlining the process for placing blood into and removing it from the operating suite blood fridge.
- Template emergency blood management plan - The National Blood Authority has developed a National Blood Supply Contingency Plan to ensure a rapid response should there be threat to the safe and adequate supply of blood. It is expected that health services have an Emergency Blood Management Plan to ensure an appropriate response should the NBSCP be activated. The template is designed to be modified by health services to suit local requirements, while meeting the intention of the NBSCP.
- - the National Blood Authority has developed a National Blood Supply Contingency Plan to ensure a rapid response should there be a threat to the safe and adequate supply of blood. It is expected that health services have an Emergency Blood Management Plan to ensure an appropriate response should the NBSCP be activated. The template is designed to be modified by health services to suit local requirements while meeting the intention of the NBSCP.
COVID 19 Newsletters and posters
A series of newsletters developed by Blood Matters to provide information regarding the safety and security of the blood supply and measures to reduce use, prevent waste and ensure staff safety during the COVID-19 pandemic.
Reviewed 18 November 2021