Department of Health

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.

The Australian Health Service Safety and Quality Accreditation (AHSSQA) scheme assessor orientation video is available to anyone interested in gaining a better understanding of the assessment process and the requirements of assessors.

There is also an assessor orientation course available.

To help prepare for assessment against the National Standards the AHSSQA provides:

  • user guides
  • accreditation workbooks
  • advisories
  • factsheets.

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 Australian health ministers’ conference statement on national stewardship expectations for the supply of blood and blood products.

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

    Victorian Health Service Blood Management or Patient Blood Management Committee guidance - 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. 

    EN transfusion competency guide - 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. 

    EN transfusion competency template - 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.

    Nurse practitioner prescribing guidance (PDF/Word) - this provides a framework to assist health service identify the requirements for nurse practitioners to include blood and blood product transfusion prescription into their scope of practice.

    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.

    Implement policies and procedures

    Royal Children’s Hospital - Management of blood refusal procedure - the RCH guide for staff making decisions for patients, where consent for blood transfusion for a child has been withheld.

    Austin Health Inter-hospital transfer and blood transfusion 2020 - Austin Health procedure for managing blood that has arrived with a patient from another health service.

    Austin Health - Administration of red cells - 2020 - provides guidance to safely administer red cells, and assist in recognising and managing reactions associated with red cell transfusion.

    Barwon Health blood product dispatch - 2020 - 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. 

    Austin Health - Accessing blood from the blood fridge clinical procedure - 2020 (7.1, 7.10) - developed by Austin Health outlining the process for placing blood into and removing it from the operating suite blood fridge.

    Manage risks

    Risk management should be undertaken in conjunction with the Risk Management Team using the local Risk Management Framework and procedures.

    Identifying training requirements

    Blood Matters massive transfusion scenarios (7.1) - aimed at helping health services test the functionality of their massive transfusion protocol, and identify areas for improvement.

    Applying quality improvement systems 7.2

    This includes blood management quality performance indicators, quality and safety improvement, and quality surveillance.

    Job description for Transfusion Nurse/Safety Officer - 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.

    Job description for Transfusion Trainer - 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.

    Blood Matters Transfusion Resource Handbook 2021 - 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.

    Blood Matters Health Service Blood Management Committee reports - 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

    Royal Melbourne Hospital Quality Improvement Summary - 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.

    Report outcomes

    Blood Matters Audits and reporting - 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.

    The data collection tool are available for health services to conduct audits on blood management and transfusion practice. The tools available include:

    • 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.'

    Consent for blood transfusion BMJ (2010) - 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 Medical Treatment Planning and Decision Act 2016 (Victoria) has given statutory recognition to advance care directives and simplified and contemporised laws relating to medical treatment decision making for people without decision making capacity. 

    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 Office of the Public Advocate provides services for those with diminished capacity and resources for clinicians and the general public to assist with medical decisions.

    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 Jehovah’s Witness Medical information to Clinicians 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.

    The emergency number for the Jehovah’s Witness Hospital Liaison in Victoria is 0414 842 827, and is available 24 hours 7 days per week.

    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 Jehovah’s Witness Religious and Ethical Position statement.

    Further information regarding patient blood management can be found on the Patient Blood Management page.

    Informed consent for blood transfusion template (7.3) - This can be used in the format provided, or adapted as required. Independent legal and professional advice should be sought before using this document.

    St Vincent’s Hospital - Consent for administration of blood and blood products - 2021 (7.3) - St Vincent’s Hospital Melbourne policy on obtaining informed consent for blood and blood products.

    Effective communication

    Consumer information

    Bendigo Health: What to expect before, during and after the transfusion - A visual pathway developed at Bendigo Health detailing what to expect before, during and after a blood component transfusion.

    Blood transfusion information for patients - Patient information sheets in a standard and simple/visual format that have been developed by Blood Matters with input from consumers/patients.

    Clinical Excellence Commission, Blood Watch program has multiple information sheets - The information is in English, Arabic, Chinese Simplified, Chinese Traditional, French, Filipino, Greek, Hindi, Italian, Korean, Macedonian, Persian, Russian, Spanish, Turkish and Vietnamese.

    • 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.

    SA Health’s BloodSafe program - Blood transfusion factsheet, 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.

    Health Translations has information available on RhD immunoglobulin – you and your baby, in English, Arabic, Chinese and Vietnamese.

    Australian Red Cross Lifeblood My Transfusion has patient information on patient blood management and blood and blood product transfusion for adults and children.

    Eastern Health - Neonatal/paediatric information sheet - 2014 (7.3) - the Eastern Health procedure for administration of blood and blood products for neonatal/paediatric patients.

    Australian Red Cross Lifeblood transfusion searchable factsheets and resources (7.3) - the factsheets provide a basic level of information about blood products and blood management. Search for the relevant factsheet.

    Royal Children's Hospital - Consent and patient information (7.3) - intended as a framework for clinicians; it provides an overview of consent, obtaining consent and information for patients and families.

    Blood Matters - Core elements of informed consent for transfusion (7.3) - aimed at assisting health services to develop processes for informed consent for blood transfusion.

    Informed consent for blood transfusion template (7.3) - a template for obtaining informed consent for blood and blood product transfusion. It can be used as is or adapted for local requirements.

    Eastern Health - Jehovah’s Witness blood component and products information sheet 2018 (7.3) - aimed at providing guidance/general information related to the use of blood and blood products for patients who are Jehovah’s Witnesses.

    Western Health - Refusal/consent to Blood, blood products and conservation (7.3) – the blood and blood product consent and refusal form developed at Western Health. 

  • 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 patient blood management
    • 7.5 documenting
    • 7.6 prescribing and administering blood and blood products
    • 7.7 and 7.8 reporting adverse events.

    Resources regarding 7.4 Optimising and conserving patient’s own blood is located under patient blood management.

    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.

    Documenting 7.5

    Austin Health - Blood Prescription and Administration Form - 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.  

    Barwon Health - Blood product prescription form - developed by Barwon Health, this prescription form includes a transfusion decision algorithm.

    Royal Melbourne Hospital - Blood component prescription (includes consent) 2018 - this form is the one used by Royal Melbourne Hospital prior to implementing an electronic medical record.

    Royal Melbourne Hospital - Blood order and administration form 2020 (7.5 and 7.6) - used when the electronic medical record is not available.

    Western Health - Blood and blood product consent and prescription form - 2016  (7.3, 7.5 and 7.6) - developed by Western Health the form is used for prescription, administration and documenting consent.

    Prescribing and administering blood and blood products 7.6

    The Blood Book: Australian Blood Administration Handbook is a comprehensive resource to assist with safe bedside transfusion practice. Australian Red Cross Lifeblood.

    Blood Matters - Two-person independent checking for safe transfusion poster - the posters are designed for health services to use as an easy reference to assist with best practice for blood administration.

    Blood Matters and Macopharma - How to spike a blood bag (poster and swing tag) 2017 - the posters and swing tags use a pictorial format to demonstrate how to safely and effectively spike a blood component bag for administration.

    Australian Red Cross Lifeblood transfusion website (7.6, 7.7 and 7.8) - The website provides information for clinicians on a range of blood related topics.

    Reporting and adverse events 7.7 and 7.8

    Australian Red Cross Lifeblood - Classification and incidence of adverse effects (7.7 and 78) - information for clinicians on adverse events and incidents including the classification of transfusion reactions and estimated incidence.

    The Serious transfusion incident reporting (STIR) is a voluntary reporting, state based system for reporting serious blood management and transfusion practice errors and transfusion reactions.

    Eastern Health - Acute transfusion reaction flow chart - (7.7 and 7.8) - a flowchart developed by Eastern Health showing the required management of suspected acute transfusion reactions.

    Eastern Health - Delayed transfusion reaction recognition chart - (7.7 and 7.8) - a flowchart developed by Eastern Health showing the required management of suspected delayed transfusion reactions.

    Royal Melbourne Hospital - Transfusion related adverse event form (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.

    St Vincent's Health - Transfusion reaction notification investigation form (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.

    Western Health - Acute transfusion reaction flowchart (7.7 and 7.8) - a flowchart developed by Western Health showing the management of suspected acute blood, blood product reactions in adults.

    Western Health - Delayed adverse transfusion reaction flowchart (7.7 and 7.8) - a flowchart developed by Western Health showing the management of suspected delayed blood, blood product reactions in adults.

    Western Health - Transfusion reaction investigation eform (7.7 and 7.8) – the form was developed by Western Health to report suspected transfusion reactions for investigation.

  • 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 2010 Blood storage and handling report contains an audit tool which may assist health services when developing a blood management and storage policy.  

    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 Traceability requirements of blood and blood products – January 2021 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. 

    Availability of blood (7.10)

    • National Blood Authority - BloodNet (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.
    • Austin Health - Accessing blood from the blood fridge clinical procedure - 2020 (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.
    • 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 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

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