A. Introduction
Blood transfusion is an essential component of health care. An insufficient or unsafe blood supply for transfusion has a negative impact on the effectiveness of key health services and programs to provide appropriate patient care in numerous acute and chronic conditions. To ensure lifesaving blood transfusion, access to whole blood and blood components is vital. For these compelling reasons, it is important to ensure access to safe, effective and quality-assured blood products.[1]
A robust national blood service and blood regulator, with effective systems for monitoring the safety of blood donations and blood product use is also key to building and strengthening national capacities to respond to emergency situations, including natural disasters, humanitarian crises and emerging infectious threats.. [2]
B. Aim
- To strengthen leadership and governance of the national blood transfusion service
- To support coordination and collaboration
- To ensure access to a safe and sufficient supply of blood and blood products
- To strengthen the provision of safe blood and blood products to meet patients’ needs
- To promote appropriate clinical use of blood and blood products
- To promote the adoption of evidence-based practices
- To strengthen quality system management throughout the blood transfusion chain
C. Framework and guiding principles of HCAC Hospital Standards
The HCAC Blood bank and Transfusion Services Accreditation Standards provide the guiding framework within which Blood bank performance is evaluated, the standards specify quality management essentials in that in total form quality management system along with requirements for blood donation services, component production, testing, equipment management, staff training and competency, as well as documentation and reporting. The standards are built using the WHO Action framework to advance universal access to safe, effective and quality-assured blood products (2020-2030).
The goal of the framework is to improve the availability, safety, affordability and accessibility of blood and blood products in Jordan in order to reduce mortality and morbidity.
D. Guiding Principles
- Availability of a well-organized and coordinated blood transfusion service.
- Collection of blood and blood components from voluntary, non-remunerated and regular blood donors from low-risk populations
- Quality-assured testing of all donated blood, including screening for TTIs, ABO and Rhesus D grouping, and compatibility testing
- Reduction in unnecessary transfusions through appropriate clinical use and safe administration of blood and blood products
- Implementation of effective quality systems in all areas, including quality management, development and implementation of quality standards, effective documentation systems, training of all staff and regular quality assessment.
E. Eligible Institutions
Any Blood bank may apply for Blood bank and Transfusion Services Accreditation program if it meets the following criteria:
• Is in compliance with applicable local laws and regulations and has a valid licensure by the approved entity to provide blood bank services.
• Has been providing consolidated blood donation, testing, and component preparation services for at least six months or more prior to the time of survey.
F. Organization of the standards Manual
The standards will provide blood banks with a framework for addressing service delivery and coordination, planning, policy, management and the relationship with other service providers and the wider community. The standards introduce the most important elements of patient safety to a blood bank and create the capacity for the blood bank to continually improve its quality of services to benefit patients
The standards are organized into key functions referred as “clusters”; they are divided into seven clusters. The clusters are arranged as follows:
Cluster 1: Governance and Leadership
Cluster 2: Client Rights
Cluster 3: Human Resources Management
Cluster 4: Technical Operations
- Donation Services
- Components Production
- Transfusion Services
- Reagents Management
- Equipment Management
- Quality Control
Cluster 5: Environmental Health & Safety
- Blood bank Safety
- Infection Prevention and Control
- Emergency Management
Cluster 6: Quality Improvement
Cluster 7: Records and Documents
Blood bank Information System
For each cluster, there is an intent statement that assists the blood bank staff members to understand the standards and a list of the key documents that are required for review by the surveyors. In each cluster, every standard is listed followed by the measurable elements, and survey process. The survey process is identical to what the surveyors will look for to determine how to score the standard.
G. Classification of standards
Standards are classified as critical, and core. The guiding definitions are as follows:
Critical (28 Standards)
Critical standards are those standards that address laws and regulations or, if not met, may cause death or serious harm to clients, patients, or staff.
Core (95 Standards)
Core standards are the standards addressing systems, processes, policies and procedures that are important for patient care. However, partially met compliance with these standards must not pose a threat of harm or death for clients, patients, or staff.
Stretch (0 Standards) **
Stretch standards are standards that are important, but not easy to implement due to time or resource constraints, or a need for culture change.