System for Accreditation in Blood Banks
Salwa Hindawi
MSc, FRCPath, CTM
Assistant Professor in Haematology Director of Blood Transfusion Services
KAUH, Jeddah Saudi Arabia
• Introduction
• Accreditation Concept
• Accreditation Process
• Examples of different Systems for Accreditation
• Benefits of Accreditation
• Local experience
Introduction
• Certification, licensing and accreditation are terms used to describe the organisational
mechanisms that support and enforce the established quality systems in individual establishments
• The accreditation program assesses the quality and operational systems in place within the
facility.
Most of the accreditation programs develop and reviews quality standards and guidance to
ensure that quality and its Quality System
Essentials (QSEs) cover the entire spectrum of
the clinical laboratory services.
Concept of Accreditation
To Improve quality of our services and increase safety of our Customers.
To improve staff performance
Accreditation
Accreditation is a voluntary process.
The health care organization or provider undergoes a survey process by a team of health care
professionals from the accrediting agency.
AABB, CAP, ISO, Local (CBAHI)
Accreditation Process
• It is a process of peer review by experts to
ensure the compliance of practice with the
recognized standards.
Accreditation Process
• Application
• Pre-assessment
• Assessment
• Corrective actions
• Decision on Accreditation
• Re-assessment
How Is a Survey Conducted?
• A team surveys the institution through:
– Review of required documents (policies &
procedures)
– Review of documents implementation:
• Charts
• Control sheets
• Employees’ file
• Interviews with staff and patients
• Environmental rounds
How Is a Survey Conducted?
Conclusions and reports are provided at the end of survey
Nonconformance or deficiencies is to be included in the report.
Action plan to be initiated by the facility for improvement.
Certificate granted to the facility.
The Key to maintaining
Licensing and Accreditation
Therefore need to
• Make sure QMS is fit for purpose
• Keep up to date with regulatory requirements and guidance
• Make use of Benchmarking and learn from others
• Continuous review of QMS through:
Audit the system
self inspection, should be examined at intervals following a pre-arranged programme in order to verify their conformity with the principles of
Quality Assurance.
Systems for Accreditation
•
There are many Established systems for accreditation which can help any institution to know its strengths,weaknesses and opportunities through an informed review
• Accreditation Systems either International or National.
• There are 3 different systems:
• General Accreditation System JCI, Canadian, SAUDI
• Laboratory Accreditation System as CAP, CPA
• Blood Banks Accreditation System as AABB
Accreditation to ISO 15189
The Process
• Peer Review
• Register of 70 qualified assessors/experts
• Hired on a contract basis
• Assessment Team
• Confidentiality / Conflict of Interest issues addressed
College of American Pathologists (CAP)
The goal of the CAP Laboratory Accreditation Program is to improve the quality of clinical laboratory services
through:
• voluntary participation
• professional peer review
• education and compliance with established performance standards.
The AABB Accreditation
• In 1958 the association implemented the Inspection and Accreditation Program
• The Program objective is to improve the quality and safety of collecting, processing, testing, distributing and
administering blood and blood products and to advance quality in tissues and blood transfusion services.
NATIONAL ACCREDITATION BOARD FOR HOSPITALS & HEALTHCARE
PROVIDERS (NABH) India:
• The accreditation program assesses the quality
and operational systems in place within the facility and/or Blood Banks/ Blood Centers and
Transfusion Services.
• The accreditation includes compliance with the
NABH standards, applicable laws and regulations.
NABH Accreditation Procedure
• Application for accreditation + Quality Manual (By Blood bank)
• Acknowledgment and Scrutiny of application (By NABH Secretariat)
• Pre - Assessment visit (By Principal Assessor)
• Final Assessment of Blood bank/ blood centre (By Assessment team)
• Review of Assessment Report (By NABH Secretariat)
NABH Accreditation Procedure
• Recommendation for Accreditation (By Accreditation Committee)
• Approval for Accreditation (By Chairman, NABH)
• Feedback To Blood bank/ blood centre
• And Necessary Corrective Action Taken By Blood bank/ blood centre
• Issue of Accreditation certificate (By NABH Secretariat)
The Central Board of Accreditation for Healthcare Institutions (CBAHI)
• Saudi national accreditation program.
• It is a non-profit organization that provides
expertise and guidance to Healthcare Institutions across Saudi Arabia for improving the quality of services and patient safety.
Benefits of Accreditation
• Provides assurance that Blood Bank is operating to a prescribed level of technical competency that meets Regulatory requirements.
• Increases public confidence in accuracy of Blood Bank results on which decisions can be made.
• it provides for continuous learning and professional development of all the staff.
Benefits of Accreditation
• To ensure the quality of health care through the application of quality concepts.
• To foster a culture of patient safety and minimize the risk of medical errors.
• To achieve optimum organizational results with available resources.
Local Experience
• AABB Accreditation for the last 6 years
• AABB established in 1958 with 50 year of experience.
• BBTS (Blood Banks, Transfusion Services, Blood Donor Centers).
• 1500 Accredited Facilities.
• 42 International in 13 Countries.
• 12 in Saudi Arabia
Outcome of Local Experience
• Increase awareness among staff about importance of quality for safe practice.
• Educational Opportunities (ASCP, SBB).
• Help in change of attitude and increase self confidence among staff.
• Build trust between customer and BTS staff.
• Encourage team work.
• Continuous improvement to the quality of our services.
Conclusion
– Accreditation requirements are not just a
burden, but are a framework that labs can use to ensure best practices.
– Accreditation results in improving the quality and safety of collection, processing, testing,
transfusion and distribution of blood and blood products.
Conclusion
• the accreditation is a continuous process for
improvement of quality and safety of participating institutes or facilities
• we should encourage all health institutes to be
involved in one or another system for accreditation.
• There is a need for a national or regional
accreditation system for health institutes especially for blood transfusion services to help in the
development and improvement of the quality of their services.
