Recently the Blood Transfusion laboratory at Sunnybrook Health Sciences Centre underwent their American Association of Blood Banks (AABB) assessment to review the laboratory’s transfusion standards and quality systems.
The team was well-prepared, but was thrilled when they received a score of 100 per cent, indicating a perfect compliance.
The blood transfusion lab at Sunnybrook had one lead/sole assessor, Keith Hoerth, Manager of the Transfusion Services at the University of Wisconsin Hospitals, who spent a period of one and half days looking over the laboratory.
Leading this assessment for Sunnybrook was Sneha Patel, MLT, Quality Assurance Officer.
“It was my first experience leading an assessment and it was made possible only through the immense support I received from all the staff members and management. I found this assessment to be a great educational opportunity.”
The AABB standards are based on an ISO quality system framework and during an assessment the laboratory’s operations are reviewed to determine how well the institutional quality system complies with the established standards.
The assessment evaluates not only your technical procedures but also how your operations from resources to customer service are structured to ensure quality results are produced every time and that process improvement is continuous.
An example would be, as per AABB standards requirement ‘1.4 Emergency Preparedness’- The blood bank or transfusion service shall have emergency operation policies, processes and procedures to respond to the effects of internal and external disasters.
They are assessing the Blood and Tissue Bank to see how we meet the above stated requirement i.e.
- What policies, processes, and procedures we have in place to respond to internal and external disasters that adversely affect the operations of the blood bank or transfusion service
- How do we ensure that all staff knows how to respond in the event of an internal or external disaster?
“The accreditation assessment process and preparation both requires strong team work, said Sneha. “There is a lot of hard work that goes into the pre and post assessment and it’s a very proud moment for our Blood and Tissue Bank Department to have achieved 100% compliance.”
“Keith was very impressed with our operations and this was reflected in his report which identified no non-conformances,” said Lisa Merkley, Director, Laboratory Medicine, Sunnybrook Health Sciences Centre.
A significant amount of work goes into preparation for the assessment includes providing all the required documents to the AABB Accreditation Program prior to the onsite assessment such as Facility Contact Information, Pre-assessment Packet with requested materials (facility organizational chart, summary of facility’s quality system, list of all Proficiency Tests performed since last AABB assessment etc).
Prior to the assessment, a self-assessment is conducted by appropriate staff within the Blood and Tissue Bank to identify gaps in compliance with the 29th edition of the AABB Standards (effective May 2014) and to develop a corrective action plan for the identified gaps. A list of documents for on-site review is provided by AABB prior to the site visit and these needs to be ready and accessible to the assessor on the day of the assessment.
“Our blood transfusion has done it again – demonstrating to all of us in the labs, across the entire hospital and throughout the laboratory medicine community that they are truly world leaders,” said Brad Davis, Executive Director, Laboratory Medicine. “I know that we have a tremendous team and that everyone does their best for our patients every day and I’m thankful and appreciative to your commitment to patient care.”
“We were fortunate to have an assessor who works for a facility that supported similar programs to ours (trauma, NICU, tissue banking) and utilizes the same laboratory information system,” said Sneha. “We were able to exchange information for the laboratory information system and on laboratory processes for improvement.”
Looking back on the assessment and the work that went into it, Lisa added that “these kind of results require a team effort which you demonstrate every day-always there ‘when it matters most’!”