An e-Network colleague has inquired whether the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) requires hospitals to have a Transfusion Committee.

This question was researched by Dr. Sunita Saxena, a member of the CBBS and chair of the Transfusion Committee at the Los Angeles County+USC Health care Network. According to Dr. Saxena, the JCAHO has the following standards which define how an organization should approach blood use review:

• Standard PI.3.1.1
• Standard PI.3.1.3
• Standard TX.5.1
• Standard TX.5.2
• Standard TX.5.2.1
• Standard TX.5.2.2

Standard PI.3.1.1 requires an organization to collect data to monitor the performance of processes that involve risks or may result in sentinel events. Organizations are to select performance measures for processes that are known to jeopardize the safety of the individuals served or associated with sentinel events in similar health care organizations. At a minimum, the organization identifies performance measures related to the processes as appropriate to the care and services provided (EXAMPLE: USE OF BLOOD AND BLOOD COMPONENTS).

According to Standard PI.3.1.3, the organization collects data to monitor improvements in performance. Examples of Evidence of Performance for PI.3.1.3 include:

• Discussions with leaders, improvement teams, and information services staff
• Data collection priorities, strategies, and plans
• Data collection strategies and plans, data displays, and monitoring and improvement reports
• Improvement activities documentation
• Documentation of reviews
• Meeting minutes
• Data collection tools

Standard TX.5.1 requires an organization to determine the appropriateness of a procedure for each patient is based, in part, on a review of the need to administer blood or blood components.

Standard TX.5.2 requires that before obtaining informed consent, the risks, benefits, and potential complications associated with procedures are discussed with the patient and family.

Standard TX.5.2.1 requires that alternative options are considered.

Standard TX.5.2.2 requires discussions with the patient and family about the need for, risk of, and alternatives to blood transfusion when blood or blood components may be needed are considered. Evidence for compliance include documentation that patients receive adequate information to participate in care decisions and provide informed consent. If the patient's condition does not allow for such interaction, appropriate documentation is provided in the medical record.

As can be seen, none of the above standards specifically require that a hospital have a separate 'transfusion committee', so long as the hospital is addressing the above Standards to the satisfaction of the JCAHO.

AND, an assessor for the JCAHO was also consulted and he reported that many of the JCAHO standards are function driven, rather than required structures (such as a specific committee). For example, some places still have a Tissue committee, others do it through an overall QA committee. The same applies to transfusion review. Whether a separate committee exists is not critical. The issue is, simply stated: Is there ongoing review, and is it meaningful. The latter is where there is subjectivity, whether from JCAHO, CAP, or AABB. In the opinion of this JCAHO surveyor there is a simple starting yardstick for any hospital and any inspector for any accrediting organization. If the hospital's Transfusion committee, or surrogate, can find no instances of questionable transfusion, and has made no reviews of newer issues in transfusion since the last inspection, then one suspects meaningful review/guidelines are not present.

ADDENDA Jan. 8, 2006

1. Editor's note: The following article by Shulman and Saxena is germane to this discussion:

Shulman IA, Saxena S. The transfusion services committee - responsibilities and response to adverse transfusion events. Hematology (Am Soc Hematol Educ Program). 2005;:483-90.

Please submit comments to the e-Network Forum.

Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator