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Comments requested on Joint Commission meeting to determine the need to incorporate blood management performance measures into their survey and accreditation process | ||
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The Editor has been made aware of a meeting on February 5, 2007, where the Joint Commission, formerly known as JCAHO, held a stakeholders meeting to determine whether there was a need to incorporate blood management performance measures into their survey and accreditation process. The meeting was attended by representatives of various professional societies, as well as by representatives from the United States Department of Health and Human Services, the American Red Cross, the National Institutes of Health (NIH), the Food and Drug Administration (FDA). Reportedly, the Joint Commission will proceed with forming an Advisory Committee that will work toward developing specific performance measures. The Editors ask if any colleagues who were present at the meeting might comment. The following comments have been received. ADDENDA Feb. 20, 2007 1. Dr. Jonathan Waters (attribution used with permission) attended the stakeholders meeting as a representative of the Society for the Advancement of Blood Management (SABM). He reports that the following individuals were also present, and which organizations they represented:
ADDENDA Mar. 17, 2007 2. A doctoral scientist in Illinois is encouraged by the actions being taken by The Joint Commission to proceed with forming an Advisory Committee that will work toward developing specific performance measures for transfusion practice. He feels that this is as an important step in improving patient care and reducing costs, while conserving blood supply and reducing adverse effects due to transfusions. He wonders if any colleagues are privy to information on whom to contact for more information on the future potential membership of this committee. ADDENDA July 25, 2008 3. According to Dr. Steve Apfelroth, Director, Blood Bank at the Jacobi Medical Center of the Albert Einstein College of Medicine (attribution used with permission), the blood bank community should be aware that a Joint Commission technical advisory group of "stakeholders" has come up with a list of 19 "performance measures" that are being proposed for tracking performance in blood management. In his opinion, while there is some basis for each of the measures individually, compiling and analyzing the data for the proposed measures may be extremely burdensome. He is concerned that these measures will be considered "patient care and safety related" and be applied even to blood banks that are already CAP and/or AABB accredited. This is on the basis of the interpretation that the deemed status of the inspections of those organizations only applies to "in the laboratory" issues and that the Joint Commission is entitled to reinspect patient care related "overlap" issues. To begin with, he thinks that this is an interpretation (already applied to critical value notification issues) that if allowed to stand will ultimately lead to the end of the utility of submitting to those peer-group organization inspections, and for this reason should be vigorously resisted by those who believe in peer inspections. Secondly, he does not think there has been enough involvement by the working blood bank community in developing (or resisting the scope of) these measures, and the community should consider providing input through the online survey process (by August 19th), or directly to the 20 technical advisory group members identified below. The following information is from the Joint Commission website. Performance Measurement Initiatives Background Technical Advisory Panel Jonathan H. Waters, MD, Co-Chair Neil Bangs, MS, MT (ASCP) SBB Richard J. Benjamin, MD, PhD, FRCPath, MS Laurence Bilfield, MD Victor A. Ferraris, MD, PhD John Freedman, MD, FPCPC Jonathan C. Goldsmith, MD Lawrence Tim Goodnough, MD Penny S. Gozia, MD, FACOG, MBA Jerry Holmberg, PhD., MT (ASCP) SBB Harvey G. Klein, MD Joseph E. Kiss, MD Mark T. Lucas, MPS, RCS, CCP Vijay K. Maker, MD, FACCS John (Jeffrey) McCullough, MD Aryeh Shander, MD, FCCM, FCCP Bruce D. Spiess, MD, FAHA Jeffrey Wagner, BSN, RN Rosalyn Yomtovian, MD ADDENDA July 30, 2008 4. The following reply has been submitted by Dr. Waters in response to the July 25, 2008 comments of Dr. Apfelroth. "As the co-chair of the Joint Commission committee which formulated these performance measures, I feel obligated to respond to Dr. Apfelroth's commentary. First, the committee representation was composed of individuals who were recommended by societies or organizations which play a role in transfusion therapy. This would include the blood banking community as well as end users. The committee had membership from the ARC, FDA, NHLBI and AABB as well as several independent blood banks. The committee also had representation from end users such as the American Society of Anesthesiologists, the American College of Surgeons, the Society of Critical Care Medicine and the American Society of Hematology. I would encourage the Forum readers to go to the Joint Commission website and review who these individuals were. I personally feel that the committee was a fair representation of groups that would be impacted by the measures. The goal of the committee was to review approximately 80 measures that were submitted to the Joint Commission. The submission period was open to all parties that had an interest in the project. Virtually, all hospitals in the US were notified of this open submission process. The committee reviewed these measures for validity and whether the measures would have an impact on patient safety. These 19 measures were the final result of the committee review." "Once the measures were vetted by this group, a Joint Commission staff member and myself worked to put the measures into a format which provided a numerator and denominator for the measure as well as providing an evidence based rationale for the measure. I can state unequivocably that this was not easy. These measures now appear on the Joint Commission web site for public commentary. As Dr. Apfelroth suggests, I too would strongly encourage everyone who has an interest to provide commentary which we will try to incorporate into the final measures. The final measures will be a sub-segment of what currently appears for public comment." ADDENDA July 31, 2008 5. A bench tech who works in a hospital setting is concerned that if the Joint Commission added the proposed measures, the data gathering for all these measures would fall on her. She has read each of the measures carefully and from her past experience as a blood bank supervisor, she believes each measure does need to be in place. However, if these measures are adopted by Joint Commission, then AABB and CAP would probably also put guidelines in place to ensure their accredited facilities performed the adopted measures. She does not believe the fears of having peer-review organizations excluded are well-founded. She does agree that the fact gathering would be extremely time-consuming, possibly one FTE in hospitals of greater than 500 beds. Once an algorithm is in place to collect this information, then keeping track would not be so overwhelming. She knows of at least one hospital software program that could be "tweaked" to collect most of the information suggested by the measures. She sees the biggest problem as lack of documentation of the pretransfusion, mid-transfusion and post-transfusion hemoglobins, reasons for the transfusion and the mind-set that one unit of blood is never a valid treatment. If these measures are put in place, is there an entity within (especially) smaller hospitals that can ensure physician compliance? 6. A transfusion services medical director in New England is concerned that most of the representation of the Advisory Group co-chaired by Dr. Waters does NOT include TRANSFUSION SERVICE directors. The New England physician only recognizes two on this Advisory Group that are possibly Transfusion Service directors. Also, many of the Transfusions Service directors in the US are PATHOLOGISTS at medium to smaller-sized hospitals and are not affiliated with the AABB, but are affiliated with the College of American Pathologists, which was not mentioned as a group that was represented. Blood suppliers and end users seemed to be well represented in this Advisory Group, but are unlikely to be the ones responsible for coordinating the collection and analysis of this type of data, which is maintained mainly in the Transfusion Service databases (many of which may require manual review for data collection). ADDENDA August 12, 2008 7. Dr. Irwin Gross, Medical Director, Transfusion Services at Eastern Maine Medical Center (attribution used with permission) comments that he is surprised by what he perceives to be a generally negative tone of the document posted by the AABB “detailing issues, concerns, advantages and disadvantages of the Joint Commission’s 19 proposed Blood Management Performance Measures.” The AABB document seems to reluctantly suggest that many of the measures “may lead to outcomes improvement” while going into great detail about the disadvantages of each proposed measure. He adds that gathering the data required for many of the measures presents a challenge for many hospitals. However, he believes that in many instances the resources to do this might be made available by redirecting resources currently dedicated to gathering data for “quality measures” that have had little impact on transfusion practices and quality of care. The tremendous variation in transfusion practices between institutions and between providers within institutions strongly suggests the need to improve transfusion practices. In his opinion, AABB needs to be more proactive in ensuring appropriate clinical use of blood products. Under the guiding principle of “no opposition without a proposition” he would like to see the relevant AABB committees make a greater effort to suggest constructive alternatives to the Joint Commission’s proposed Blood Management Performance Measures or suggestions on how the proposed measures might be improved. He urges e-Network Forum readers to review the Draft Blood Management Candidate Measure Profiles, fill out the survey, and provide constructive suggestions on how the proposed measures might be improved." ADDENDA August 17, 2008 8. Dr. Waters (see his postings of Feb. 20, 2007 and July 30, 2008) concurs with Dr. Gross (posting of August 12, 2008) in that multiple criticisms of the Joint Commission performance measures have been vocalized, but few of these criticisms have been constructive. Having spent considerable time pondering these measures, Dr. Waters can tell the readership that it was not easy to formulate the performance measures so that they are fair to all parties affected. The point of putting the proposed performance measures out for public comment is to gather good ideas to improve them. In this way, it is hoped that they make positive improvements in patient care. So, if colleagues don't like the measures, Dr. Waters asks for constructive suggestions for how to write a nominator and denominator with appropriate exclusion groups that gets at the heart of the proposed outcome improvement.
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Please submit comments to the e-Network Forum. Ira A. Shulman, MD W. Tait Stevens, MD |
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 Printable PDF of this pagePosted: Feb. 19, 2007 Addenda: Feb. 20 & Mar. 17, 2007; July 25, 30 & 31, Aug 12 & 17, 2008 |
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