Standard 1 Leadership and Structure

1. Standard 1Leadership and Structure Presented by: Brenda Depena Gray, BS, BSN, RN Director of Transfusion Alternatives Program Atlanta Medical Center September 2012

2. Leadership and Structure DISCLOSURES I have no financial gain or incentives from the products or processes which may be discussed during this presentation

3. Administrative and Clinical Standards for PBM • Leadership and Program Structure • Consent Process and Patient Directives • Blood Administration Safety • Review and Evaluation of the PBM Program • Preoperative Anemia Management • Perioperative Autologous Blood Collection for Administration • Acute Normovolemic Hemodilution • Phlebotomy Blood Loss • Minimizing Blood Loss Associated with Surgery, Procedures, Underlying Medical Conditions . . . . • Massive Transfusion Protocol • Transfusion Guidelines • Management of Anemia in Hospitalized Patients

4. Administrative and Clinical Standards for PBM

5. Leadership and Structure OBJECTIVES Define the roles and responsibilities of the Medical Director of a Blood Management Program Decide which candidate is most qualified for the position Understand Blood Management Program structure

6. Dr. Clueless& Dr. GOTACLUE

7. Leadership and Structure Medical Director Has knowledge and experience in the use of blood, blood products and treatment modalities. Provides leadership in establishing clinical protocols for blood management Consults with, assists, and educate hospital physicians Oversees policies and procedures development.

8. Leadership and Structure Program Manager Has experience in transfusion medicine or Blood Management( RN, RX, MT). Has working knowledge of blood components and treatment modalities. Can navigate the health system. Handle day to day operations Provide guidance and education to staff as needed Develop Community education seminars Team player

9. PROGRAMINDICATORS

10. Leadership and Structure STRUCTURE!!!! WHAT IS THAT?

11. Mission Vision Values Goals Purpose of Program Leadership and Structure

12. Leadership and Structure There is a written mission, vision and value statement that describes the purpose of the program and how it fits the institution’s mission and values.

13. Leadership and Structure MISSION STATEMENT Our Mission is to serve the region with a program dedicated to providing quality care and appropriate blood management to all seeking our services and to respect the patient’s rights. Our Goal is to continue in the development of technique, skills and services in blood conservation that set standards for other hospital programs to follow.

14. Leadership and Structure The scope of service defines the clinical areas affected by the program

15. Leadership and Structure CLINICAL AREAS INCLUDE: Hematology Cardiology General Surgery Anemia Clinic Vascular Internal Medicine Anesthesiology Cancer Urology

16. Leadership and Structure Job descriptions are maintained for both the physician medical director and the program manager.

17. Job Descriptions • DO EVERYTHING • EVERYDAY • FOR EVERYBODY • Your signature_____________________

18. Leadership and Structure Written interdepartmental policies and procedures guide practice and process

19. EXAMPLE of Policy Statement: PURPOSE: To define hospital policy and procedures for the Atlanta Medical Center Transfusion Alternative Program (TAP) for any competent adult patient who requests not to receive blood transfusion under any circumstances (“Bloodless). POLICY: These guidelines are meant to assist the physicians, nursing staff, ancillary staff, and administrators in ensuring that all necessary steps are taken to protect both the patient and the hospital while preserving the autonomy and dignity of all parties involved with Transfusion Alternative Program (TAP).

20. Leadership and Structure Clinical Protocols and guidelines are written, followed and available to the staff at all times.

21. Blood Conservation and Transfusion Alternative Program Order Set PAGE 1 OF 1 PROCEDURE (CHECK ONE): ______ Pre-Surgical Diagnosis Code: 285.9/VO7.8 Hct: _________ ______ Iron Deficiency Anemia Diagnosis Code: 280.9 Hct: _________ Secondary ______ 579.9 Unspecified Intestinal Malabsorption Hct: ______ V12.79 Personal History of Other Specified Digestive Disease Hct: _________ ______ Anemia of Chronic Disease Diagnosis Code: 285.29/VO7.8 Hct: _________ Diagnosis Code for Chronic Disease: _______________ Hct: _________ ______ Myelodysplastic Syndrome Diagnosis Code: 238.72 Hct: _________ ______ Anemia of Renal Disease Diagnosis Code: 585.9 Hct: _________ ___x__ Blood Conservation Program Referral and Screen

22. Leadership and Structure EDUCATION: There is a comprehensive education program targeting physicians, mid-level providers, nurses, pharmacist and other ancillary health care staff regarding the blood management program’s goals, structure and scope.

23. Blood Management Program Striving 5In Service / Education Date:_____________Time:__ _______ The Goal of this in service is to provide a basic protocol for the initial contact and care of the Bloodless Medicine patients.

24. STRIVING 5

25. Leadership and Structure Quality and outcome measures are identified, with data collection and reporting to the hospital quality improvement committee as scheduled.

26. MONTHLY REPORTS Decrease % PRBC in Ortho Surgery HGB, HCT levels of pre-surgical patients Amount of blood products used monthly Length of patient stay post surgery Patient outcome review.

27. Leadership and Structure Leadership Commitment: A leadership level is represented on the transfusion or Blood Management Committee.

28. Blood Management Meeting • Multidisciplinary Team

29. THANK YOU

30. References • Administrative and Clinical Standards for patient Blood Management Programs, society for the advancement of blood management Unpublished work 2010, Standard 1 • Atlanta Medical Center Transfusion Alternative Program documents

31. Leadership and Structure Are there any questions?