EVALUATING THE EVALUATORS. EXPERIENCE OF A CENTER AND STATE OF ACCREDITATION IN TRANSFUSION MEDICINE IN ANDALUSIA.
(Abstract release date: 05/19/16)
EHA Library. Garcia Fernandez J. 06/09/16; 135117; PB2217
Mr. Jose Ramon Garcia Fernandez
Contributions
Contributions
Abstract
Abstract: PB2217
Type: Publication Only
Background
In transfusion medicine implementing a quality management system certified by an external entity,allows the development of a safe and efficient activity, while contributing to the involvement of all staff to improving a continuous quality system. In Spain there are two entities accredited byENAC for certification in transfusion: Transfusion Accreditation Committee (CAT) and the Agency for Health Quality of Andalusia (ACSA), although the latter with a specific program limited to transfusion centers
Aims
To describe the situation related to quality management system in transfusion medicine in Andalusia, a region in the south of Spain.
Methods
On the basis of data published by the CAT and ACSA we exposed the number of certified centers in Andalusia compared to national data. The experience of the local hospital was also evaluated Baza as externally certified center.
Results
1. Although only half transfusion centers are certified by CAT, 100% of them are validated by the ACSA specific program.2. 34% of centers accredited in Spain are accredited in Andalusia,3. The relationship with the referral hospital and transfusion center seems to be the most important predisposing factor for a certification program.With respect to the certification program in the form of management is notfully adapted to “little” hospital, because if it´s true that there is a hospital responsible for haemovigilance, hemotherapy isn´t an exclusive dedication for him. In the aspect of non-conformities, the effort in a program of continuous improvement quality is very significant. Comparing our data center initial certification (2010) in which the 3rd edition of the standards was used, with reaccreditation (2014) which use the 4th. Table 2 shows comparative nonconformity according to the specific field deviations observed: it is noteworthy that the percentage remains the same, the most frequent on the requirements of quality control system.TABLE 1: Transfusion centers and hospital of public national health service in Andalusia, classified in provinces. Between parentheses certified centers.
TABLE 2: Evaluation of non-compliance related to, in two consecutives external audits.
Conclusion
1. The implementation of a management system certified qualityby an external entity is a clear need in all transfusional centers involved, although the percentage of certified centers in Andalusia is less than 50%, representing a 34% of the certified centers nationwide.2. Certification of CAT hospital is the only feasible option, but its adaptation to community hospitals is so complicated which is evident in the low number of certified centers. 3. Continuous quality improvement represents an additional workload sometimes unacceptable, it would be required a limited version adapted to district centers.
Session topic: E-poster
Type: Publication Only
Background
In transfusion medicine implementing a quality management system certified by an external entity,allows the development of a safe and efficient activity, while contributing to the involvement of all staff to improving a continuous quality system. In Spain there are two entities accredited byENAC for certification in transfusion: Transfusion Accreditation Committee (CAT) and the Agency for Health Quality of Andalusia (ACSA), although the latter with a specific program limited to transfusion centers
Aims
To describe the situation related to quality management system in transfusion medicine in Andalusia, a region in the south of Spain.
Methods
On the basis of data published by the CAT and ACSA we exposed the number of certified centers in Andalusia compared to national data. The experience of the local hospital was also evaluated Baza as externally certified center.
Results
1. Although only half transfusion centers are certified by CAT, 100% of them are validated by the ACSA specific program.2. 34% of centers accredited in Spain are accredited in Andalusia,3. The relationship with the referral hospital and transfusion center seems to be the most important predisposing factor for a certification program.With respect to the certification program in the form of management is notfully adapted to “little” hospital, because if it´s true that there is a hospital responsible for haemovigilance, hemotherapy isn´t an exclusive dedication for him. In the aspect of non-conformities, the effort in a program of continuous improvement quality is very significant. Comparing our data center initial certification (2010) in which the 3rd edition of the standards was used, with reaccreditation (2014) which use the 4th. Table 2 shows comparative nonconformity according to the specific field deviations observed: it is noteworthy that the percentage remains the same, the most frequent on the requirements of quality control system.TABLE 1: Transfusion centers and hospital of public national health service in Andalusia, classified in provinces. Between parentheses certified centers.
| Huelva | Sevilla | Córdoba | Cádiz | Málaga | Jaén | Granada | Almeria | TOTAL | |
| Transfusion Centers | 1(1) | 1(1) | 1(1) | 1(1) | 1(1) | 1(1) | 1(1) | 1(1) | 8(8) |
| Regional Hospitals | 1 | 2(2) | 1(1) | 1(1) | 1(1) | 6(5) | |||
| Speciality hospitals | 1(1) | 4(2) | 2(1) | 1 | 1 | 9(4) | |||
| Community hospitals | 1 | 2(1) | 3 | 1(1) | 3(1) | 3 | 2(2) | 2 | 17(5) |
| 2010 AUDIT | 2014 AUDIT | TOTAL | |
| Quality control system | 5 | 8 | 13 |
| Equipment control | 4 | 5 | 9 |
| Reactive control | 1 | 1 | 2 |
| Transfusion procedures | 4 | 6 | 10 |
| Registers | 4 | 3 | 7 |
| Hemosurveillance | - | 1 | 1 |
| Comments of improvement | 2 | 2 | 4 |
| TOTAL | 20 | 26 | 46 |
Conclusion
1. The implementation of a management system certified qualityby an external entity is a clear need in all transfusional centers involved, although the percentage of certified centers in Andalusia is less than 50%, representing a 34% of the certified centers nationwide.2. Certification of CAT hospital is the only feasible option, but its adaptation to community hospitals is so complicated which is evident in the low number of certified centers. 3. Continuous quality improvement represents an additional workload sometimes unacceptable, it would be required a limited version adapted to district centers.
Session topic: E-poster
Abstract: PB2217
Type: Publication Only
Background
In transfusion medicine implementing a quality management system certified by an external entity,allows the development of a safe and efficient activity, while contributing to the involvement of all staff to improving a continuous quality system. In Spain there are two entities accredited byENAC for certification in transfusion: Transfusion Accreditation Committee (CAT) and the Agency for Health Quality of Andalusia (ACSA), although the latter with a specific program limited to transfusion centers
Aims
To describe the situation related to quality management system in transfusion medicine in Andalusia, a region in the south of Spain.
Methods
On the basis of data published by the CAT and ACSA we exposed the number of certified centers in Andalusia compared to national data. The experience of the local hospital was also evaluated Baza as externally certified center.
Results
1. Although only half transfusion centers are certified by CAT, 100% of them are validated by the ACSA specific program.2. 34% of centers accredited in Spain are accredited in Andalusia,3. The relationship with the referral hospital and transfusion center seems to be the most important predisposing factor for a certification program.With respect to the certification program in the form of management is notfully adapted to “little” hospital, because if it´s true that there is a hospital responsible for haemovigilance, hemotherapy isn´t an exclusive dedication for him. In the aspect of non-conformities, the effort in a program of continuous improvement quality is very significant. Comparing our data center initial certification (2010) in which the 3rd edition of the standards was used, with reaccreditation (2014) which use the 4th. Table 2 shows comparative nonconformity according to the specific field deviations observed: it is noteworthy that the percentage remains the same, the most frequent on the requirements of quality control system.TABLE 1: Transfusion centers and hospital of public national health service in Andalusia, classified in provinces. Between parentheses certified centers.
TABLE 2: Evaluation of non-compliance related to, in two consecutives external audits.
Conclusion
1. The implementation of a management system certified qualityby an external entity is a clear need in all transfusional centers involved, although the percentage of certified centers in Andalusia is less than 50%, representing a 34% of the certified centers nationwide.2. Certification of CAT hospital is the only feasible option, but its adaptation to community hospitals is so complicated which is evident in the low number of certified centers. 3. Continuous quality improvement represents an additional workload sometimes unacceptable, it would be required a limited version adapted to district centers.
Session topic: E-poster
Type: Publication Only
Background
In transfusion medicine implementing a quality management system certified by an external entity,allows the development of a safe and efficient activity, while contributing to the involvement of all staff to improving a continuous quality system. In Spain there are two entities accredited byENAC for certification in transfusion: Transfusion Accreditation Committee (CAT) and the Agency for Health Quality of Andalusia (ACSA), although the latter with a specific program limited to transfusion centers
Aims
To describe the situation related to quality management system in transfusion medicine in Andalusia, a region in the south of Spain.
Methods
On the basis of data published by the CAT and ACSA we exposed the number of certified centers in Andalusia compared to national data. The experience of the local hospital was also evaluated Baza as externally certified center.
Results
1. Although only half transfusion centers are certified by CAT, 100% of them are validated by the ACSA specific program.2. 34% of centers accredited in Spain are accredited in Andalusia,3. The relationship with the referral hospital and transfusion center seems to be the most important predisposing factor for a certification program.With respect to the certification program in the form of management is notfully adapted to “little” hospital, because if it´s true that there is a hospital responsible for haemovigilance, hemotherapy isn´t an exclusive dedication for him. In the aspect of non-conformities, the effort in a program of continuous improvement quality is very significant. Comparing our data center initial certification (2010) in which the 3rd edition of the standards was used, with reaccreditation (2014) which use the 4th. Table 2 shows comparative nonconformity according to the specific field deviations observed: it is noteworthy that the percentage remains the same, the most frequent on the requirements of quality control system.TABLE 1: Transfusion centers and hospital of public national health service in Andalusia, classified in provinces. Between parentheses certified centers.
| Huelva | Sevilla | Córdoba | Cádiz | Málaga | Jaén | Granada | Almeria | TOTAL | |
| Transfusion Centers | 1(1) | 1(1) | 1(1) | 1(1) | 1(1) | 1(1) | 1(1) | 1(1) | 8(8) |
| Regional Hospitals | 1 | 2(2) | 1(1) | 1(1) | 1(1) | 6(5) | |||
| Speciality hospitals | 1(1) | 4(2) | 2(1) | 1 | 1 | 9(4) | |||
| Community hospitals | 1 | 2(1) | 3 | 1(1) | 3(1) | 3 | 2(2) | 2 | 17(5) |
| 2010 AUDIT | 2014 AUDIT | TOTAL | |
| Quality control system | 5 | 8 | 13 |
| Equipment control | 4 | 5 | 9 |
| Reactive control | 1 | 1 | 2 |
| Transfusion procedures | 4 | 6 | 10 |
| Registers | 4 | 3 | 7 |
| Hemosurveillance | - | 1 | 1 |
| Comments of improvement | 2 | 2 | 4 |
| TOTAL | 20 | 26 | 46 |
Conclusion
1. The implementation of a management system certified qualityby an external entity is a clear need in all transfusional centers involved, although the percentage of certified centers in Andalusia is less than 50%, representing a 34% of the certified centers nationwide.2. Certification of CAT hospital is the only feasible option, but its adaptation to community hospitals is so complicated which is evident in the low number of certified centers. 3. Continuous quality improvement represents an additional workload sometimes unacceptable, it would be required a limited version adapted to district centers.
Session topic: E-poster
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