Standard 7: Blood and Blood Products

NSQHS Standard 7: Blood and Blood Products describes actions for ensuring safe and appropriate use of blood and blood products in health services.
The blood products covered under NSQHS Standard 7 are listed in both the NSQHS Standards and in the Safety and Quality Improvement Guide (available from the Commission’s web site). Some health services may not use all these products, as such only the actions relating to the products that are used will apply. Organisations that perform tests on blood, but do not transfuse or infuse any blood or blood products to patients are exempt from Standard 7.
Below are two questions often asked with regards to NSQHS Standard 7.
What is expected of the health service organisation when blood management is outsourced?
Actions 7.7.1-3 describe actions relating to the safe and high quality management of blood and blood products, including actions to reduce risks associated with receipt, storage, collection and transport, and to reduce wastage. Some health services have sought clarification about what is expected of them where blood management within a facility is outsourced, such as where blood is received from an external pathology provider. Where this occurs, health services are expected to confirm their external pathology provider is meeting the safety and quality expectations outlined in the NSQHS Standard 7. This may include having reporting arrangements from the pathology provider to report on their safety and quality activities, and documenting a process for the health service to receive reports to enable monitoring of quality improvement actions where required.
How do we get started with NSQHS Standard 7?
Macquarie University Hospital, NSW, underwent accreditation against all of the NSQHS Standards in 2013. Edwina Moran, Clinical Nurse Educator at Macquarie University Hospital, has provided the below tips about implementing NSQHS Standard 7:

1. Develop or identify a Transfusion Governance Group that is responsible for the oversight of safety and quality improvement activities relating to blood and blood products. Make sure the group is identified within the hospital’s clinical governance structure. In some smaller facilities it may not be possible to have a designated Transfusion Governance Group; in this instance it might be feasible to use existing patient review committees.


2. Undertake a gap analysis to determine what is currently done in your facility, and what needs to be done to align with the actions required in NSQHS Standard 7.


3. Once these gaps have been identified protocols, policies and procedures that align with the national evidence based guidelines will need to be developed. Existing policies should be reviewed to ensure that they are current and in alignment with national guidelines.


4. Develop tools and education programs to support staff in implementing the policies, procedures and protocols.


5. Audit current practice, identify and implement safety and quality improvement actions to improve compliance. Remember the extent of the actions expected from each health service organisation needs to demonstrate that the actions are commensurate with the level of compliance identified through your audit.


6. Document all these actions systematically, and develop or identify evidence for each action under NSQHS Standard 7 that will demonstrate an ongoing commitment to improving safety and quality relating to that action. This needs to include clear documentation of your assessment of the risks associated with the scope of activities under NSQHS Standard 7 and the activities that have been implemented to mitigate those risks.

Further information about NSQHS Standard 7, including tools and resources to support implementation, and national evidence based guidelines relating to patient blood management, are available through the National Blood Authority (www.blood.gov.au)
More information and resources to support implementation of the NSQHS Standards is available on the Commission’s website at www.safetyandquality.gov.au or by contacting the Commission’s Advice Centre on 1800 304 056 or accreditation@safetyandquality.gov.au