The Joint Commission Blood Management Performance Measures

Editor’s note (TH):  This month’s guest contributor is Harriet Gammon, who works for The Joint Commission’s Division of Quality Informed consent documentMeasurement and Research. Ms. Gammon is a nurse who is a passionate advocate of quality patient care, and she has played a central role in moving the Blood Management Performance Measures project from concept towards reality. While there have always been existing regulatory standards for blood utilization oversight and transfusion safety from a variety of agencies (AABB, CAP, TJC, state boards of health), elevation of these standards to performance measures is a “game changer.” The Joint Commission is the acknowledged leader in developing standards for quality and safety for healthcare, and for evaluating performance within healthcare organizations based on these standards. Considering the fact that more than 18,000 health care providers use The Joint Commission standards to guide how they administer care and improve performance, the establishment of Blood Management Performance Measures will shine a bright light on an important area of patient care that has been inadequately addressed in many hospitals.

The Joint Commission’s Division of Quality Measurement and Research has been involved in the development of standardized performance measures for the past 20 years. Most hospitals are familiar with the measures that evaluate condition-specific topics such as acute myocardial infarction, heart failure and pneumonia. The number of sets of standardized measures has expanded over the years and there are currently ten measure sets from which hospitals can select to meet the accreditation requirement of data collection on four measure sets. The Joint Commission’s experience to date suggests that implementation of standardized performance measures has the potential to maximize patient outcomes by facilitating the identification of opportunities for improvement based upon the principle, “what gets measured gets managed.” Due to the increased interest in the area of blood utilization and blood management, The Joint Commission initiated a project in 2008 to identify, specify and test a set of standardized performance measures addressing blood management for hospital inpatients. Additional background information about this project

The Blood Management Performance Measures project is now completing the pilot testing phase. More than 75 hospitals across the country participated from February 2010 – July 2010, including several hospitals who are clients of Strategic Healthcare Group. Listed below are the seven DRAFT measures:
• Transfusion Consent
• RBC Transfusion Indication
• Plasma Transfusion Indication
• Platelet/Prophylactic Platelet Transfusion Indication
• Blood Administration Documentation
• Preoperative Anemia Screening
• Preoperative Blood Type Screening.

The first measure evaluates transfusion informed consent regarding documentation of patient education of the risks, benefits and alternatives of blood transfusion. Three measures assess transfusion of red blood cells, platelets and plasma for inpatients greater than four months of age. For these measures, a clinical indication and pre-transfusion laboratory value are needed to pass the measure. One measure addresses compliance with nursing documentation of vital signs during transfusion administration. The last two measures evaluate select elective surgical patients at high-risk for blood transfusions who are greater than 18 years of age. These measures assess whether preoperative anemia screening and blood type screening were completed before the operation begins. Patients may be eligible for all or a sub-set of the measures based on ICD-9-CM procedure and diagnoses codes depending on the measure, and rates are proportions reported by patient or number of transfusions evaluated.

Through the summer of 2010, The Joint Commission staff conducted reliability testing at a sample of the pilot hospitals. This testing consists of reabstraction of a sub-set of the records abstracted by hospital staff to compare reabstraction findings to the hospital’s original responses in order to determine the accuracy and completeness of the original abstraction of the data elements from which the measures are derived. The Joint Commission staff is also conducting focus group discussions to talk about the measures and listen to the hospital’s suggestions for enhancements to the specifications. After The Joint Commission staff compiles the pilot and reliability test results, the technical advisory panel will convene in late 2010 to determine and recommend a final set of measures to move forward for possible endorsement by the National Quality Forum (NQF). The fully specified final measures will be placed in The Joint Commission’s internet-based Measure Reserve Library for use by hospitals at the local level and may also be used nationally.

The Blood Management Performance Measures project is a tremendous opportunity to develop a set of evidence-based, standardized blood management performance measures that will have a positive impact on patient care as well as focus attention on the appropriate utilization of this important resource. It is anticipated that the blood management measures will provide even more information with less abstraction burden as hospitals transition to an electronic health record. Pilot participants have already noted that the data abstraction experience has revealed areas for improvement as they examine their current blood management processes. The Joint Commission looks forward to completing this important project and believes that hospitals will be interested in taking a closer look at these measures when they are completed.