Problem: The volume of blood transfusion consent fallouts has been a chronic issue with inability to sustain compliance improvements. Goal of the project: Quality Specialist to connect with Nursing and Clinic leadership to establish a collaborative and supportive relationship providing timely fallout data to engage and educate frontline staff.
Measurement: The tool utilized included a dashboard for each Keck and Norris Hospitals showing four consecutive quarters of blood transfusion consent fallouts for sampled cases, with sample size of approximately 30% of total transfusions. The blood transfusion consent fallout data is reported in the bi-monthly Transfusion committee meeting.
Analysis: Data for CY 2020 consent fallouts were reviewed for Keck and Norris Hospitals. It was noted that blood consent fallouts for CY 2020 sampled cases ranged from zero to 43%. Engaging front line managers and staff in the compliance workflow was an identified gap in previous improvement efforts.
Implementation: The previous workflow provided blood consent fallout data to nursing unit managers quarterly. A new workflow was implemented to provide monthly notifications to key stakeholders to promote timely review of events with frontline staff accompanied by education to drive best practice-informed blood consent compliance prior to transfusion event.
Results/Discussion: Project began with Q1-2021 data with the blood consent compliance rate showing an overall improvement. Post workflow implementation fallout rates: Q2-21 Keck with1.4%, Norris with 7%; Q3-21 Keck with 3.6%, Norris with 4%; Q4-21 Keck with 3%, Norris at 4%. Continued collaboration with frontline staff is essential for continued improvement.