Quality Management was foreseen in as ‘Quality Management Trainings’. This area was, however, later addressed by a more multi-dimensional method, aiming to develop longer lasting concrete grounds for ‘Quality’ in the Blood Transfusion Services.
The first edition of the Standards and Guidelines for Blood Transfusion Services was published by the Ministry of Health, Government of Pakistan in August 1999. It was compiled by a team comprising senior members of Pakistan Society of Haematology, the programme managers of Blood Transfusion Services from all the provinces of Pakistan, officers of the National AIDS Control Programme and the WHO representative in Pakistan at that time. A major portion of the first edition of ‘National Standards and Guidelines for BTS in Pakistan’, was, however, adopted from the latest edition of ‘Guidelines for BTS in the UK’ at that time. The approved National Standards and Guidelines, despite being widely distributed, remained un-implemented, the blood transfusion services of Pakistan remained fragmented and of poor quality at large. A revision of the document took place by the Technical Cooperation Team. The document provides Standards and Guidelines for BTS, including those for (1) Blood Donor Selection; (2) Blood Component Preparation and Storage; (3) Testing of Blood Donations; and (4) Pre-Transfusion Testing. Each chapter consists of two sections, i.e. Section A states the minimum standards while Section B comprises guidelines on how to meet the standards. The document has been developed by a team of experts (Task Force) through several technical meetings and consultations.
A flyer providing a structured listing of the SOPs along the entire vein to vein transfusion chain was developed, segregating the essential SOPs in terms of their application in the relevant structures (RBC, HBB and Hospital Ward) as well as their functional areas.
Standard Operating Procedures are an integral part of a quality system, as they facilitate consistency in the performance of procedures in accordance with standards. The SOP manual details all the operational procedures along the entire vein to vein transfusion chain. The manual covers all testing procedures and working procedures. These SOPs have been generated with a novel methodology. The process started with a field analysis, in which the SBTP team collected all available SOPs from a sample of public and private blood banks, listed them in relation to the key domains addressed and documented both availability and gaps. The development of new SOP templates was planned as a joint collaborative effort. The clear breakdown of the transfusion chain domains into consecutive procedures, as outlined in the flyer, served as a reference for the identification of suitable working groups. Members of the working groups represent their respective specialties, but at the same time share the wealth of their regional experience. This bottom up approach is expected to have resulted in SOP templates of high practical value, though both international literature and a previous version of SOPs for Pakistan were consulted in the process. Instead of copying existing international manuals, a participatory approach was chosen with the intention to draw on existing expertise in the country, which would increase the likelihood of formulating procedures that can and will be followed in Pakistan. Six mixed working groups (Haematologists, Blood bank incharges, Blood Bank Technicians) were established, working on the sub-sections of the process chain. The participants of these working groups have become the authors of the new SOP Manual, which is thus based on real life experiences from various well reputed blood bank establishments all over the country, mostly from secondary or tertiary hospitals. The 62 SOPs collected in the Manual will also be printed for wall display as a permanent reference tool for the staff.
Urdu Translation of National SOP Manual by USAID-Jphiego
The SBTP developed a National SOP Manual for blood banks with the help of national experts in 2013. The document provides step by step technique of all the procedures performed in the blood banks. As part of the SBTP-Jhpiego collaboration, this document has also been translated in Urdu by Jphiego (2017). The document is being used for trainings to the blood bank personnel in Interior Sindh and also in rest of the country. It is available on the SBTP and IBTA websites.
The extremely diverse educational background of blood bank technicians (either formally educated or just trained on the job in pathology laboratories and blood banks) strongly reflects the ‘fragmentation’ of the blood transfusion system in Pakistan. The SBTP has deepened the analysis of the curriculum development required and focused on strategies of standardization, while the actual development of training curricula remains pending. The curriculum should be based on an appropriate needs analysis of the blood transfusion modules in Pakistan. A ‘round table meeting’ with ten Blood Bank paramedical staff provided information about the content of existing curriculum for blood bank technicians. The areas completely neglected in the curriculum include quality control and quality assurance, quarantine of blood, issue of blood and inventory control whereas the relatively well covered sections include anticoagulants, blood grouping and cross-matching.
The need for a general and standardized curriculum was recognized across the sector, as current training courses cater for specific audience with insufficient training and according to the specific academic environment through
Inadequately trained instructors. When addressing the community of scholars,
Teachers and practitioners, the Safe Blood Transfusion Programme (SBTP) received an overwhelming response. A national Working Group was formed with more than 160 members who supported the design work with feedback based on ground realities and needs. The Group provided recommendations for the structure, contents, target groups and academic pathway to be followed. SBTP contributed through a small team of international and national experts, who were developing the structure and writing up the curriculum.
Inventory of Institutes, Programmes and Curricula in Pakistan
Concomitantly with the development of the properly structured, well organized and uniform curriculum, the Programme collected data and curricula for an “Inventory of Institutes, Programmes and Curricula in Pakistan”, which is published as a separate document.
Development of National QC Guidelines 2017
The Programme through an extensive national consultation developed the National Guidelines on Quality Control in Transfusion Medicine in 2017. The document aims to encourage blood banks and transfusion services to develop strong quality assurance programmes, organize scheme of management and employ training and competency evaluation programmes. Standardized forms developed by the Programme are also provided which must be routinely used in the blood centres. The guideline draws from the documents of the World Health Organization, European Union, International Haemovigilance Network and Technical Manual of American Association of Blood Banks. The guidelines complement the earlier documents developed by the Programme through the TC component. The Programme endeavours to implement these guidelines through capacity building workshops so that by the end of 2017 at least 100 blood centres have adopted these guidelines in earnest.
National Data Collection
One of the main challenge in developing the national plans and strategies is the absence of credible national statistics. To address this critical programmatic gap, the SBTP initiated a national exercise in 2016 to collect the 2015 data directly from the blood centres in the country. The SBTP thus generated a National Data Collection Report in 2016 which documented and analyzed data received from public and private sector blood centres. Similar reports were also compiled in 2017, 2018 and 2019. The latest report is covering almost 2.7 million donations collected from 650 blood centres.