Blood Matters – Translating Ideas Into Action
Authors: Boyce Neil 
Published: September 2010

On behalf of the ‘Blood Matters’ Planning Group. The Blood Matters Collaborative was structured around a series of specific projects designed to improve distinct aspects of the sequence of care processes that ultimately determine the safety of each and every fresh blood product (red cell, platelet, fresh frozen plasma and cryoprecipitate) transfusion. These commence with the appropriateness of the clinical decision to transfuse blood products, then move to ensure that procedures for patient, sample and blood product identification and blood administration are robust and that any procedural errors and adverse events associated with transfusion are captured, analysed and acted upon. Finally and very importantly the collaborative sought to improve the patient and carers understanding of the risks and benefits of transfusion. It was an ambitious program of work but there seemed little alternative other than addressing all of the interdependent processes that determine the quality and safety of transfusion. All elements in this chain contribute to the actual levels of transfusion safety. With support from the Clinical Innovation Agency and planning group members, local multi‐disciplinary hospital teams set out to deliver changes to improve transfusion safety. The collaborative methodology, initially developed by the Institute of Healthcare Improvement in the United States of America, has been adopted and used by a large number of health systems internationally and within Australia. It is based on answering three key questions [Q1. What are we trying to accomplish? Q2. How will we know that a change is an improvement? Q3. What changes can we make that will result in improvement?] and testing ideas through the plan, do, study, act cycles of change. Individual projects monitored progress using ‘run charts’ to record their measured performance. These indicated progress towards achieving locally set targets and collaborative improvement goals. Our objectives were translated into tangible benefits for patients requiring blood product transfusion. Fundamental to the collaborative approach to improving transfusion practice is the belief that changes can be tested rapidly on a small scale without risk. For example, an idea can quickly be tried with one patient, one clinic or ward, a single consultant or hospital. Only if it proved successful was it suggested for wider adoption as an improvement in care across an entire Health Service or system of care. Our successes reinforced the value of using a systematic method for translating ideas into practice such as that used by the collaborative. The governance structures and teams established during our participation in the collaborative have helped us to identify key local issues and implement strategies to enhance the quality of our transfusion services to our patients. Our aim is to ensure that the continued review and improvement of transfusion practices becomes an integral part of the way that clinical teams and hospital and health system clinical governance structures work. The role of state or national bodies is to support this to happen. We hope to build a series of improvement partnerships that all focus on optimising the quality of transfusion services and the outcomes of patients receiving transfusion during their clinical care.