Assessment of the Key Performance Indicator Proposed by NABH in the Blood Centre of a Tertiary Health Care Hospital in Southern India

John Gnanaraj; Rajendra G Kulkarni; Dibyajyoti Sahoo; B Abhishekh

doi:10.1007/s12288-022-01563-9

Assessment of the Key Performance Indicator Proposed by NABH in the Blood Centre of a Tertiary Health Care Hospital in Southern India

Indian J Hematol Blood Transfus. 2023 Apr;39(2):308-316. doi: 10.1007/s12288-022-01563-9. Epub 2022 Aug 2.

Authors

John Gnanaraj¹, Rajendra G Kulkarni¹, Dibyajyoti Sahoo¹, B Abhishekh¹

Affiliation

¹ Department of Transfusion Medicine, JIPMER (Jawaharlal Institute of Postgraduate Medical Education and Research), Puducherry, India.

Abstract

Quality indicators are tools for continuous improvement to enable the blood center to achieve its standards of the highest quality. Hence, they have to be established and monitored regularly for which NABH (National Accreditation Board for Hospitals) accreditation should be sought for. This study was undertaken to assess the Key Performance Indicators (KPI) through clinical audit quality control study of ten parameters, with a goal to improve and meet the benchmark as defined by NABH. All 10 Key Performance Indicators defined by NABH were analysed prospectively in a tertiary care blood centre of southern India. Parameters were compared to that of bench mark standards. Root cause analysis of all non-conformance parameters were done. Problem were identified and action taken to achieve KPI benchmarks in all deviations. Out of the ten KPI's which were studied, more than 50% meet the quality standards. The ones that did not meet the bench mark were TTI-HIV% which was 0.44%, TTI-Syphilis (RPR)% 0.26%, Number of units received back for discarding 5.96%, PRBC wastage% (on-shelf) was 2.11%, FFP, Cryoprecipitate wastage % (on-shelf) was 2.71%, the mean TAT for crossmatch of emergency PRBC blood was 18.3 min, 41.11% of FFP QC failure failed, Delay in transfusion time beyond 30 min after issue was 19.14%, Donor Deferral rate was 16.36% and TTI Outliers% No. of deviations beyond ± 2SD for HBsAg, HCV, HIV were 14.43%, 12.59% and17.73% respectively. Present study has helped to understand the flaws and problems faced by a tertiary care blood center in sustaining quality. It also actively captured and analysed multiple cross sections of non-conformances.

Keywords: Blood bank; KPI; NABH; QC; Quality.

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