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ARCHIVED - Summative Evaluation: Blood Safety Contribution Program

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Management Response and Action Plan
  Evaluation Recommendations Manag-ement Response Management Action Plan Deliverables Expected Completion Date Responsibility Accountability
#1 Greater effort could be made to emphasize and promote the link between 'blood safety' and 'patient safety', to underscore and refresh the consistency of the BSCP with broader government and department priorities that are currently receiving significant attention.

Agree

When BSCP was first created, the major risk of transfusion was transmissible diseases. Ten years later, the risk of transmissible disease has diminished and ABO incompatibilities and transfusion errors are the highest risk for patients. To-date, no data exist on the incidence of adverse events to transplantation (infectious disease, graft failure and malignancy). Improved linkages internally and externally will be required to demonstrate how transfusion and transplantation adverse events impact on patient safety in Canada. This includes networking with those already involved in CPSI.

Implement strategies to develop awareness of blood, tissue and organ surveillance within PHAC.

Strengthen BSCP linkages with other PHAC and government departments to ensure alignment with the current plans and priorities.

Develop relationship with Canadian Patient Safety Institute through participation in CPSI initiatives, conferences.

Treasury Board submission for renewal of Terms and Conditions will frame BSCP with a focus on patient safety and linkages with PHAC RPP, Strategic Plan, etc. (internal discussion around G & C tool).

Ongoing



Ongoing



Fall 2009



Fall 2009

Director, BSSHCAID


Director, BSSHCAID


Manager, TTI Section


Manager, TTI Section

Director General-
CCDIC, IDEPB

#2

A Strategic Human Resource Plan should be developed and implemented by PHAC over the next twelve months, taking into account the current and future needs of the program to support achievement of its full potential. This may include focussing on the identification and recruitment of:

  1. In-house expertise in blood safety and/or transfusion medicine (particularly among epidemiologists);
  2. In-house IT expertise;
  3. In-house statisticians (particularly those capable of sophisticated modelling) who will be able to make the most of the existing data, and improve the timeliness of analysis and reporting; and
  4. General support staff to reduce delays in agreement processing, funding, reporting, etc.

It is acknowledged that implementation of this recommendation may have resource implications; however specific cost implications cannot be estimated at this point. Further investigation and consideration will be required.

Agree

The TTI Section has been working to address the human resources situation to improve support of the BSCP activities.  TTI Section will continue to focus on the recruitment and retention of staff, especially those with specialized skill-sets for transfusion medicine.  However, this continues to be impacted by the fluidity of the public service and the human resources requirements for permanent staffing.

The Section continues to participate in Agency-wide recruitment initiatives to build pools of qualified candidates.

  1. As the pool of individuals with blood safety expertise is very limited, the Section will continue to recruit individuals with strong epidemiological/statistical skill-sets and provide them with transfusion medicine education.
  2. IM-IT will be utilized to provide IT support to the surveillance systems.  Where this is not possible, contractors will be used as required.
  3. The Section will continue to focus on maintaining in-house statisticians to support the surveillance systems.  It will liaise internally to allow for sophisticated modelling.
  4. The TTI Section will review the allocation of staffing resources directed at the processing of contribution agreements and make recommendations to facilitate improvements.

Ongoing




Ongoing







Ongoing






Ongoing






Fall 2009

Manager, TTI Section




Manager, TTI Section






Manager, TTI Section




Manager, TTI Section






Manager, TTI Section
Director General -

CCDIC, IDEPB

#3

Continue establishing and improving upon existing BSCP components:

  1. ForTTISS: ensure adequate participation of the provinces and territories, and work towards more timely reporting. Continue to improve data quality. Conduct analyses to enable risk identification for high risk populations.
  2. For TESS: ensure adequate national representation among participating hospitals (particularly small hospitals), and ensure timely reporting. Also, consider further streamlining of the error coding system to promote simplicity and enhance data quality.
  3. For CTOSS: this system still needs to be developed, piloted, refined, and implemented across the country. The feasibility of developing and implementing CTOSS, even if done incrementally, within the current allocated budget should be critically reviewed. Next steps (e.g., reallocating BSCP budget, request for additional funding) should be considered as appropriate.
  4. For public health linkages: these need to be fostered more consistently in the provinces and territories, as well as nationally.
  5. For the blood sample archive: agreements need to be reached about confidentiality and testing, so that testing can be carried out and results reported.
Agree

The Division is strongly committed to continue with the establishment and improvement to the components of the BSCP.  Through continued linkages with participating provinces and territories; Health Canada regulators, Canadian blood manufacturers; transplantation organizations and international associations, the BSCP components will be strengthened and expanded to improve patient safety in Canada.

  1. TTISSTTISS reporting will be improved by increasing the transfusions captured from 75% to 90%.
  2. TESSTESS will transition from a pilot project to a sentinel site program to allow for benchmarking the incidence of transfusion errors in Canada. 
  3. CTOSS:  Implementation of the CTOSS pilot will continue.  Opportunities for additional funding will be explored (ie. reallocation of BSCP budget).
  4. Public health linkages:  PHAC will re-establish linkages with CCMOH for knowledge transfer re:  BSCP initiatives.  In 2010/11, TTI Section will request formal linkages with public health to be included in provincial/territorial BSCP funded activities. 
  5. Blood sample archive:  Work with recipient to develop agreement to obtain data regarding adverse events in haemophiliac out-patients.  Work with recipient to explore avenues for testing and result reporting.

March 2011





Spring 2010





Fall/Winter 2009







Fall/Winter 2009




Fiscal 2010/2011






Fiscal 2009/2010



Fiscal 2010/2011

Manager, TTI Section





Manager, TTI Section





Manager, TTI Section







Manager, TTI Section




Manager, TTI Section






Manager, TTI Section



Manager, TTI Section
Director General-
CCDIC, IDEPB

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