Original Article

Performance indicators: A tool for

continuous quality improvement
Nidhi M Bhatnagar, Shital Soni, Maitrey Gajjar, Mamta Shah, Sangita Shah,
Vaidehi Patel

Department of
Immunohematology and
Blood Transfusion, BJ
Medical College and Civil
Hospital, Ahmedabad,
Gujarat, India
Abstract:
Background: Performance monitoring is an important tool which can be used for setting priorities for process improvement.
At our centre, we have been monitoring every step in the processes, right from inventory of consumables (both critical and
routine) to number of donors reactive for TTI. We conducted a study to measure the impact of monitoring Performance
Indicators and how it could be used as a tool for Continuous Quality Improvement (CQI). Materials and Methods: The
present study was a retrospective study where the performance indicator (PI) data of blood bank was analyzed for over
four years. For certain parameters, benchmarks or thresholds were set that represented warning limits or action limits.
The yearly data were collated from monthly data. “Shifts” or “Trends”, if any, were identified and Corrective and Preventive
Action (CAPA) taken accordingly. At the end, outcomes of the analysis were charted. Results: After the yearly data evaluation,
outcomes obtained were used to plan, correct and amend processes and systems in the blood center. It was observed
that the workload of the center showed an upward trend. This helped us to plan for the purchase of consumables and
management of manpower. The monitoring of usage and discard of blood helped in the efficient management of blood
stocks. The need for any new equipment could also be judged by the trends in workload. Conclusion: Performance
indicators are indispensible tools which various stakeholders in the Blood Transfusion centres should implement to
improve on quality performance.
Key words:
Blood center, continuous quality improvement (CQI), performance indicator (PI) monitoring

Background the preestablished criteria and objectives as a

Access this article online
Website: www.ajts.org
DOI: 10.4103/0973-6247.175398
Quick Response Code:
Correspondence to:
Dr. Nidhi M Bhatnagar,
2nd Floor, Kamdhenu
Complex, Toran Dining
Hall Lane, Opposite Sales
India, Ashram Road,
Ahmedabad - 380 009,
Gujarat, India.
e-mail: bhatnagarnidhi@
ymail.com
A quality management system includes the
organizational structure, responsibilities, policies,
processes, procedures, and resources established
by the management to achieve and maintain
quality. The purpose of quality checks is to provide
feedback to the operational staff about the state of
a process that is in progress. Examples of quality
control measures include reagent quality control
(QC), product QC, clerical checks, and temperature
measurements.
On the other hand, quality assurance activities
are not tied to the actual performance of a
process. Rather, they include activities such as
the development of documents such as standard
operating procedures (SOPs) and training of
personnel. They also include retrospective reviews
and analyses of operational performance data to
determine whether the overall process is in a state
of control and to detect “shifts” and “trends” that
require attention.
Performance monitoring is an important tool,
which can be used for setting priorities for process
improvement. [1] It is defined as a method by
which procedures, activities, or human resources
can be assessed on certain parameters keeping
benchmark. It is a well-established procedure
in the human resource department worldwide.
Benchmarking is a structured, continuous,
collaborative process in which comparisons for
selected indicators are used to identify factors,
which when implemented will improve transfusion
practices. Performance monitoring is one type
of internal audit, which helps us to improve our
quality standards in transfusion practices. The
present study was conducted to measure the impact
of monitoring performance indicators (PIs) and how
they could be used as a tool for continuous quality
improvement (CQI).
This is an open access article distributed under
the terms of the Creative Commons Attribution-
NonCommercial-ShareAlike 3.0 License, which
allows others to remix, tweak, and build upon the
work non-commercially, as long as the author is
credited and the new creations are licensed under
the identical terms.
For reprints contact: reprints@medknow.com
Cite this article as: Bhatnagar NM, Soni S, Gajjar M, Shah M,
Shah S, Patel V. Performance indicators: A tool for continuous
quality improvement. Asian J Transfus Sci 2016;10:42-7.

42 © 2016 Asian Journal of Transfusion Science | Published by Wolters Kluwer - Medknow

 Bhatnagar, et al.: Continuous quality improvement by performance monitoring

Materials and Methods Remarks/Suggestions: ___________________________________

The present study was conducted in a tertiary care multispeciality
hospital-based blood bank, catering to all types of patients.
Faculty-in-charge _________________ Sign _________________
Technician-in-charge _______________ Sign _________________
†
TTI: Transfusion-transmissible infection

Study design Format 2: Performance indicator form (serology)

The present study was a retrospective study where the PI data to be filled monthly
of the blood bank were analyzed for over 4 years. For certain Sr. Parameter Observation Benchmarks Remarks
parameters, benchmarks or thresholds were set that represented No.
warning limits or action limits. The yearly data were collated 1 No. of samples —
accepted
from monthly data. “Shifts” or “trends,” if any, were identified and
2 No. of samples —
corrective and preventive action (CAPA) was taken accordingly. rejected
3 No. of units —
At the end, outcomes of the analysis were charted. crossmatched
4 No. of units issued —
Parameters of performance indicators measured 5 No. of PRC†/WB‡
crossmatched
Format 1: Performance indicator form (donor area) 6 No. of PRC/WB
to be filled monthly issued
Sr. No.Parameter Observation Benchmarks Remarks 7 CT ratio <2:1
8 Turnaround time <1 h (routine
Pre donation
(TAT) request)
1 No. of donors —
9 No. of PCVs given —
registered across the group
2 No. of donors — 10 No. of 0
accepted transfusion
3 No. of donors — reactions
rejected Mild Moderate Severe
4 No. of voluntary — 11 No. of ABO —
donations (in-house) discrepancies
5 No. of voluntary — 12 No. of unexpected —
donations (outdoor) antibodies
6 Total no. of voluntary 100% 13 Clinician’s 0
donation and % of feedback (No.
Voluntary donation of negative
7 Total no. of outdoor — remarks)
camps 14 No. of units <5%
Donation discarded
1 Total donation time Max 60 min (From donor Total
entry to exit Reactive
from blood HIV#
bank) HBsAg¥
2 No. of double needle 0 HCV*
pricks Syphilis
3 No. of donors 100%
Malaria
counseled
Leakage
(TTI†-reactive)
Low volume
4 Less volume <10%
Others
collections
No. of
(A) Outdoor camps
components
(B) In-house
expired
5 No. of complaints 0
Remarks/Suggestions:- __________________________________
(in-house)
Faculty-in-charge ___________________ Sign ________________
6 No. of units in which 0 Technician-in-charge _______________ Sign ________________
cold chain was not †
PRC: Packed red cells; ‡WB: Whole blood; CT: Crossmatch:transfusion;
maintained (from #
HIV: Human immunodeficiency virus; ¥HBsAg: Hepatitis B surface antigen;
camp to blood bank) *HCV: Hepatitis C virus
Post donation
1 No. of adverse donor 1 in 50 Format 3: Performance indicator form (TTI area)
reactions to be filled monthly
(A) In-house Sr. No. Parameter Observation Benchmarks Remarks
(B) Outdoor camps 1 No. of reactive units
2 No. of complaints 0 with %
(camp) (A) HIV# 0
3 No. of repeat donors — (B) HBsAg¥ 0
4 No. of replacement — (C) HCV* 0
donors converted to (D) Syphilis 0
voluntary (B) Malaria 0

Asian Journal of Transfusion Science - Vol 10, Issue 1, January - June 2016 43
 Bhatnagar, et al.: Continuous quality improvement by performance monitoring

2 Indeterminate — Remarks/Suggestions:-___________________________________
result/initial reactive Faculty-in-charge ____________________Sign _______________
(A) HIV — Technician-in-charge___________________ Sign ______________
†
QC: Quality control; *WB: Whole blood; ‡PRC: Packed red cells; #FFP: Fresh
(B) HBsAg —
frozen plasma; CYRO: Cryoprecipitate
(C) HCV —
(D) Syphilis —
(E) Malaria — Performance indicators measured yearly
3 No. of rapid test — 1. Number of blood donations with type of donations.
For SDP
2. Number of adverse donor reactions.
(A) HIV
(B) HBsAg 3. Number of blood groupings and antibody screenings.
(C) HCV 4. Crossmatch:transfusion ratio.
(D) Syphilis 5. Number of transfusion transmitted infection-reactive donors.
For confirmation 6. Total number of components discarded.
(A) HIV 7. Number of adverse transfusion reactions.
(B) HBsAg
(C) HCV
(D) Results
Syphilis
4 No. of invalidated —
The PI data of the blood bank was analyzed for over 4 years.
TTIs run interpreted
by L J chart The yearly data were collated from the monthly data. The data of
5 No. of — some of the parameters are as follows [Tables 1-8 and Figures 1-6].
nonconforming/
partially conforming After the yearly data monitoring, outcomes obtained were used to
results of EQAS
plan, correct, and amend processes and systems in the blood center.
6 Number of —
nonconforming/
partially conforming Discussion
results of inter
blood bank
comparison For all operations in blood bank, critical control points (CCPs), and
Remarks/Suggestions:- ___________________________________ key elements (KEs) can be delineated. Each center can list out its own
Faculty-in-charge __________________Sign ________________ CCPs and start a process of monitoring them. CCPs are those major
Technician-in-charge _______________ Sign _________________
processes of the operating systems that have to function properly
#
HIV: Human immunodeficiency virus; ¥HBsAg: Hepatitis B surface antigen;
*HCV: Hepatitis C virus; TTIs: Transfusion-transmissible infections; if quality outcomes must be obtained. On the other hand, KEs are
SDP: Single donor platelets; EQAS: External quality assurance scheme operational steps that lead to CCPs. These KEs have to be effectively
managed for the process to be free from errors. Identification of the
CCPs and KEs for transfusion medicine operational system therefore,
is a fundamental prerequisite for determining where quality
Format 4: Performance indicator form (component area)
to be filled monthly Table 1: Number of blood donations
Sr. No. Parameter Observation Benchmarks Remarks Year Voluntary Replacement Total
1 No. of component 95% 2011 10,871 12,575 23,446
prepared and % 2012 11,243 17,196 28,439
(A) Red cell — 2013 11,116 19,452 30,568
(B) Platelets — 2014 17,651 20,081 37,732
(C) Fresh frozen —
plasma
(D) Cryoprecipitate —
2 No. of leucoreduced —
products
Red cell —
Platelets —
3 No. of whole blood —
4 No. of units given for —
fractionation
5 No. of units not <25%
meeting QC†
standards
(A) WB* —
(B) PRC‡ —
(C) FFP# —
(D) Platelet —
(E) CRYO —
6 No. of components —
not separated within
6h Figure 1: Trends in blood donation

44 Asian Journal of Transfusion Science - Vol 10, Issue 1, January - June 2016
 Bhatnagar, et al.: Continuous quality improvement by performance monitoring

Table 2: Number of adverse donor reactions Table 3: Number of blood grouping and antibody
Year In-house Outdoor camp Total blood units screening
collection collection collected Year Donor Patient Total
2011 55 72 23,446 2011 23,446 44,500 67,946
2012 47 70 28,439 2012 28,439 44,946 73,385
2013 33 63 30,568 2013 30,568 66,951 97,519
2014 24 53 37,732 2014 37,732 77,820 115,552

Figure 3: Trends in blood grouping and antibody screening

Figure 2: Incidence of adverse donor reactions

Table 6: Number of adverse transfusion reactions

Table 4: Crossmatch:transfusion ratio Year Mild Moderate Severe
Year Crossmatch Transfusion Ratio
2011 2 1 1
2011 58,591 54,313 1.07:1 2012 6 2 0
2012 75,824 64,009 1.18:1 2013 3 0 0
2013 46,905 31,740 1.47:1 2014 4 0 0
2014 67,592 36,178 1.86:1

Table 5: Component discarded

Year No. of components No. of components Discard rate
prepared discarded (%)
2011 5,9432 2,741 4.61
2012 70,911 3,032 4.27
2013 85,058 2,932 3.45
2014 99,448 4,267 4.29

Figure 5: Adverse transfusion reactions

AABB has described “monitoring and assessment” as a component of

Figure 4: Component discard rates
quality management system. Assessments are systematic examinations
to determine whether actual activities comply with planned activities,
are implemented effectively, and achieve objectives. Assessments can
be internal or external. Quality indicators are performance measures
designed to monitor one or more processes during a defined time and
are useful for evaluating service demands, production, personnel,
inventory control, and process stability.

indicators placements are desirable.[2] CCPs give an “objective” Most of the studies on quality indicators worldwide are based
assessment of process flow in a transfusion center. on the monitoring of data such as the crossmatch:transfusion (CT)

Asian Journal of Transfusion Science - Vol 10, Issue 1, January - June 2016 45
 Bhatnagar, et al.: Continuous quality improvement by performance monitoring

Table 7: Number of TTI-reactive donors et al.[4] evaluates the CT ratio, transfusion index, transfusion
Year HIV† (%) HBsAg‡ (%) HCV (%) Syphilis (%) probability, RBC unit expiration rate, RBC unit wastage rate,
2011 55 (0.23) 205 (0.87) 95 (0.40) 77 (0.32) packed RBC: whole blood ratio.
2012 55 (0.19) 244 (0.85) 117 (0.41) 93 (0.32)
2013 50 (0.16) 199 (0.65) 74 (0.24) 83 (0.27)
Not many studies have evaluated the PIs for all operations in a
2014 103 (0.27) 281 (0.74) 131 (0.34) 45 (0.12)
blood bank. At our center, we have been monitoring every step in
†
HIV: Human immunodeficiency virus; ‡HBsAg: Hepatitis B surface
the processes, right from the inventory of consumables (both critical
antigen; HCV: Human immunodeficiency virus
and routine) to the number of donors reactive for TTI. This has
helped our center achieve higher standards of services. The staff at
all cadres is trained to identify, assess, and report any outliers so that
root cause analysis and appropriate actions could be taken timely.

The monitoring of adverse transfusion reactions showed a decreased

incidence. This could be because of the implementation of the Blood
Bank Data Management System (BDMS) (Manufacturer: Easy Software),
a software catering to all functions of the blood bank. Chances of error
have been reduced greatly. Another reason could be underreporting
from the clinical side. Mild reactions are treated and not reported to the
blood bank. Regular annual training given to all hospital staff includes
topics such as “hemovigilance” to increase awareness regarding the
reporting of adverse events related to blood transfusion.

Our CT ratio was also under acceptable limits. Regular CMEs

have helped us to maintain it below 2.

Figure 6: Trends in TTI reactivity The ultimate goal of quality improvement is to enable an
organization to attain higher levels of performance by creating
Table 8: Outcome of monitoring new or better standards or removing the deficiencies in products,
Performance indicator Results obtained Outcome of monitoring processes, or services. These improvements must be based on
Number of blood Increased Planning for data-driven analysis; an ongoing measurement and an assessment
donations consumables and program are fundamental to that process.[5]
manpower
Number of adverse Decreased Better postdonation
Process control allows the staff to recognize when things are going
donor reactions care and
counseling (quality wrong and to make appropriate modifications or amendments in
parameter) the process. Performance monitoring should be done by comparing
Number of blood Increased Planning for the actual results to expected results. Monitoring may include
grouping and antibody consumables and quality indicator data or targeted audits of a single process. It
screening manpower enables the early detection of trends or problems and makes it
C:T ratio (measured Decreased Time, consumables, possible to develop preventive actions before blood components,
across all groups of and HR† management and ultimately patient safety is adversely affected.
patients) (quality parameter)
Number of components Decreased Monitoring wastage of
discarded blood Conclusion
(quality parameter)
Number of adverse Decreased Quality parameter
For the smooth functioning of blood transfusion services, it is of
transfusion reactions (hemovigilance
program established) utmost importance that the CCPs be identified and be constantly
Number of TTI‡- Acceptable rates Efficacy of test kits used monitored. By doing this, we are assured that at no point, there is
reactive donors as per national and effective donor laxity of services. The ultimate goal is to provide safe transfusion
ranges counseling to the patients.
Inventory of Rate of Stock of critical
consumables nonavailability consumables Quality indicators are indispensable tools, which various
of critical maintained
consumables:
stakeholders in the blood transfusion establishment now demand to
zero adjudge and improve quality performance. Practitioners as well as
†
HR: Human resource; ‡TTI: Transfusion-transmissible infection
policymakers in transfusion medicine need to ensure that the quality
indicators they institute are appropriately selected and analyzed to
be effective and efficient monitors of quality. Knowledge of basic
ratio, the rate of red blood cell (RBC) unit expiration, and the rate building blocks of CCPs is therefore, a fundamental prerequisite.
of RBC unit wastage. These tools are fundamental for monitoring
the “usage of blood.” A study by David et al.[3] evaluates the various Performance monitoring is a proactive strategy, which allows
practice characteristics in 1,639 institutions across the USA. The the consultants in transfusion medicine to have the reins of the
authors have analyzed the CT ratio, RBC unit expiration rate, and blood bank in their hands and the assurance that quality work is
RBC wastage rates in different institutions. A study by Memtombi being done at the blood center.

46 Asian Journal of Transfusion Science - Vol 10, Issue 1, January - June 2016
 Bhatnagar, et al.: Continuous quality improvement by performance monitoring

Financial support and sponsorship 2. Anyaegbu CC. Quality indicators in transfusion medicine: The
Nil. building blocks. ISBT Sci Ser 2011;6:35-45.
3. Novis DA, Renner S, Friedberg R, Walsh MK, Saladino AJ.
Conflicts of interest Quality indicators of blood utilization: Three College of American
Pathologists Q-Probes studies of 12,288,404 red blood cell units in
There are no conflicts of interest.
1639 hospitals. Arch Pathol Lab Med 2002;126:150-6.
4. Devi KM, Sharma AB, Singh LD, Vijayanta K, Lalhriatpuii ST,
References Singh AM. Quality indicators of blood utilization in the
tertiary care center in the north-eastern India. J Dent Med Sci
1. Motschman TL, Je BW, Wilkinson SL. Quality management 2014;13:50-2.
systems: Theory and practice. In: Fung MK, Grossman BJ, Hillyer 5. World Health Organization. Quality Systems for Blood Safety.
CD, editors. Technical Manual. 18th ed. Bethesda, MD: American Quality Management training for Blood Transfusion Services,
Association of Blood Banks (AABB); p. 1-38. Modules1-5: World Health Organization; 2005. p. 17.

Asian Journal of Transfusion Science - Vol 10, Issue 1, January - June 2016 47
Copyright of Asian Journal of Transfusion Science is the property of Medknow Publications
& Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to
a listserv without the copyright holder's express written permission. However, users may
print, download, or email articles for individual use.