New Tissue Standards for Hospitals: Seeking, Achieving Compliance

Since tissue storage and issuance standards became effective July 1, 2005, hospitals nationwide have been scrambling to institute policies and practices that comply.

The road to full compliance is complicated and time-consuming, and can stretch hospital resources to new limits. But it is also necessary to ensure the utmost safety in tissue transplantation.

Harborview's operating room nurse manager,
Ketra Marie Hayes

In this region, Northwest Tissue Center is assisting many institutions in setting up systems to deal with the new standards put forth by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the nation’s oldest and largest accrediting body.

With upcoming JCAHO site surveys slated to include reviews of tissue standards compliance, an increasing number of hospitals are turning to the Tissue Center for assistance.

“We’ve been getting more and more calls from hospitals asking for our help,” says the Tissue Services’s Candy Wells, R.N., B.S.N., and hospital services supervisor. “So we’ve developed information packets and sent them to hospitals; we’re setting up meetings and making presentations to their key staff.”

“The Tissue Services helped
spark some ideas for us to run with.”
–Ketra Marie Hayes, R.N., C.N.O.R.

Leading by Example
One of the Tissue Services’s first presentations took place at its service area’s primary tissue transplant facility, the University of Washington’s Harborview Medical Center.

Wells and Jeff Routh, lead product services coordinator, spoke to and answered questions from operating room staff about tissue banking in general and compliance in particular. There was a major difference, however, between this presentation and most others that Wells and Routh would make.

That's because Harborview, in keeping with its standing as a leading healthcare institution, had already developed and put into place its own tissue standards policy and procedures.

As a past recipient of one of the highest JCAHO scores in the country, Harborview quickly took the initiative when the new tissue standards werereleased.

“When we found out about the new standards, we went to the Tissue Center,” said Ketra Marie Hayes, R.N., C.N.O.R., and Harborview’s operating room nurse manager. “It was helpful to tour the Tissue Center facility and actually see how they log tissue in and out, store tissue, and all the systems they had in place to deal with tissue. We’ve always done that to some extent, but not to the level or expectation of the JCAHO standards. The Tissue Center helped spark some ideas for us to run with.”

The tour was a natural for both institutions. “We have a good relationship with the Tissue Services as far as procurement of tissue is concerned; they keep up with our demands,” says Don Millbauer, Harborview’s director of perioperative services, who coordinated the medical center’s compliance efforts. “Our surgeons feel comfortable and confident in working with the Tissue Services and its products.”

After seeing the Tissue Services model, Millbauer and Hayes then devised their policy in conjunction with fellow staff involved with various services and tissue storage issues at Harborview. “We all sat down as a work group and pieced it together,” Hayes noted.

Getting a jump on compliance took great concentrated effort; so does maintaining resultant systems. “It’s labor-intensive,” says Millbauer. “We had to develop new forms and do a lot paperwork. It works, but it’s not easy.”

With a chuckle, Hayes adds that the entire process was more difficult than anticipated. The intricacies and variables of storage needs made it a challenge to meet the updated standards.

Fortunately, as the compliance process progressed, the initial flurry of paperwork lessened as a result of the many staff-hours of thought and work that went into implementing Harborview’s policy on tissue standards. The job is not complete, though.

“Certainly, we continue to refine it as we go along,” notes Hayes.

In any case, Harborview staff and management have put together a prime example of an enviable tissue standards compliance program.

As the Tissue Services’s Wells remarks, “Harborview has invested great time and energy into putting together a policy to address JCAHO standards. And Ketra and Don have been very helpful in allowing us to share that policy with other hospitals that need an example in order to get started.”

	The Tissue Services' Jeff Routh speaks to hospitals about tissue banking and compliance with JCAHO standards.

Here to Help
For those hospitals in which compliance programs are still works in progress, the Tissue Services is perhaps the most valuable resource available.

Says Wells: “Our role in assisting hospitals become compliant with JCAHO tissue standards really falls within our partnership with them. We’ll walk them through the process, assist them with policy and procedure development and documentation, and answer any questions. Being available to help is the key element for us.”

Experience has led the Tissue Services to its high level of expertise. As Wells explains, “The thing that we have that is a great advantage to hospitals is that we track our tissue to the patient. Many tissue banks track only to the hospital. We’ve been tracking to the patient for years.”

Such experience can be crucial. “Tissue now has to be tracked from the moment it enters the hospital and to the patient. Then if there are any adverse reactions, there must be a procedure in place for what to do and who to notify,” says Wells.

“That’s not been a standard for hospitals before,” she adds. “But we can help.”

“Since we are the community tissue bank, we’re dedicated to a partnership with hospitals and we’re willing to spend whatever time is necessary to help them develop processes that make them compliant with the new standards.”