Standards › Standard 5 › Policies
Policy · BLD-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 5.8
At a glance
- The blood bank has a written quality system for procedures, equipment, audit and training.
- Each procedure has an owner and a review date.
- Equipment is checked and calibrated on schedule.
- The quality system is audited each year and reported to the governing body.
- Stop and get help straight away if: a procedure is in use with no owner or past its review date, or an audit finding is open past its due date.
1. Purpose
To make sure the blood bank works the same way every day, and that its quality is checked (5.8).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A blood bank without a quality system depends on the memory of its people. A written system covering procedures, equipment, audit and training keeps the service the same from one shift to the next.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Blood bank director | Owns the quality system | Clinician |
| Quality manager | Runs the audit and training plan | Quality |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Write.
- Keep the procedures, equipment list and training plan written and current.
Key point: Written, owned, dated.
Step 2. Audit.
- Audit each procedure each year against its written standard (BLD-FRM-004 for the emergency release audit, and others as set).
Key point: Audit finds the gap before the patient does.
Step 3. Act.
- Close each finding by its due date and report the status to the governing body.
Key point: Findings close.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Procedures in date | 100% | Quarterly | Quality manager | Escalate to governing body |
| Audit findings closed by due date | At least 90% | Quarterly | Quality manager | Escalate to governing body |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| STF-SOP-001 | Staff credential verification and recheck | Staff |
| GOV-PLN-002 | Quality improvement plan | Plan |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on ISO 15189:2022 for medical laboratories. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)