CBBS Today. Our Mission Statement

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1 CBBS Today Journal of the California Blood Bank Society Fall 2015 Vol. 33, No. 2 In this issue... Our Mission Statement CBBS educates, develops, and inspires healthcare professionals in transfusion medicine and cellular therapy to improve practice and patient outcomes. President s Message Page 2 Board of Directors Page 2 Leadership vs. Management: Which one do you need? Page 3 Reciprocal Behavior: We are all Donor Recruiters Page 6 The CBBS Emergency Preparedness Plan: A Lifeline in Times of Crisis. Page 9 Connecting the Dots to the Lutherans; It s Harder Than You Think Page15 Developing a Blood Bank Training Symposium Page 19 How Can Donor Collections Staff Motivate, Educate and Increase Credibility With Our Donors.... Page 23 CBBS Treasurer s Report Page CBBS/SCABB Joint Annual Meeting Summary..... Page 26 CBBS Today Page 1 Fall 2015, Vol. 33, No. 2

2 President s Message Congratulations to California Blood Bank Society (CBBS) for 65 great years filled with many historical triumphs and so many good stories! Be sure to join us at our 2016 Annual Meeting in beautiful San Diego at the Paradise Point Resort & Spa on April 6-9, This is a birthday celebration you will not want to miss. The committee teams are prepared to deliver a sensational educational program with a party that will be the talk of the town. Here we are, 65 years later, and still growing strong as a professional organization that educates, develops and inspires healthcare professionals in transfusion medicine and cellular therapy to improve practices and patient outcomes. If Dr. John Upton and Mrs. Bernice Hemphill, founders of CBBS, were looking down at us, I think they would be smiling and pleased with how we have grown. As a healthcare professional, I have always been grateful to be part of a vibrant society fueled by the vast experts, renowned physicians and passionate health professionals who care and make the difference. So proud to be a part of it! Last year marked a significant new era for CBBS as we launched the new website and brought new expertise into the Central Office. If you haven t had a chance yet to see the new website, it is worth a look. Please explore and you will find that you can update your profile, renew membership online, post jobs, learn about upcoming events, access CBBS Today, learn about CBBS history, view the current leadership, and find a list of pastpresidents. Even more exciting is what will be coming very soon new enetwork Forum to discuss riveting questions and answers as well as the long awaited updated Emergency Preparedness Plan. We are now in the era of instant information and CBBS adapts to the technology that will serve our members best. As we review the year and look forward to the next, we have every reason to be both proud and hopeful for the future. The Board of Directors is committed to strategic planning sessions to evaluate our organization s focus and relevance to the changing industry. The collective expertise and brain power of our committed team will certainly be challenged to bring new ideas, technology and initiatives to keep CBBS vital and healthy. Thank you all for your continued support, confidence and patience. Sincerely, Terrina Yamamoto CBBS President CBBS Board of Directors Terrina Yamamoto, President Blood Centers of the Pacific tyamamoto@bloodcenters.org Holli Mason, MD, Past President Cedars Sinai Medical Center masonhm@cshs.org Steve Ferraiuolo, President-Elect Blood Centers of the Pacific tyamamoto@bloodcenters.org Susan Noone, MPH, CQA (ASQ), Treasurer Bloodsource steve.ferraiuolo@bloodsource.org Linda Aldridge, Secretary City of Hope National Medical Center laldridge@coh.org Directors Robert Bayer MT(ASCP)BB RBayer@bloodsystems.org Don Fipps, Director UC San Diego Health System dfipps@ucsd.edu Magali Fontaine, MD, PhD Department of Pathology University of Maryland School of Medicine mfontaine@umm.edu Kim-Anh Nguyen, MD, PhD Blood Bank of Hawaii knguyen@bbh.org Central Office MaryAnne Bobrow, CAE, CMP, CMM, CHE Bobrow Associates, Inc Sunrise Blvd., Ste. 119 Citrus Heights, CA (916) Phone (866) Fax mbobrow@cbbsweb.org CBBS Today Page 2 Fall 2015, Vol. 33, No. 2

3 Leadership vs. Management: Which one do you need? Joe Ayer, MBA BloodSource Regional Director Over the last twenty years many articles have been written about leadership and management. From John Kotter s legendary article titled What leaders really do to Abraham Zaleznik s article Managers and leaders; are they different? We have been inundated with interesting insights on the topic of management and leadership and scholars in both of these areas have hypothesized which style is better. Which administrative approach provides the more desirable outcome? Organizational leaders evaluate the effects of management and/or leadership on groups, companies, organizations, and nonprofits. Their observations demonstrate that front line leaders continue to struggle with which approach to apply to the groups of people that they oversee. How do management and leadership approaches differ? Management is defined as the process of dealing with or controlling things or people. An alternate definition is that management is the oversight or control of processes. These processes may be ones that individuals or devices perform, or an implemented algorithm. Management is focused more on process than on people. Leadership, on the other hand, is defined as the action of leading a group of people or an organization. Leadership focuses on people and not as much on processes. As a blood banker for the last seven years I have observed that our industry s approach to operation oversight is often from the scientific realm. We want everything to fit into a box, checklist, or standard operating procedure. We tend to lean to a management approach in all that we do, whether it is the laboratory department or the marketing department. Some examples of the management approach vs. the leadership approach are outlined for us by Warren Bennis, in his book The Essential Bennis Bennis articulates the following points. Managers administer while leaders innovate. Think of a time clock from the mechanical era of the 50 s. It is rusty, old, and primitive but it still works like a charm, if you have the right kind of time card to insert into it. The next image you can think of is a new time clock, one that has a digital display and utilizes a biometric thumb print scanner to clock in. In this scenario, the manager might look at the two and quickly decide that the old clock is good enough. Managers typically say, if it ain t broke, then don t fix it. The leader however looks at the two and asks, Can we improve upon the new time clock, perhaps add a retinal scan for clocking in? Or maybe we do not even need a time clock and can use an RFID card in each person s wallet to clock in and out?. The leader looks to change things and make them better. The leader is forward thinking and the manager is not. The manager is a copy while the leader is an original. Managers do not like to rock the boat. This fits nicely with the philosophy of if it ain t broke, don t fix it presented previously. Managers will simply complete the task. They will do it right, and in the same way it has always been done. Managers typically do not look for innovation or to change things unless they are forced. The leader, on the other hand, says How can we break it and make something new?. The leader rocks the boat so much sometimes that passengers fall out. This is part of the innovative spirit that a leader typically displays. As you can imagine, both approaches have positive and negative aspects. (Continued on Page 4) CBBS Today Page 3 Fall 2015, Vol. 33, No. 2

4 Leadership vs. Management: Which one do you need? (Continued from Page 3) The manager focuses on systems and structure while the leader focuses on people. The manager will ask How do we fit this process or these people into a box, flow chart, checklist, etc? Managers have a need to place boundaries and controls on everything and everyone. This process is very helpful for a strong locus of control. However the leader is more focused on people and the emotional side of things. Leaders will ask, How are people doing? What are they thinking, feeling, etc.? They will recognize that these factors influence the productivity and the output of work from the employee. The manager relies on control while the leader inspires trust. If I were presenting this visually to explain my point, I would show two different pictures. I would show a picture of a manager gripping a piece of paper tightly to symbolize the need to control people and things. For the leader, I would show a picture of an open hand, allowing people and processes to flow in and out freely. This symbolizes the trust that a leader gives to their subordinates to complete tasks and solve problems without the leader s watchful eye. As you can see in the above examples, both management and leadership have a place in the structure of overseeing employees and working with people. In some situations you may need to apply a management approach, and in others you will need to apply a leadership approach. There are also situations where you may need to apply both. I refer to a person who is able to apply both approaches as a managerial leader. Managerial leadership is the practice of both approaches dependent upon the person and the situation that is presented. To paint the picture of managerial leadership in the real world, let us hypothesize that you have two employees, we will call them employee M and employee L. Employee M is a go getter who is able to take a task and complete it fully as long as you structure the path to success for him. This type of person relates to a management type of style that provides more monitoring and control over what he does and how he does it. If you take just a leadership approach and give him the task, expecting him to get there on his own, you will not see it completed. This employee needs you to take a more managerial role to achieve the desired outcome. You will need to lay out each step and then you will need to monitor each step to ensure success. Employee L, on the other hand, has the ability to take a task and lay out his own path to successful completion. For employees like L, you simply need to designate the end result that you desire and they will get there on their own. You also need to trust the employee to finish the project on their own, meaning you cannot intrude in their process. If you take a management approach with employee L and closely control or monitor his work, you may find it interferes with success. To be a good managerial leader, you must be able to identify your employees preferences for management or leadership oversight and apply the appropriate style to their work tasks. Much like our examples above, people resonate with various approaches. In order to get the desired results from your employees, you must first make sure that you apply the proper approach. In some situations you may need to apply a little bit of both management and leadership. The practice of managerial leadership means that you will identify the needs and apply the proper approach. As a blood banker in a highly complicated industry with shrinking budgets, expanding service areas and ongoing mergers and acquisitions, we must commit to applying managerial leadership to our organizations. Managerial (Continued on Page 5) CBBS Today Page 4 Fall 2015, Vol. 33, No. 2

5 Leadership vs. Management: Which one do you need? (Continued from Page 4) leadership is a flexible style that utilizes the best parts of leadership and management, and merges them together to accomplish the most desirable outcomes. As we continue to see our industry change and evolve, we must continue to change and evolve our approaches to leading these life-saving organizations. Managerial leadership allows us to more effectively move our organizations ahead and see them thrive in today s world. References: Bennis, Warren. The Essential Bennis. San Francisco, CA: Jossey-Bass; Kotter, John P., What Leaders Really Do. Harvard Business Review; Zaleznik, Abraham, Managers and leaders, are they different?. Harvard Business Review; Retrieved from the Internet: a=x&ei=u11cvcrdfov6oqsigoh4da&ved=0cayq_auoaa&dpr=1 a=x&ei=u11cvcrdfov6oqsigoh4da&ved=0cayq_auoaa&dpr=1#q=what+is+the+definition+of+leadership CBBS Today Page 5 Fall 2015, Vol. 33, No. 2

6 Reciprocal Behavior: We are all Donor Recruiters Michael Johnson Business Source Production Manager California United Blood Services Scott Edward District Donor Recruitment Director United Blood Services California Introduction Who is responsible for recruiting blood donors? This seems like a simple question, yet it may contribute to interdepartmental debates as blood organizations reduce in size and place increased stress on available resources. Many organizations are discovering that their ability to implement recruitment tactics has diminished, yet the need still remains; blood donors are crucial to the supply chain. This article will provide insight into how blood bank organizations can benefit from establishing synergy among the various departments. It will also demonstrate that the donor recruitment process is a shared responsibility and that environmental conditions are contributing to a philosophical change in how business is conducted. Industry and organizational leaders are now tasked with educating and motivating employees to maximize each donation experience so that the right products are collected to meet customer needs. To support internal and external donor recruitment efforts, the relevance of marketing to an evolving donor base will also be examined. Establishing Synergy Blood bank organizations typically have segmented operations. Departments such as laboratories, hospital services, donor collections, record review, and administration are cordoned off into separate areas within an infrastructure, and the division of labor reflects the division of responsibility. The one common thread that all departments share is a reliance on volunteer blood donors. Without donors, an individual department or a combination of all the other aforementioned operations would not exist; hence the need for each employee to evolve into a donor recruiter. Tenured organizational personnel may scoff at the idea of contributing to this concept, as the breadth of their roles and responsibilities extend beyond the simple asking of a potential donor s vital resource and time. When an organization s leadership is able to facilitate change from departmental division to a shared approach to donor recruitment, the availability of recruitment tactics and programs opens up. Recruitment departments are still responsible for building and creating effective strategies; however, the entire organization should have a role in implementing and monitoring these and suggesting strategic modifications. Blood Collections Environment One of the biggest benefits gained when shifting away from the idea that a donor recruitment department has sole responsibility for recruiting donors is the leveraging of the blood collections operations to support recruitment. Once the paradigm shift is accepted, an organization has an expanded team to support the importance of donating blood according to blood type. As a result, more staff members are available to thank blood donors for their time, increase awareness in the community, and offer new ideas to organizational leadership in an effort to recruit more blood donors. Within an enhanced and well-informed blood collections environment, blood donors benefit from receiving more (Continued on Page 7) CBBS Today Page 6 Fall 2015, Vol. 33, No. 2

7 Reciprocal Behavior: We are all Donor Recruiters (Continued from Page 6) attention and engagement, which improves their donor experience. When blood donors decide to donate their time and part of themselves to our industry s mission, they like reassurance that they have made the right choice. When donors not only understand that their donations make a difference, but also how their donation helps, the entire blood bank community benefits. Likewise, as department personnel are educated on how to present recruitment marketing materials and statements, and are able to reinforce the current recruitment strategies, the synergy within the organization becomes apparent to customers and donors. This united front becomes even more important as recruitment strategies to target donors by blood type have become the industry norm. Effective Marketing Techniques In addition to improving donor experience, a synergistic interdepartmental approach can create new opportunities to implement marketing strategies. United Blood Services California has reorganized its management philosophy and is using joint department focus to test a series of marketing techniques outlined below: Reinforcing Donor Education. Marketing brochures, videos, and posters already exist to educate donors on how their specific blood type can be used. Donor education has been heightened by having donor collection staff engage donors in meaningful dialogue that expands on these recruitment materials. Specifically, meaningful engagement by all staff interacting with donors has increased participation in automation programs. At United Blood Services California, AB Whole donors are routinely approached by collection staff to switch donation type to an automated plasma donation. Even with s, brochures and mailed letters, the AB plasma automation program benefits greatly from collection staff s direct engagement. Expanding Perspective. Sharing the full perspective of an organization can create a stronger connection and expand the volunteer donors perspectives on how their donations fit into the process. Simple team building techniques, such as social media videos of staff in the lab explaining the need for blood donations, can provide unique content for websites. Thank you programs also benefit by having donors receive letters signed by Hospital Services managers and lab technicians. Replacing the Phone. Telerecruiting is becoming less effective as the donor base shifts to different communication technologies. Improving all staff interaction with donors is necessary to help replace traditional telerecruitment. One specific technique is to stimulate donor collections engagement with donors by establishing rebooking programs. To help instill a culture of rebooking donors, organizations can take advantage of the more intimate interaction that occurs between donors and collection staff. An interdepartmental approach to recruiting donors leverages this employee-donor relationship and boosts the efficacy of a rebooking program. United Blood Services California recently implemented this approach and early data suggests that a 70% rebooking rate is possible. With a successful rebooking program, marketing efforts can then shift to encouraging donors to keep their appointments. Success in rebooking will also reduce the reliance on telerecruiting, and recruitment resources can then be shifted to other recruitment tactics. Conclusion Changes in the healthcare industry, declining blood transfusion trends, and generational shifts within the donor base are contributing to a philosophical change in how business is conducted. From a donor resource perspective, organizations can actually increase their focus on volunteer blood donors during times of dramatic change. Building a (Continued on Page 8) CBBS Today Page 7 Fall 2015, Vol. 33, No. 2

8 Reciprocal Behavior: We are all Donor Recruiters (Continued from Page 7) culture of joint engagement with donors will maintain the donor base and allow for acceptance of evolving recruitment strategies. References Akremi, A. E., Nasr, M. I., & Richebé, N. (2014). Relational, organizational and individual antecedents of the socialization of new recruits. 17(5), Burns, G., & Napier, B. (1994). Linking creativity, common vision and customer connection: Synergy for organizational.. National Productivity Review (Wiley), 13(4), Chand, A., Sharma, V. K., & Uddin, M. (2010). Customer relationship management: The success mantra of present generation marketers. Pranjana: The Journal Of Management Awareness, 13(1), Fombelle, P., Jarvis, C., Ward, J., & Ostrom, L. (2012). Leveraging customers' multiple identities: identity synergy as a driver of organizational identification. Journal Of The Academy Of Marketing Science, 40(4), doi: /s Koen, P. A., Bertels, H. M. J., & Elsum, I. R. (2011). The three faces of business model innovation: Challenges for established firms. Research Technology Management, 54(3), Kuratko, J., Hornsby, J., & Goldsby, M. (2012). Innovation acceleration: Transforming organizational thinking. Upper Saddle River, NJ: Prentice Hall. Martin, W. C. (2014). Independent versus incentivized word-of-mouth Effects on listeners. Academy Of Marketing Studies Journal, 18(1), Northover, J. (2014). Technology and trends in blood utilization: the time for change is here. MLO: Medical Laboratory Observer, 46(10), 14. Phillips, R. L., Blair, J. D., & Schmitt, N. (1987). Beyond group cohesion: The concept of organizational synergy and its impact on performance. National Journal Of Sociology, 1(2), Sadatsafavi, H., & Walewski, J. (2013). Corporate sustainability: The environmental design and human resource management interface in healthcare settings. Health Environments Research & Design Journal (HERD) (Vendome Group LLC), 6(2), Varma, R. R. (2012). Enhancing and empowering: Customer experience. SCMS Journal Of Indian Management, 9(3), CBBS Today Page 8 Fall 2015, Vol. 33, No. 2

9 The CBBS Emergency Preparedness Plan: A Lifeline in Times of Crisis Joy L. Fridey, MD, MBA Chair, CBBS Emergency Preparedness Committee Regional Medical Director American Red Cross Blood Services, Southern California Region California now has a population of more than 37 million people living in 163,700 square miles, making it the most populous and geographically the third largest state in the US. A devastating event such as an earthquake, a massive wildfire, or the detonation of an explosive device could impact untold numbers of people. The collections and manufacturing operations of local blood centers could be overwhelmed or come to a standstill, and the movement of blood into the affected area could be complicated by impassable roads or other conditions. A reminder is the 1989 World Series Earthquake that affected the San Francisco Bay area, causing sixty-three deaths and injuring almost 4000 people. Sections of the Oakland Bay Bridge and Nimitz Freeway collapsed, and many thoroughfares were severely damaged. The CBBS Disaster Plan was activated, and the Golden Gate Bridge was used to deliver blood to San Francisco to treat the injured. Because of its many community blood centers and several hospital-based donor centers, California is uniquely positioned to serve as its own first responder for blood needs, and has one of the largest networks in the country. Fourteen California blood centers are CBBS member institutions, and at least four hospitals that are institutional members also collect blood. The CBBS Emergency Preparedness Committee (formerly the Disaster Planning Committee ) is now in its 32nd year, and maintains an Emergency Preparedness/Disaster Response Plan that: includes a network of CBBS blood center members that potentially could serve the needs of an incapacitated area; provides information about alternate methods of communication; and identifies relationships with volunteer flight organizations and other emergency response agencies. This article is intended to provide basic information about the CBBS Disaster Plan ( The Plan ) and answer important questions such as What should my institution do if a disaster occurs and we suddenly need more blood? How can my hospital get help through the CBBS Emergency Preparedness Plan? This short review will not cover everything in detail, so hospitals and blood centers should familiarize themselves with the plan, which is available at no charge to members and non-members alike on the CBBS Website. The Plan can be accessed through the website Communities tab, and then by clicking on the Resources tab in the Emergency Preparedness section. 1 Copies are available upon request from the CBBS Central Office. In the text of this article, specific appendices are sometimes mentioned to assist navigation of the on-line version. The primary goals of The Plan are to facilitate communication among California blood centers regarding disasterrelated blood shortages, determine the capability of unaffected centers to provide or arrange for transport of blood, and when necessary, work with state, federal, or other agencies that manage emergencies. Centralization, preparedness, and backup plans are core essentials. Centralization The Area Emergency Operations Centers (AEOC) The AEOCs are three regional California blood centers that together provide coverage for Southern, Central, and Northern California. Each AEOC has a dedicated phone number through which the point person can notify or be notified about an event in California and subsequently initiate the plan if necessary. The AEOCs and corresponding regions are in Table 1. (Continued on Page 10) CBBS Today Page 9 Fall 2015, Vol. 33, No. 2

10 The CBBS Emergency Preparedness Plan: A Lifeline in Times of Crisis (Continued from Page 9) Area Emergency Operations Center Region Contact Number San Diego Blood Bank, San Diego Southern California Houchin Community Blood Bank, Central California ; Bakersfield BloodSource, Sacramento Northern California The Northern California AEOC in Sacramento (BloodSource) is the State Disaster Control Center for blood and the main blood center liaison with the California Emergency Management Agency (Cal-EMA, formerly Office of Emergency Services) operating out of Sacramento. If the Northern AEOC were incapacitated or became unable to function, the Central AEOC, Houchin Community Blood Bank, would assume that liaison responsibility. The network is based on a command and control model. The first step in many scenarios would involve an AEOC becoming aware of a disaster that could impact blood availability, trigger massive transfusion, or require transport of blood around the State. This AEOC would obtain preliminary information about the extent of injuries, anticipated blood needs, and accessibility of major transportation routes, and will contact the other AEOCs. All AEOCs will then communicate with blood centers in their respective regions (North, Central, or Southern California) to assess blood availability and resources. Community blood centers should be prepared to interact with the hospitals they serve, especially those impacted by the disaster. Conversely, hospitals in affected areas should contact their main blood provider about their anticipated transfusion needs; preferably, hospitals should not contact the AEOCs directly unless it happens to be their blood bank. In some situations, hospitals may need to reach out to the closest regional blood center even if it is not their main provider. Information about an emergency could come to an AEOC or blood center from numerous sources, including televised media, social networking, the Internet, an affected blood center, or simply through a phone call from someone familiar with the network. An AEOC could also be alerted by federal, state, or regional agencies, such as FEMA, California Emergency Management Agency (Cal-EMA), or the Emergency Medical Services Authority (EMSA). The key to activating the CBBS plan is awareness of its existence and thinking to take the appropriate follow-up steps. A good rule of thumb is this: if a disaster occurs that could precipitate an acute need for blood in your institution, and the CBBS Disaster Plan crosses your mind, put those thoughts into action if you are a blood center, contact your AEOC; if you are a hospital, contact your blood center. Early notification is always a good idea, even if no immediate assistance is needed. Awareness of a potential emergency can save crucial time if a situation rapidly changes. Preparedness Blood Centers The CBBS Disaster Plan primarily intended for institutional member use - is concise. The six core sections appear in large print, are laid out in easy-to-use tables, occupy only 13 pages, and include: 1. Overview, definitions, and specific emergency preparedness actions 2. Network activation and contact numbers 3. Communications traditional and alternate 4. Transportation for blood products air and ground 5. Donor Processing 6. Record Keeping and Media Contact (Continued on Page 11) CBBS Today Page 10 Fall 2015, Vol. 33, No. 2

11 The CBBS Emergency Preparedness Plan: A Lifeline in Times of Crisis (Continued from Page 10) Several appendices provide contact numbers of CBBS Emergency Preparedness Committee Members and institutional contacts (Appendix A, which is available only to CBBS institutional members), a disaster response checklist for blood centers, amateur (HAM) radio information and frequencies, and several forms such as emergency blood requests and After Action Reports (discussed subsequently). Two important documents that list preparedness elements are Section 1 of the Plan and Appendix C which is a comprehensive checklist. Section 1 recommends that, at a minimum, blood centers have the following: An emergency response team Plans for an off-site alternate command center Development of alternate means of communication such as HAM radio or texting on cell phones Plans for self-sufficiency for at least 6 days A triage system for hospital blood orders Appendix C is a significant expansion of Section 1 and provides additional details which, if implemented in advance, could prove critical in a major disaster. Each CBBS institutional member should have the contact information of all Area Emergency Operating Centers and other blood centers in an accessible location at work and home. Maintaining these numbers in a smart phone contacts lists or even hard copy would facilitate phoning and texting. Institutional members should also notify the CBBS Central Office in real-time when personnel or contact information changes2. The CBBS Central Office serves a vital role by sending an updated Appendix A to institutional members on a regular basis. Annually, the CBBS Emergency Preparedness Committee contacts institutional members to obtain updated information. Hospitals The Joint Commission and AABB require that hospitals have emergency management plans. Standard 1.4 of the 29th edition of the AABB Standards for Blood Banks and Transfusion Services states The blood bank or transfusion service shall have emergency operation policies, processes, and procedures to respond to the effects of internal and external disasters. The emergency management plan, including emergency communication systems, shall be tested at defined intervals3. Clearly, both of these accrediting organizations expect hospitals to be prepared to meet unexpected demands for blood. The CBBS Disaster Plan primarily focuses on its institutional members, most of which are blood centers or hospitals with donor centers. However, the Hospital Supplement (Appendix I in the plan) highlights essential procedures and resources for hospitals, examples of which are listed in Table 2. (Continued on Page 12) CBBS Today Page 11 Fall 2015, Vol. 33, No. 2

12 The CBBS Emergency Preparedness Plan: A Lifeline in Times of Crisis (Continued on Page 12) Table 2. Minimum disaster preparedness for hospitals Communications system with the blood provider and reagent vendors for critical supplies. Backup phone numbers, updated at least annually. Alternate communication methods such as a satellite phone, a HAM radio operator, priority access to government phone emergency systems, or even texting capabilities if phone lines are down. Adequate emergency power for the transfusion service and a back up fuel source. An alternate transfusion service site, in the event of structural damage. Rapid communication with the Emergency Department to assess injuries and blood needs. Massive transfusion protocols and policies for ABO typing and use of O negative red cells and plasma type. A procedure for rapid inventory assessment. In the context of this article, bullet one ( Communication system with the blood provider ) is the most relevant. Hospitals can best access resources available through the CBBS AEOCs and blood centers by working directly with their local or main blood provider. Back-up systems A key tenet of disaster preparedness is to assume that some or all of the primary systems communication, contacts, and transportation, to name a few could fail. This assumption is the reason for contingencies included in The Plan. AEOC Back-ups Back-ups reside even at the top of the hierarchy the AEOCs. Although the model is quasi-geographic in nature with each one serving blood centers in its respective region, any AEOC can receive an emergency call and activate the response system if another center is unreachable or impacted by a disaster. If a blood center cannot connect with their AEOC, they may contact one or both of the other two. Should a worst-case scenario occur and none of the AEOCs appear to be responding, a blood center can reach out to national organizations listed in Table 3. This approach should only be used as a last resort, so that duplication of efforts and generation of conflicting information do not occur if other organizations become involved. Table 3: National organizations capable of responding to an in-state California emergency National Blood Exchange AABB Interorganizational Task Force on Domestic Disasters and Acts of Terrorism American Red Cross Blood Services Blood Systems, Inc. Communication Blood centers and hospitals need to be prepared for the possible failure of normal means of communication. Normal communication generally implies electricity-powered telephones, wireless phones, cell phones, , and fax/scanners. It is entirely plausible that most or all of these devices and systems could crash. Attempting to use published or emergency phone numbers of hospital or blood supplier main switchboards could prove futile, frustrating, and waste precious time, as these switchboards become swamped. A restricted line for the supplier and a similar restricted number for your transfusion service should be used for bi-directional communication. These (Continued on Page 13) CBBS Today Page 12 Fall 2015, Vol. 33, No. 2

13 The CBBS Emergency Preparedness Plan: A Lifeline in Times of Crisis (Continued from Page 12) numbers should be confirmed quarterly, because a remodel, re-organization, or personnel change in your institution may disrupt your restricted lines. Alternate technologies for communication include satellite phones and landlines, the latter of which operate directly off the power in phone lines. A subscription to Government Emergency Telephone Services (GETS) gives priority access to landline telephone networks and requires use of an assigned calling card and access code. An analogous service for cell phones is the Wireless Priority Service (WPS); this is a feature that would have to be requested as part of the user s cell phone service4. Your facility can register for either or both by calling or or through the DHS.gov/GETS website (select non-federal in the registration link). Although it may not be possible to make routine cell phone calls, texting uses less bandwidth, and anecdotal information suggests that it has been effective when cell phone transmission towers are overwhelmed with calls. For texting to be feasible, the cell numbers of point personnel at the AEOCs, blood centers, and hospitals need to be known and available. The CBBS Emergency Preparedness Committee has also discussed the use of social networks as a potentially valuable messaging option. Due to lack of confidentiality and the inability to transmit complex messages, CBBS does not yet plan to officially endorse social networks as communication backups. However, because blood centers use social media for donor recruitment and outreach, the Emergency Preparedness Committee does recommend that centers develop a mechanism through which social media could be adapted to convey emergency needs for blood to inventory or order management departments. Currently, the chosen alternate form of communication in the CBBS Plan is a network of Amateur (HAM) Radio Operators. Although HAM radio sounds antiquated, the reality is that in a worst-case scenario involving electronic and Internet disruptions, HAM radio communication is still one of the most reliable, especially for those facilities who do not have working satellite phones. Many CBBS institutional members are affiliated with at least one HAM radio operator. If the standard communication was disrupted in an emergency, AEOCs would activate the HAM radio network that, under the guidance of an assigned coordinator ( RadioNet Control ), would handle message transmission among blood centers and AEOCs. Blood centers that do not have a HAM radio contact in their disaster response plan can obtain information about volunteer operators from the local American Radio Relay League at hq@arrl.org, or Hospital transfusion services are also encouraged to have an established relationship with a HAM radio operator in their area. Transportation Working through County Resources Regional blood centers may not be able to rely on routine means of transportation and delivery into the affected areas. Each blood center should be prepared to coordinate with its county Public Health Department s Communications Directors and Regional Disaster Medical Coordinators (listed in Appendix F) so that coordination of blood delivery happens at all levels, preventing delivery to regions not in need. Air transport product delivery When air traffic was grounded for several days after 9/11, specimen tubes and blood were shipped mainly by ground transportation. However, a major seismic event or fire could take out bridges, overpasses, and surface streets. Air transport may be the only means of accessing ground zero for blood deliveries. As part of disaster preparedness, (Continued on Page 14) CBBS Today Page 13 Fall 2015, Vol. 33, No. 2

14 The CBBS Emergency Preparedness Plan: A Lifeline in Times of Crisis (Continued from Page 13) blood centers should develop emergency flight contacts but work through their AEOC to avoid confusion. At least four entities that can support air transport are Angel Flight West (whose pilots are volunteers and should be informed that they would only be delivering blood, not flying patients), the California Highway Patrol Aero Division, the Salvation Army Territorial Disaster and Western Division Services, and the USAF Civil Air Patrol. These services are for urgent or extreme situations, and should only be used when other options are severely limited. The contact numbers for these organizations are listed in Section 4 of the CBBS Disaster Plan. While there would be numerous logistics to work out, of particular importance is that blood and specimen tubes should be packed per institutional procedures, and clearly marked Human Blood. The Morning After Report There are several useful forms in the Disaster appendices, but the After Action Report (AAR) in Appendix H is a particularly important aid for summarizing problems and successes experienced during actual disasters or practice exercises. The AAR allows AEOCs, blood centers, and transfusion services to track what has occurred, and enables primary team members to function as a unit and integrate actions with other organizations when help has been requested. In true disasters or acts of terrorism as declared by the Federal Government, AARs can also be used to support requests for government financial assistance. An AAR form should be used during local and regional exercises and a copy submitted to the CBBS Central Office so information can be shared.2 Preparedness Begins At Home Knowing that we could be anywhere when a disaster strikes, we should all have a personal emergency preparedness plan and kits for our homes and vehicles. Once an emergency occurs, any of us could be left without the necessary resources to provide for ourselves, our families, and our pets. Many excellent resources are available online that provide comprehensive information about how to prepare, what to include in emergency kits, things to consider for communicating with family or loved ones during a disaster, and how to establish neighborhood or community emergency plans. 5-7 Conclusion This overview of the CBBS Disaster Plan is intended to explain how it can be implemented in an emergency, and provides specific actions that blood centers and hospitals should take to prepare for a potential catastrophe. We urge you to review the plan in detail and keep it available in hard copy and on a portable electronic device. The Plan could be a lifeline to any of us. References cbbs@cbbsweb.org 3. Standards for Blood Banks and Transfusion Services, 29th Ed. Leavitt J, Chair. AABB, Bethesda safety/ education/ public-education Other Resources: AABB Disaster Operations Handbook and Disaster Operations Handbook: Hospital Supplement (aabb.org; Under Programs and Services Disaster Response ) ( FDA Guidance for Industry: Recommendations for Blood Establishments: Training of Back-Up Personnel, Assessment of Blood Donor Suitability and Reporting Certain Changes to an Approved Application. November, 2010 CBBS Today Page 14 Fall 2015, Vol. 33, No. 2

15 Connecting the Dots to the Lutherans; It s Harder Than You Think Karen Rodberg, MBA, MT(ASCP)SBB Director, Immunohematology Reference Laboratory American Red Cross, Southern California Pomona, California It was a dark and stormy night Actually, it was probably a sunny California day, but I love a good story, and this is a good story, if you re a Reference Lab geek, that is. So, it was a typical day in our Immunohematology Reference Laboratory (IRL). A sample arrived from one of the local cancer hospitals. The request was for routine antibody identification on a 58-year old female patient with multiple myeloma. She was an outpatient who had a negative antibody screen on her previous visit three months earlier. She had received two units of packed red blood cells (RBCs) at that time. On the current visit, the Blood Bank was seeing weak reactivity with all panel cells and suspected an antibody with high titer, low avidity ( HTLA ) characteristics. Our initial panel showed very weak reactivity with all panel cells when tested by indirect antiglobulin test (IAT) using polyethylene glycol (PEG), low ionic strength saline (LISS), and ficin-pretreatment. Pursuing the idea of an antibody with HTLA characteristics, we performed antibody titer and neutralization. This antibody appeared to have a titer of 128 and was not neutralized by pooled normal sera, excluding anti-ch and anti-rg. In order to further characterize the reactivity, we tested a panel of dithiothreitol (DTT)-treated RBCs, which showed that the reactivity was DTT-sensitive. Next, we thawed rare RBC samples from our frozen RBC library that were negative for high prevalence antigens whose corresponding antibodies are known to share similar reactivity to that of the patient. We tested the patient s sample against these rare panel cells which had the following phenotypes: Yt(a ), JMH, Ge: 2, 3, Kn/McC, LW, Lu(a+b ), Lu(a b ), Cs(a )/Yk(a ), Do(b ), K0, plus a few others. Six of seven examples of Lu(a b ) RBCs were non-reactive with the patient s plasma, suggesting anti-lu3 specificity. But when we tested the patient s RBCs for Lu-related antigens, she did not appear to be Lu: 3, which is the expected phenotype of a patient who has made this antibody.1 Based on the Lu-related antibody suspected, our laboratory recommended performing a Monocyte Monolayer Assay (MMA), which can help predict whether the patient is likely to have rapid clearance of incompatible transfused RBCs. At one point in the conversation, the hospital Blood Bank staff mentioned that this patient was receiving a new drug as part of a clinical trial. The name of the drug was Daratumumab (DARA), a monoclonal anti-cd38. The staff member said that their lab was seeing similar serology in a second patient receiving the same drug. Several of the IRL staff remembered two recent AABB abstracts, one by Chapuy2 and one by Hannon3, describing the serology seen in patients receiving DARA. The abstract by Chapuy et al. reported that patients receiving this drug presented with an antibody in their plasma that mimicked an antibody to a high incidence antigen, and that the antibody did not react with DTT-treated RBCs. Since the antibody, based on this new information, appeared to be a passive antibody resulting from the DARA, random units were recommended for transfusion instead of rare RBCs. Whew! That was a relief for all. One week later, a sample arrived from a different hospital for a routine workup. Not much clinical information was provided, other than that the patient was a 60-year old male oncology patient who was being transfused with RBCs every two weeks. The hospital s results were a positive antibody screen with all cells reacting 1+ by gel method, but non-reactive by conventional tube technique. Their conclusion was unidentified antibody, but they sent the sample for confirmation. The request form listed the patient s diagnosis as unknown, medications as unknown and hemoglobin/hematocrit as unknown. Our lab confirmed the ABO/Rh as group O Rh positive, but we were unable to get a valid Rh phenotype because there was evidence of mixed-field reactivity with the antisera, consistent with a recently transfused patient. The direct (Continued on Page 16) CBBS Today Page 15 Fall 2015, Vol. 33, No. 2

16 Connecting the Dots to the Lutherans; It s Harder Than You Think (Continued from Page 17) antiglobulin test (DAT) was microscopically positive with anti-igg. In a recently transfused patient, the positive DAT could be evidence of alloantibody sensitizing some of the transfused RBCs, so our workup would include an elution. We started with our routine panels, testing by PEG IAT and with ficin-treated RBCs. Both of these conventional tube panels were non-reactive. We set up a panel by gel, and were able to duplicate the weak reactivity that the hospital had reported. An eluate of the patient s RBCs was non-reactive by PEG IAT and by gel IAT. We also tested by saline IAT (no enhancement) and found that the strongest reactivity with this patient s sample was seen using the saline IAT. Stronger reactivity by saline IAT was thought to be due to the minute incubation required for this method. Autologous controls for the tube and gel methods showed the same weak reactivity as seen with the DAT, but since the eluate was non-reactive, this antibody did not appear to be an autoantibody. The weak reactivity made us suspect an antibody with HTLA characteristics, but when we performed the titration, there was no reactivity in any of the dilutions. So, where do we go from here? Reference techs love a good challenge, but antibodies that are strongly reactive are easier to investigate. We hate having to report unidentified reactivity because it feels like the antibody won and we lost. We had excluded all common clinically significant alloantibodies by the initial PEG panel, and had excluded autoantibody by the negative eluates, so the reactivity was investigated as a possible antibody to a high incidence antigen. We thawed a number of rare RBCs from our frozen library of RBCs stored in liquid nitrogen. We focused first on the blood group antigens that are often associated with weakly or variably reacting antibodies, e.g., Kn/McC, JMH, Ge, Lu, and Yta. While several examples of Lu(a+b ) RBCs were reactive with the patient s plasma, we found that 7 of 7 examples of Lu(a b ) RBCs were non-reactive. Hallelujah! This information suggested that the blood group system Lutheran was involved. Our library of Lutheran-related high incidence antigen negative RBCs is limited, as is true for all IRLs, simply because there are few examples of these rare RBCs to share. We phenotyped the patient for Lua and Lub; the patient appeared to be Lu(a b+). While we did not have the exact specificity of the antibody, we had the blood group family, Lutheran-related, to report. Since most Lutheran-related antibodies are relatively benign, and since Lu(a b ) RBCs are exceedingly rare, we recommended transfusing with caution or requesting an MMA, and also testing family members to see if they might be compatible donors for this oncology patient. We had done our job, and the case report was mailed and filed, and forgotten. In retrospect, we now wonder if this patient s diagnosis was multiple myeloma being treated with DARA, but we had not yet connected the dots. Six months later, we received a sample from a different patient from a third hospital. A different IRL staff member worked on it. In this case, the patient was a 46-year old male oncology patient. No diagnosis was indicated on the request form, but the patient s hemoglobin was 7.6g/dL with 22.1% hematocrit. The hospital had no record of recent transfusion and two units of compatible RBCs were requested. Our initial panel showed 1+ to 2+ reactivity with all RBCs tested by PEG, ficin, and LISS IAT. The patient s DAT was weakly positive with anti-igg only, but his RBCs reacted 2+ by PEG IAT as the autologous control. This serum reactivity was somewhat consistent with warm autoantibody, but the eluate was non-reactive by PEG IAT. The antibody appeared to be of high titer (>128) and was sensitive to DTT-treatment of the test RBCs. So back we went to the liquid nitrogen-stored rare RBC library for RBCs that often fit these serologic characteristics. We tested RBCs of the following rare phenotypes: Ge: 2, 3, Yt(a ), Gy(a ), Do(b ), Lu(a+b ), Lu(a b ), and a few others for good measure. We found that 2 of 2 examples of Lu(a b ) RBCs were non-reactive. Next, we thawed one example each of Lu:-6, Lu:-8, Lu:-13, and Au(b ) RBCs, but all of those were 2+ reactive. Our conclusion, again, was that this antibody was Lutheranrelated, but we did not know the exact specificity and did not have compatible blood for transfusion. In discussing options with the Blood Bank staff at the hospital, we suggested an MMA for this patient as well. During (Continued on Page 17) CBBS Today Page 16 Fall 2015, Vol. 33, No. 2

17 Connecting the Dots to the Lutherans; It s Harder Than You Think (Continued from Page 16) one of the conversations, we were told that the patient had received intravenous gamma globulin (IVIG) for treatment of multiple myeloma. IVIG is made from large pools of plasma and may contain any antibody (including anti-a and anti-b) that was present in the plasma of donors in the pool. We wondered if the antibody in the patient s plasma was due to the IVIG he received. Our Specialist in Blood Banking (SBB )student also keyed into the fact that the patient s diagnosis was multiple myeloma, because she remembered reading the abstracts about multiple myeloma patients receiving Daratumumab. She called the hospital s Blood Bank supervisor asking if this patient was receiving DARA, and found out that he was. In this case, no MMA was needed because we were sure this was passive or DARA-associated antibody, not alloantibody. Random ABO/Rh-compatible units would be appropriate. Approximately six months later, a fourth hospital sent a sample from a 66-year old male patient with multiple myeloma. The hospital reported 1+ reactivity with all RBCs by Echo (Immucor, solid phase methodology). The antibody workup by our lab proceeded similarly to those above. We saw weak reactivity with RBCs of common phenotype; the reactivity had a titer of >2000 and was DTT-sensitive. In this patient, we did not see any antibody specificity. Lu(a b ) RBCs were reactive, as were all other rare phenotype RBCs tested. Although no medications were listed on the consultation request form, we were now on the alert for patients with multiple myeloma and serology suggesting an antibody to a high incidence antigen, and wondered if this patient was receiving DARA. We called the hospital Blood Bank to ask about medications, but they suggested that we call the physician and gave us his phone number. We called the physician, who actually happened to be the patient himself, who confirmed that he was in a clinical trial and was being given a different manufacturer s anti-cd38, called SAR. Once again, we were able to recommend giving ABO/Rh-compatible units, although in this case, we were unable to exclude anti-k so recommended K units. At this point, the full article by Chapuy4 and co-workers was in press, so we were able to provide the article to the patient/physician. Another article in the same journal issue, this one by Oostendorp5 et al, reports similar findings in patients receiving DARA. They caution that Blood Banks are likely to see more and more of these therapeutic monoclonal antibodies in compatibility testing, as this type of treatment option expands. The Chapuy article is very informative, explaining how the monoclonal anti-cd38 therapy targets myeloma cells; but since there is a small amount of CD38 on RBCs, the monoclonal antibody circulating in the patient s plasma can be detected in routine Blood Bank testing. The article describes in detail how that group proved that the antibody in these patients is indeed passively acquired DARA. Their recommendation for investigation is to use DTT-treated panel RBCs to exclude common alloantibodies, with the exception of anti-k. We have actually seen a few additional cases like the four described above. To date, we are unaware that any other lab has seen the Lutheran-related specificity we have seen in all but the SAR case. We have now been sensitized to inquire about medications and diagnoses in patients who present with similar serology when such information is not completed on our request form. We were also fortunate that several members of our Reference Services laboratories are well-read in terms of current transfusion medicine literature. It took several patient samples weeks or months apart for us to really connect the dots and learn to ask the right questions; but, in our defense, we have a variety of technologists who were involved in working on each of these samples. And since we frequently work on 100 samples in any given week, the details of a workup done even one week ago can seem like a vague memory. (Continued on Page 18) CBBS Today Page 17 Fall 2015, Vol. 33, No. 2

18 Connecting the Dots to the Lutherans; It s Harder Than You Think References (Continued from Page 17) 1 Reid, ME, Lomas-Francis, C., Olsson, ML. The Blood Group Antigen FactsBook, Third Edition. Elsevier/Academic Press, Chapuy et al. Development of a Robust Method to Negate the Daratumumab Interference with Routine Blood Bank Testing, Transf 2014;54:SP254 3 Hannon et al. Serological Findings Related to Treatment with a Human Monoclonal Antibody (Daratumumab) in Patients with Advanced Plasma Cell Myeloma, Transf 2014;54:SP265 4 Chapuy et al. Resolving the daratumumab interference with blood compatibility testing, Transf 2015;55: Oostendorp et al. When blood transfusion medicine becomes complicated due to interference by monoclonal antibody therapy, Transf 2015;55: CBBS Today Page 18 Fall 2015, Vol. 33, No. 2

19 Developing a Blood Bank Training Symposium Theresa Dunning, MSQA, MT(ASCP)SBB, QM/OE(ASQ) Regionwide Blood Bank Practice Leader, Kaiser Permanente, Northern California, TPMG Background In 2006, the Regionwide Laboratory Quality and Compliance office based within The Permanente Medical Group (TPMG) regional laboratory established routine internal assessments of each Kaiser Permanente hospital-based clinical laboratory in Northern California. These internal audits have provided valuable feedback and consultation on compliance with laboratory accreditation standards, regulatory requirements and standardized best practice work instruction. Additionally, the implementation of a standardized Biological Product Deviation (BPD) procedure provided information for potential regional process improvement projects as well as for education initiatives. Identifying a Need for Basic Blood Bank Training Trending observations from internal assessments, FDA BPD public reports and a valuable AABB publication Serological Problem-Solving: A Systematic Approach for Improved Practice, 1 identified common gaps in proper technical work practice. This gap analysis was incorporated into our training program (Refer to Table 1). Concurrently, our Laboratory Scientist Labor Management Partnership (LSLMP) committee recognized the need to develop and offer training in blood bank technical instruction and key standardized transfusion service procedures to all Clinical Lab Scientist (CLS) employees scheduled to work in the transfusion service on a rotational basis. Table 1: Gaps in Proper Work Practice Event Misidentification of anti-jka demonstrating dosage. Misidentification of anti-f Antibody identification results did not clearly list antibodies not ruled out. ABO discrepancies lacked documentation of resolution. Root Cause Antibodies demonstrating dosage were not recognized and instead considered non-specific reactivity or cold agglutinins. In one case the antibody was prewarmed away. Antibodies to compound antigens were not recognized and properly addressed. Antibodies which could not be ruled out were not clearly noted as such and managed properly. Antigen negative blood was not provided as a preventive measure. Group O blood would be provided but specific tests to resolve and properly report a resolved type were not performed. The LSLMP prepared and submitted a business case to the Kaiser National Workforce Planning and Development Department to request financial support through a trust fund designated for employee training programs. The business case identified sponsors, purpose for the training, expected outcomes, course structure, delivery method, budget and measurable indicators that would be monitored to demonstrate the success of the proposed training program. The planned blood bank training would be a three day course taught by a contracted trainer with subject matter expertise. It would be conducted in a classroom setting, using customized training manuals and TechChek (Continued on Page 20) CBBS Today Page 19 Fall 2015, Vol. 33, No. 2

20 Developing a Blood Bank Training Symposium (Continued from Page 19) competency kits, one per student. The course offering would include two days of technical instruction and a third day of training on regional standardized procedures. In order to provide a standard measure of technical knowledge gained from the course, a pre and post training test containing the same questions were administered before training began on the first day and at the conclusion of the second day of technical training. The average pre-test and post-test scores were compared to assess knowledge gained. Pre and post test scores for each participant were evaluated and scores below a pass / fail measure would trigger a follow-up to their supervisor with suggested areas of additional technical study for continued improvement. Performing a Needs Assessment A needs assessment identifies the desired performance, the current performance, and the gap between these two performance levels.2 This gap represents the training need. A needs assessment can be done by looking at these training needs from different perspectives and by using sources or information gathering tools summarized in Table 2. Table 2. Needs Assessment Sources Source Category: Expert defined / Presumed need Participant Defined / Expressed Need Observed need / Demonstrated Environmental Scanning Examples Subject matter experts or committees presume a need based on their expertise. Intended trainees express a need through surveys or polls. Data collected and analyzed (audits, error logs, BPD case reports and competency test results) demonstrate a need. Professional news forums, publications document a need. For the Kaiser Blood Bank Training Symposium, all four types of needs assessment sources were used to develop training content. The first two days of training were led by the contracted subject matter expert. The third day was led by the Regionwide Blood Bank Practice Leader. The contracted trainer was selected based on her experience as a nationally recognized expert in the field of transfusion medicine, and her professional expertise as a reference laboratory manager and university educator. A partial agenda with traceability to the needs assessment completed is provided in Table 3. (Continued on Page 21) CBBS Today Page 20 Fall 2015, Vol. 33, No. 2