Specimen of 360 Degree Performance Appraisal by jle31578

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									                    TRANSFUSION MEDICINE AND HEMOSTASIS


Four to five months on Transfusion Medicine and Hemostasis are required during the combined
AP/CP residency. Additional elective time is available.



   PATIENT CARE that is compassionate, appropriate, and effective for the treatment of health
   problems and the promotion of health. Residents must demonstrate a satisfactory level of
   diagnostic competence and the ability to provide appropriate and effective consultation in the
   context of pathology services.

      1. Residents should become familiar with all aspects of Transfusion Medicine as they
         pertain to blood donation, laboratory testing and patient care issues (including
         familiarity with the contents of the current Standards for Blood Banks and
         Transfusion Services published by the American Association of Blood Banks
         [AABB]). Subjects include:
              a. Fundamentals of Blood Group Serology and Biochemistry.
             b. Pre-Transfusion Testing.
              c. Selection and Recruitment of Blood Donors.
             d. Qualification of Blood Donors via Transmissible Disease and
                 Immunohematologic Testing.
              e. Blood Donor Management of Disqualified Donors.
              f. FDA Regulation of Biologics in the U.S.
             g. Blood Center Operations
                     i. Management
                     ii. QC, QA and Compliance
                     iii. Manufacturing (blood component preparation, testing, quarantine,
                          disposal, labeling, and release)
                     iv. Customer Service (hospitals, blood donors, volunteers, recipients,
                          media, and general public)
      2. Residents should obtain an understanding of procedures commonly performed in the
         blood bank and hemostasis laboratories and be able to direct and/or consult on
         technical performance of such procedures and have expertise in the interpretation of
         results. The residents should then be able to make appropriate recommendations
         regarding the transfusion of blood components based upon these results.
      3. Residents should become familiar with the procedures utilized in the laboratory to
         evaluate suspected transfusion reactions.
      4. Residents should learn the policies and procedures regarding the screening of blood
         donors, collection of blood, collection of apheresis components, infectious disease
         testing of blood donors, preparation of blood components, storage and transport
    specifications for blood components, and composition of the various blood
5. Residents should learn and understand all aspects of the Transfusion of Blood
    Components (red cells, platelets, fresh frozen plasma, cryoprecipitate, and
    granulocytes) including indications, doses, modifications, monitoring and
6. Residents should become familiar with current information regarding blood
    availability and use (in-hospital and nationally).
7. Residents should learn emergency transfusion protocols and be able to triage blood
    components (e.g. O negative red cells) in an appropriate fashion.
8. Residents should learn the diagnosis and management of transfusion reactions and
    other adverse effects of transfusion and be able to make appropriate consultative
    recommendations in these areas.
9. Residents should learn the policies, technical procedures, and indications for
    transfusion as they pertain to the transfusion of infants (< 4 months) and children.
10. Residents should learn the appropriate indications for cytomegalovirus Asafe@ blood
    (i.e., CMV negative or filtered).
11. Residents should learn the benefits of and the situations in which leukocyte-depleted
    blood components are used and be able to make appropriate consultative
12. Residents should learn the pathophysiology of transfusion-associated graft-versus-
    host disease and the appropriate indications for irradiated blood components.
13. Residents should understand the pathophysiology of hemolytic disease of the
    newborn (HDN), appropriate measures to prevent Rh immunization during
    pregnancy, laboratory procedures used to predict HDN potential (antibody titers,
    antibody score, etc.), procedures used to determine fetomaternal hemorrhage
    (qualitative and quantitative), calculate the appropriate dose of Rh immune globulin,
    be able to select the appropriate blood components for intrauterine or neonatal
    exchange transfusions, and calculate the appropriate volumes of exchange
14. Residents should become familiar with donor and patient phlebotomy and aphereseis
15. Residents should be aware of the indications for therapeutic apheresis (plasma
    exchange, cytopheresis, red cell exchanges) and be able to make consultative
    recommendations regarding appropriateness of the procedures, the number of
    procedures necessary, volumes replaced, and replacement fluids.
16. Residents should be knowledgeable regarding the infectious disease risk of
    transfusion and be able to impart that knowledge in a consultative format when
17. Residents should become familiar with the medico-legal aspects of Blood
    Transfusion, be aware of the sources of error in transfusion medicine and be
    knowledgeable with the procedures designed to minimize error.
18. Residents should be familiar with the clinically significant red cell alloantibodies,
    their detection, and the approach to safe transfusion of patients with such antibodies.
19. Residents should be familiar with the causes of the refractory state in platelet
    transfusion recipients and be able to make therapeutic recommendations to combat
           the problem (e.g. platelet crossmatching, HLA typing and provision of HLA matched
       20. Residents should be familiar with various types of red cell autoantibodies, techniques
           to detect such antibodies, the causes of autoantibodies (underlying diseases, drugs),
           procedures for detection of alloantibodies in the presence of autoantibodies, and
           consult on appropriate management of autoimmune hemolytic anemia
           (pharmacologic, in vivo biological crossmatches, etc.).
       21. Residents should be familiar with quality assurance procedures that are designed to
           assure safety and appropriateness of transfusion therapy (i.e. transfusion audits,
           transfusion committee, etc.).
       22. Residents should be familiar with the pros and cons of directed blood donations and
           should be able to provide consultation pertaining to this tissue.
       23. Residents should become familiar with blood group serology in paternity testing.
       24. Residents should be aware and be knowledgeable about blood substitutes and their
       25. Residents should become familiar with all aspects of the management of hemostatic
           defects/disorders. Subjects include:
               a. Specimen collection, processing, and storage requirements for hemostasis
               b. Techniques used in the performance of hemostasis assays.
               c. Interpretation of routine and reference-type assays.
       26. Residents should be familiar with the diagnostic approaches and treatment strategies
           for inherited and acquired hemorrhagic and thrombotic disorders and should be able
           to provide direction in diagnosis and therapy in a consultative manner.
       27. Residents should be familiar with the diagnosis and treatment options for
           thrombocytopenia (i.e. ITP, post-transfusion purpura, HELLP syndrome, HUS, TTP,
           neonatal alloimmune thrombocytopenia) and be able to provide appropriate
       28. Residents should be able to provide consultative expertise in the diagnosis of
           coagulopathy in the acute care setting (e.g. surgical emergencies, trauma, obstetrical
           accidents, patients with DIC) and be able to provide guidance in the hematologic
           resuscitation of such patients.

*Lab Observation/Reading Schedule from above list:
      Month 1 – items 1a, 1b, and 2, 3, 5-7
      Month 2—items 8-14
      Month 3—items 15-21
      Month 4—items 22-28
      Month 5—Refine knowledge acquired during prior rotations

Reading References:
 Current Edition of Henry’s Textbook of Clinical Pathology
 AABB Technical Manual

 See Appendix A below for donor center experience at Northwest Florida Blood Center and
reading assignments.

  MEDICAL KNOWLEDGE about established and evolving biomedical, clinical, and cognate
  (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge
  to pathology.

     1. Residents will acquire knowledge of the full spectrum of issues, concepts, and
        knowledge in the discipline of Transfusion Medicine.
     2. Residents will acquire a fund of knowledge of the presentation, diagnosis, and
        management of inherited and acquired hemorrhagic and thrombotic disorders.
     3. Resources to obtain such skill and knowledge include:
             a. In-Lab experience with Medical Technology Staff
            b. Didactic sessions with Pathology Faculty (Dr. Carnahan).
             c. Clinical conferences
            d. Clinical consultations, performed with Faculty oversight
             e. Computer-based investigation and learning
             f. Transfusion Medicine and Hemostasis Textbooks.
     4. Demonstrate an investigatory and analytic thinking approach to laboratory
        testing and interpretation.


  PRACTICE BASED LEARNING AND IMPROVEMENT that involves investigation and
  evaluation of their diagnostic and consultative practices, appraisal and assimilation of
  scientific evidence, and improvements in their patient care practices

     1. Residents will acquire experience in practice-based lab improvement programs
        [familiarization and participation in the quality assurance, quality improvement, and
        peer competency (e.g. CAP Survey) programs].
     2. Residents will use evaluations of performance by peers, superiors, and laboratory
        personnel (360 degree evaluations) to improve practice.
     3. Residents will be able to locate, appraise, and assimilate evidence from scientific
        studies related to specific transfusion medicine and hemostasis problems.
     4. Residents will be able to use information technology to access and manage
        information related to specific transfusion medicine and hemostasis problems.
     5. Residents will facilitate the learning of medical students, graduate physicians, and
        other health care professionals.

  INTERPERSONAL AND COMMUNICATION SKILLS that result in effective information
  exchange and collaboration with patients, their families, and other health professionals.

     1. Residents will communicate effectively with attending faculty, pathology resident
        colleagues, medical students, technology staff, and patients. Competence must be
        achieved in the areas of written and oral communication. Residents will attain and
        sustain effective and ethically sound relationships with clinicians (clinical faculty and
        residents) with regard to patients under their care. Residents will develop and utilize
        effective listening skills in order to obtain and impart clear and concise information to
        colleagues and patients. Residents will use these skills to aid their ability to work
        effectively as part of a health care team or other professional group.


  PROFESSIONALISM as manifested through a commitment to carrying out professional
  responsibilities, adherence to ethical principles, and sensitivity to a diverse patient

     1. Residents will demonstrate compassion, integrity, and respectful behavior towards
        patients and their families, pathology faculty, clinicians (faculty and resident),
        laboratory personnel and hospital staff. Residents will demonstrate knowledge and
        commitment to an ethical approach to business practices, patient confidentiality, and
        informed consent. Residents will understand and demonstrate sensitivity to issues
        pertaining to patient culture, age, disabilities, gender, and sexual orientation.
     2. Residents will attend all required conferences and actively participate in the manner
        designed and/or expected for the particular forum.


  SYSTEMS-BASED PRACTICE as manifested by actions that demonstrate an awareness of
  and responsiveness to the larger context and system of health care and the ability to
  effectively call on system resources to provide pathology services that are of optimal value.

     1. Residents will obtain knowledge of Transfusion Medicine, normal hemostasis,
        abnormal hemostasis, and the functions of the hemostasis laboratory in the context of
        understanding their roles in the overall care of patients and in the way that other
        health care professionals practice medicine (e.g., how therapeutic apheresis influences
        the overall management of thrombotic thrombocytopenic purpura). Residents will
        learn how to apply their knowledge to decisions regarding laboratory practices to
        maximize patient care in a cost effective manner (e.g.., decisions on which assays are
        important to perform in house versus those tests that can be safely and cost-
        effectively performed in a reference laboratory). The residents will learn how to use
        knowledge of Transfusion Medicine and the Blood Bank to be an advocate of quality
           patient care through day-to-day activities under faculty supervision, through
           educational and call review conferences and through committee experience (e.g., in
           the context of reviewing transfusion decisions in the hospital transfusion committee).


Residents rotating on the Transfusion Medicine and Hemostasis service are under the direct
supervision of the transfusion medicine director. The level of resident autonomy is determined
by the progression of knowledge and experience gained as residents advance through successive

1. Laboratory physician – Clinical consultant. Responsibility progresses from an apprenticeship
   type experience early in training to one of essentially functioning as laboratory director with
   guidance as necessary from the Attending Physician. All medical decisions and/or
   recommendations made by residents are reviewed by the attending physician responsible for
   the services. Residents encounter problems involving the Transfusion or Hemostasis services
   during ―on-call‖ hours (i.e., evenings and weekends). Resolution of these problems may
   require immediate consultation with the attending physician on call or they may require
   follow-up with the transfusion medicine director the next day. All problems encountered by
   residents on call are reviewed and discussed on a weekly basis at the clinical pathology call
2. Teacher. The resident may find himself/herself interacting with medical students or residents
   from other clinical departments. In addition, during the senior years, residents may instruct
   and supervise the activities of residents in their first month of the rotation.
3. Researcher. Although not required, clinically oriented research related to transfusion
   medicine or hemostasis is encouraged. Familiarity with current research activities in the
   department is expected.


While the initial educational experience is influenced by exposure to specific clinical cases, the
resident is expected to reach the general ―milestones‖ (as specifically described under diagnostic
and patient care activities) by the conclusion of his/her transfusion medicine and hemostasis

The remaining competencies not directly related to diagnostic skills are expected to be gradually
acquired throughout the rotation by the mentoring process.


1.     Morning Rounds

       The resident assigned to the Transfusion Medicine service meets/communicates with the
       Attending Physician covering Transfusion Medicine every morning (Monday - Friday).
     During this daily review, patient problems are identified, discussed, and a plan of action
     is derived. This morning review involves the Transfusion Service and the Hemostasis
     Laboratory. Actions taken may include ward rounds with interaction and consultation
     with the patient care teams and/or direction of the laboratory staff on appropriate policies
     or procedures related to the problems.

2.   Didactic Teaching Sessions

     The Attending Physician responsible for the Transfusion Medicine Service provides
     formal one-on-one teaching sessions on the various aspects of Blood Banking,
     Transfusion Medicine, and Hemostasis on a regular basis with the resident assigned to the
     Transfusion Medicine Service. These sessions consist of lectures prepared by the
     transfusion medicine director and audio and video presentations with the director
     providing added discussion. Additionally, the residents are provided the opportunity to
     receive training in immunohematologic procedures from the technologists in the blood
     bank. Some residents have extended the experience by learning to perform many of the
     procedures for themselves.

3.   Additional Conferences and Lectures

     The University of South Alabama Department of Pathology has a monthly Clinical
     Pathology Conference series. The Transfusion Medicine director contributes to this
     series by providing lectures or didactic material on aspects of Hemostasis and
     Transfusion Medicine. The residents are also encouraged to attend the lecture series on
     Hemostasis and Transfusion Medicine provided to the Medical Students of the University
     of South Alabama as part of the undergraduate Pathology course.

4.   Consultations

     The University of South Alabama Transfusion Service and Hemostasis Department
     provides consultation services which involve the residents under the supervision of the
     Director. Areas requiring consultation include immunohematologic problems (e.g., allo-
     and autoantibody problems), transfusion reactions, critical care consultations (e.g., in
     vivo biological crossmatches, exchange transfusion, apheresis), transfusion practice
     (indications for blood components), the use of special diagnostic work-up of bleeding or
     thrombotic disorders, and therapeutic recommendations for patients with bleeding or

5.   Experience at Florida Blood Services

     The resident experience in Transfusion medicine includes time spent at the Northwest
     Florida Blood Center, Pensacola, Florida. This portion of the rotation allows the resident
     to learn about the blood donation process, infectious disease testing, component
     preparation, and apheresis (see appendix A).
6.        Reference Materials

          The Director maintains an extensive collection of reference materials on Transfusion
          Medicine and Hemostasis available for use by the residents. These materials consist of
          current textbooks, specialty journals, an extensive reprint file, educational and regulatory
          publications from the American Association of Blood Banks, and regulatory materials
          related to the Food and Drug Association (i.e. memoranda and the appropriate volumes of
          the Code of Federal Regulations). The residents have used these materials for general
          education purposes, as resources for presentations, and for the preparation of periodicals
          such as the Laboratory Newsletter for Physicians (e.g. Transfusion Risks). In addition, a
          packet of articles pertaining to most of the major areas of Transfusion Medicine is
          provided to all of the residents.


The residents are evaluated by the Transfusion Medicine Physician at the end of the month. The
evaluation is accomplished by completion of the standard departmental resident evaluation form
available on New Innovations. The Transfusion Medicine and Hemostasis supervisors also
complete 360 degree evaluations for each resident at the end of the month. The designated
administrator supervising the resident rotation at the Florida Blood Services completes a written
resident evaluation for this portion of the Transfusion Medicine rotation. The residents complete
rotation and faculty evaluations at the end of each month as well.

Revised April 8, 2008


Curriculum of Pathology Residents is to be enriched by an on-site rotation at the Northwest
Florida Blood Center with emphasis on the following areas:

     1.      Donor Recruitment and Collections
             a. Scheduling – especially coping with holiday periods
             b. Fixed site versus mobile site – planning and logistics
             c. Verifying Donor’s Identification
             d. Donor information – what to know before donating blood
             e. Donor questionnaire – questions and acceptable responses
             f. Donor mini-physical exam and criteria for acceptability
             g. Mechanics of blood collection via whole blood phlebotomy
             h. Mechanics of apheresis collections -- platelets vs. erythrocytes vs. plasma
             i. Special requirements/considerations for military active duty personnel
             j. Directed Donor accommodations
             k. Autologous Donor accommodations – alternative criteria; targeting to hospital on
                date of use; liquid RBC’s vs. frozen RBC’s
2.   Component Production
     a. Centrifugation: plasma & packed RBC’s; versus plasma , platelets, and packed
     b. Leukocyte Reduction by Filtration
     c. Freezing plasma, preparing cryoprecipitate, and monitoring freezers
     d. Culture and sensitivity versus platelet product dipsticks for pH and glucose versus
        ―swirl test‖ as a means to limit bacterial contamination among platelets.
     e. Freezing and thawing Rare Donor units.
     f. Irradiation for congenital immunodeficiency patients; transplant candidates and

3.   Immunohematology Testing
     a. ABO/Rh determinations
     b. Indirect Anti-globulin Testing (or antibody screen)
     c. Alloantibody identification and alternative labeling if alloantibodies are present.
     d. Identification of Rare Donor Units.

4.   Transmissible Disease Testing
     a. Current battery of screening tests performed – EIA vs. NAT
     b. Receiving data from off-site central testing laboratory
     c. Maintenance of test result records
     d. Arranging confirmatory testing for donors with positive screening tests

5.   Quarantine and Disposal of Unacceptable Components (whether by positive test
     results or due to leakage, failure to maintain proper storage conditions, or other
     unacceptable condition).

6.   Component Labeling Process (proper labels for ABO/Rh, expiration date, component
     type and verification that the proper labels are attached).

7.   Hospital Services
     a. Receiving and processing orders for blood products from hospitals
     b. Inventory management -- avoiding outdates; moving products to meet rapidly
        changing patient needs.

8.   Communication with donors re deferrals
     a. Notification of donors re positive test results
     b. If conclusion results in deferral, how is this news communicated.
     c. Are referrals to Infectious Disease specialists offered?
     d. Reporting requirements for military active duty personnel.
     e. Communicating reportable diseases to state & federal (CDC) authorities

9.   Compliance Office Activities
     a. QA and CQI activities
           b.   Tracking new/modified regulatory requirements
           c.   Change control SOP’s and monitoring
           d.   Verification of appropriate FL licensures for personnel
           e.   Supervision of communication with donors re deferrals

   10.     Public Relations
           a. General Public
           b. Hospitals -- Transfusion Services and Administrations
           c. Physicians

Reading Topics:
-Selection and recruitment of blood donors.
-Qualification of blood donors via transmissible diseases and immunohematologic testing.
-Blood donor management of disqualified donors.
-FDA regulation of biologics in the United States.
-Blood Center Operations:
        1. Management
        2. QC, QA and compliance
        3. Manufacturing - blood component preparation, testing, quarantine, disposal, labeling,
        4. Customer Service – hospitals, blood donors, volunteers, recipients, media, and general

AABB Technical Manual
Current Edition of Henry’s Textbook of Clinical Pathology

Basic Contact Information:

Florida Blood Services             http://www.fbsblood.org/
2201 N. 9th Avenue
Pensacola, FL 32503
(850)-434-2535 Telephone
(850)-469-9514 FAX

Stephanie Mutz                        SMutz@fbsblood.org
District Executive Director
(850)-434-2534, extension 206
Roberta Buxton                               rbuxton@fbsblood.org
Secretary to Eugene E. (―Gene‖) Roberts, Jr.
Executive Director

James Picardi, M.D.                       jpicardi@fbsblood.org
Medical Director
(on-site Tuesday p.m. and Wednesday p.m.)

Barbara Holder                             bholder@fbsblood.org
Vice President, Donor Operations

John Holder                                jholder@fbsblood.org
Vice President, Information Technology

Cindy Malcomson                            cmalcomson@fbsblood.org
Vice President, Administration

Jeanne Dariotis                            jdariotis@fbsblood.org
Executive Vice President
Northern Region (Pensacola and Tallahasee)

Francis Dreadin, M.T. (ASCP)                fdreadin@fbsblood.org
Assistant Director, Hospital/Laboratory Services
t Director, Hospital/Laboratory Services

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