University of Utah Blood and Marrow Transplant Program

The University of Utah Blood and Marrow Transplant Program began at the University Hospital in Salt Lake City in 1990. Since that time the program has continued to grow in scope and currently performs transplants for several other institutions including Primary Children’s Medical Center and Huntsman Cancer Institute. The three institutions each have inpatient and outpatient units. A single stem cell laboratory provides services for these programs as well as Intermountain Health Care Transplant Program. In total the programs perform approximately 300 transplants per year, equally distributed between autologous and allogeneic.

Our program has been FACT accredited for 10 years, representing three accreditation cycles. Our approach to the initial accreditation was somewhat disjointed, lacking a single team leader. The three distinct areas (clinical, collection, laboratory) worked somewhat independently to implement the standards and gather documentation. We underestimated the time frame and scurried in the final weeks before the inspection to put everything in place. The inspection went well, however, and we were able to identify bottlenecks to help us streamline the process for future inspections. A year prior to the second accreditation process, a team was established that met monthly and then weekly as the inspection date neared. This approach allowed for a more effective preparation process, however, several areas in the standards were identified in which we had been unable to keep updated, specifically standard operating procedures review, quality assurance, and document review. To address these issues, the program created a full time position for a Quality Assurance Manager for the clinical and collection programs. Designated quality assurance individuals had already been assigned for the laboratory. Currently, compliance issues are addressed on an ongoing basis, minimizing last minute planning and enhancing the overall quality of the program.

There is program-wide support, from the top down, to comply with FACT standards and maintain accreditation. FACT accreditation is recognized as a measure of the quality of our program by all faculty, staff, and administrators.

Key points to consider:

• Secure support from Program Leaders and Administrators
• Designate a full time Quality Assurance Manager
• Commit to compliance on a daily basis
• Identify program bottlenecks and work on real solutions



FACT Consulting

Accreditation Success Story

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