Modeling global transfusion medicine education

Education, and in particular higher or academic education, was until relatively recently the privilege of clergymen and the upper class of societies. With the 18th Century enlightenment, this privilege slowly came to an end, lasting till the mid-20th Century in the immediate post World War II years when the young and driven United Nations documented the Universal Human Rights,1 which includes the right of education. 1948 – United Nations (UN) Universal Human Rights' Declaration: During ensuing decades societies changed, movements toward decolonization started and, in general, public awareness of the principle human rights gained acceptance. Yet there is a major difference between the advanced world, home to around 18% of the global population, and the less to poorly advanced part of the world, home to the larger 82% of the global population. United Nations Development Program (UNDP)2 as well as the World Bank3 mapped the world according to a number of development indices and indicators, illustrating the existing socioeconomic gaps and the huge diversity of states of development and its consequences. As a result, the UN introduced and launched a major human development program at the turn of the last Century—Millennium Development Goals 2000–20154 with strong emphasis on education to bridge the existing knowledge and socioeconomic gaps. In light of the progress achieved, this was continued with another 15-year program: 2016 – UN Sustainable Development Goals 2016–2030,5 goal number 4 of the 17 focuses on quality education, stating: “Ensure inclusive and equitable education and promote lifelong learning opportunity.” The sub-goal 4.3 reads: “By 2030, ensure equal access for all women and men to affordable and quality technical, vocational and tertiary education, including university.” To more effectively approach the major threats of poverty, hunger, and health, education was given a high priority. Unfortunately, besides protracted sex inequality, poor economics continued to dominate social and economic life, seriously impacting healthcare. In a large part of the world millions of people are forced into poverty due to poor access and unaffordable expenditures. The World Health Organization (WHO) and UN responded with the Model Lists of Essential affordable and available Medicines6 and in vitro Diagnostics,7 and the Universal Health Coverage (UHC) initiative.8, 9 In 2020, WHO launched the Action framework to advance universal access to safe, effective, and quality-assured blood products, 2020–2023, with six strategic objectives.10 Strategic objective six on partnership, collaboration, and information exchange to achieve key priorities and jointly address challenges and emerging threats at global, regional, and national levels presents among others two learning and training activities. Recently the World Health Assembly endorsed a protective patient-oriented safety initiative to enhance awareness of effective hospital care, including blood transfusion: 2019 – World Health Assembly Resolution WHA72.6 “Global Action on Patient Safety”11: Article 2 (8) reads: “to build sustainable human resource capacity, through multisectoral and interprofessional competency-based education and training, based on WHO patient safety curricula and continuous professional development, to promote a multidisciplinary approach, and to build an appropriate working environment that optimizes the delivery of safe health services.” In response to this resolution, the WHO drafted the “Global Patient Safety Action Plan 2021–2030 “Towards Eliminating Patient Harm in Health Care,” which is currently being implemented.12 Still, the Sustainable Development Goals (SDGs) 2016–20305 require new indicators for assessing the many faces of inequality in, for example, education, the impact of the global environmental and pandemic crisis on people now and tomorrow, the importance of voice, and the ways in which communities, rather than individuals, are progressing. These and many other topics should be re-examined through a human development lens, with holistic orientation toward the future. Ministry of Education, Government to guarantee formal recognition and license (diploma); policy making and overall supervision and control. Formal: Vocational and higher education institutes (Medical Laboratory Professionals [MedTech] schools, Nursing schools; Medical Schools, Universities); Informal: operational supplier and consumer institutes (Blood Establishments/Banks, hospital blood transfusion services). Delegated by Government (Ministries of Education) to the professional peer group and based on the local and national needs and opportunities; Government policy, health care system and organization, stages of development, educational approach (outcome-based, problem-based, blended learning, and so forth; principles of adult learning in education, modern methods of teaching), possibilities for implementation of international recommendations for example, 2010 UN Universal Health Coverage program,9 2013 WHO Model List of Essential Medicines,6 2018 WHO Model List of in vitro Essential Diagnostics.7 Utilizing the model for the vocational and academic development and implementation of a Certificate or Diploma in Transfusion Medicine (graduate or post-graduate) requires the acknowledgement of the issues listed in Table 1. The Transfusion Medicine vein-to-vein concept follows three levels of processes for which basic knowledge and skills are required (Table 2). Primary processes (core business) Vocational: Societal-/community-based: role of voluntary blood donor and community awareness issues. Technical-/procurement-based: collection, processing, Quality Control (QC)/testing, storage and distribution (cold chain), hygiene and asepsis, risk management, and waste management. Blood group check and pre-transfusion compatibility testing, stock control (hospital), and adverse transfusion events. Medical (HE/academic): Medical operations (blood establishment/bank)—donor selection and blood collection (responsibility), component selection and testing, hygiene and asepsis maintenance, risk and waste management control, and clinical consultation. Hospital (prescriber)—indication and decision making, informed consent, ordering, bedside practice (Patient Blood Management/PBM), patient care, adverse event handling and hemovigilance. Supportive/Secondary processes (Management/infrastructure support) Leadership, management, implementation strategies (logistics, technical/engineering, and domestic), Quality Assurance (QA), and Quality System Management (QSM)—overarching; standards, documentation, and assessment; education, hemovigilance, improvement, and development (research). Steering processes (top management, translation of governmental policies, regulations, and standards) Blood Establishment/Bank: Top management and leadership, liaison with community, consumers (hospitals) and politicians (accountability, strategic inputs), managerial and operational responsibility (product liability), environment, education and development strategies, regulatory and contract aspects, and Total Quality Management (TQM). Hospital/patient care: Transfusion policy (per discipline); consumer rights protection, overall patient care and blood management (PBM) and outcome evaluation (hemovigilance), bridging with blood establishment (supplier), regulatory aspects, and QSM. Both: Costing,14 financing, and budgeting of vein-to-vein activities in the blood establishment and hospital blood bank. The importance of knowledge of the principles of costing is grossly underestimated, because most blood establishments and hospital blood banks in low- and middle-income countries do not understand how to develop a costing structure for blood services. Hence, this leads to incapability of appropriate financing and finally leads to failure in budgeting. All these need to be considered when a model framework is provided as all students from any background should receive training that is relevant to their own particular contexts, while also being made aware of the practice of Transfusion Medicine in other contexts15 as presented in Table 3. The recent (September 2020) eLearning Africa/EdTechHub report on the “Effect of COVID-19 on Education in Africa and its Implications for the Use of Technology (ICT)”17—a survey of the experiences and opinions of educators and technology specialists from 52 countries in Africa—provides a wealth of information and illustrations regarding the wide differences between countries on just one continent, which we may use when designing a harmonious model framework for Transfusion Medicine education. The results of the two AABB Global Transfusion Forum (GTF) Education Subcommittee survey findings18, 19 provide valuable insights for the design of such model frameworks (medical, nursing, and technical). The framework or model recognizes that no one set of education or training initiatives will be appropriate in all countries or settings and should be tailored to specific settings based on the assessment of local needs.24 Fundamental and universal standards for operations25 and management in Transfusion Medicine as key elements of a quality management system to achieve basic safety and efficacy in the blood supply and clinical use. The model aims to provide a basic structure and infrastructure needed for sustained and tailor-made transfusion medicine education at all levels and irrespective of the developmental stage. Successfully implementing such a model framework also requires the recognition of role players, including their needs and functions.26 Their contributions and involvement are significant in the development, implementation, and monitoring of a Graduate Certificate or Postgraduate Diploma in Transfusion Medicine (medical, nursing or laboratory science). In specific instances, policy and regulatory frameworks require that certain procedures be followed, and conditions met in order to obtain official recognition and accreditation for a (new) program. Role players who are considered relevant to a Graduate Certificate or Postgraduate Diploma in Transfusion Medicine can be divided into internal (from within the education institute, including students) and external role players (e.g., government, professional associations, blood establishments, and hospitals). Having formal agreements, or at least a memorandum of understanding (MoU) between the institute developing the diploma, the blood establishments, and the government is likely to contribute to the success of such a program. Furthermore, existence of government regulation concerning requirements for formal education in Transfusion Medicine for personnel involved in blood services will also contribute to the success of the program especially in low- and middle-income countries. Advantages of networking and cooperation include the sharing of resources, ideas, innovation, human resources, incorporating both the theoretical and practical aspects of Transfusion Medicine as well as professionalism, stewardship and leadership aspects, improved marketing, workload sharing, and subsequent cost savings. Acquiring buy-in and involvement from all stakeholders through consultation would increase the chances of having a single, tailor-made high-quality program, rather than duplication with several small, fragmented, and potentially ineffective programs in a single country. Networking may also expand the strength of all stakeholders, both individually and jointly. An effective network is underpinned by relationships/role players, and is key to collaboration toward achieving a common goal and meeting the unmet needs in the field. Furthermore, networks need to be maintained by ensuring robust communication between role players, particularly during periods of change, for example, pandemics and humanitarian emergencies. It is therefore critical to identify relevant role players and stakeholders at an early onset and identify areas of mutual interest and potential cooperation. The roles that each party/stakeholder will play should be discussed, negotiated, and documented. In determining these, the major perspectives and needs of both the program provider and stakeholders should be considered and agreed upon. Furthermore, the relationships and the responsibilities of the various role players need to be strategically considered to ensure smooth and effective collaboration, recognizing that roles may change over time. For the design of a global Transfusion Medicine education model framework, an analysis of competencies and operational and managerial skills in the vein-to-vein transfusion chain is needed, based on the identified primary, secondary (supportive), and steering processes of the chain.27 The primary processes consist of the core business functions of the vein-to-vein transfusion chain, divided into the supply and consumption part (Table 4A). (1) procurement/manufacturing or supply part: (2) consumption or clinical part: These functions/positions need personnel with a secondary education background and a vocational (medical technicians/laboratory professionals, nurses, finance and administration/business) or academic (medical, pharmaceutical, business/MBA) higher or tertiary education. The supportive or secondary processes contain for both the procurement and the clinical aspects (Table 4B). These functions/positions require for the ancillary supportive part a minimal primary education background, and for the supportive infrastructure (Human Resource Management [HRM], Finance & Administration [FA], engineering) a secondary education background followed by a vocational and/or managerial education at higher education (HE) level. The steering processes relate to senior management (procurement and clinical use) and consist of policy making, strategy design and implementation, guidance, governance, overall education including continuous professional development (CPD), Public Relations (PR) and representation, quality management, planning (medium and long term), economics and budget accountancy. These functions/positions need well-developed leadership, stewardship and governance capacities at HE or academic level; a higher administrative education (e.g., MBA) is certainly an asset. The approach illustrates the need for an existing human resource pool of primary, secondary and HE/tertiary educated potential. The 2018 UNDP Human Development Indices and Indicators,28 and the 2020 eLearning Africa/EdTechHUB17 reports illustrate the differences in education enrolment ratios from primary into secondary and from secondary into HE/tertiary education between the four UNDP Human Development groups. The Very High, High, and Medium Human Development Index (HDI) groups of countries do have a good enrolment ratio from primary into secondary education (100%, 96%, and 72%, respectively). However, the enrolment ratios from secondary into HE/tertiary education of these three groups are, respectively, 72%, 50%, and 24%. The Low HDI group of countries shows an enrolment ratio for primary into secondary of just 43%, and of only 8% from secondary into HE/tertiary education. Eliminating certain key inequalities in education in medium and low HDI countries, such as the “gender gap,” tribal obstacles and poor economics in learning outcomes, by no means would be sufficient to ensure adequate learning levels. Eliminating such gaps will not solve the learning crisis. Focusing on “systems-related inequality” and “learning poverty” linked to poor mastery of basic knowledge and skills as a result of poor-quality schooling (primary, secondary, or tertiary) is likely to be the most productive approach to improving equity. This is most clearly understood in terms of minimum level standards, but also in terms of impartiality and redistribution, when appreciating that inequalities in “opportunities to learn” differ significantly not only according to individual student characteristics.29 These data reflect the paucity and/or capacity limitations of existing vocational and academic education institutes and systems, and their respective number of graduates (medical technicians, nurses, and As a result, there will be a in quality of education and and professional education and of these the more specific Transfusion Medicine the of and/or training programs in the low and medium HDI countries is with the higher HDI countries. technology to bridge this by having blended and learning and presented jointly by local and international at relatively low cost with no need for to These two activities to design a all universal Transfusion Medicine curricula model framework that as a tailor-made and for education on the diversity of competencies and needed in the operations and management of the blood supply and clinical transfusion Development of stewardship and leadership in an early is of the needed vocational and professional of to be in any part of the vein-to-vein Transfusion Medicine chain, the as in Table This analysis illustrates the need for personnel in a secondary education background that continued education at a higher HE and academic level to as a vocational These vocational the pool of for a Transfusion Medicine and operational or managerial within a blood establishment (procurement or hospital transfusion or The goal is improving patient safety and health Unfortunately, the pool of these graduates is in and countries ratios and 8% and ratio in high HDI a for a at that professional level in the blood supply and and the risk for a of from the blood supply institutes or Blood to larger establishments and with a larger and more and more advanced transfusion The analysis also illustrates that the educational and emphasis to three groups or of health to be nurses, and laboratory professionals, by ancillary personnel who do not need a specific Transfusion Medicine education. ancillary personnel require a primary or secondary education background and may receive or education and training to the professional hygiene and and basic risk and management, in with their respective roles and Education on and stewardship is at early of and training, appropriate to the role and of the various ancillary model for the development and implementation of an education and in Transfusion Medicine at students and nurses, and and laboratory should include an with recommendations on the required and knowledge of a such a This should to the environment and of practice required from such a vocational or academic professional and should address in and the is while into international standards of knowledge and the needs of their working and is considered more practical to provide a set of that would be in most and while as adult with the for their professional and leadership development to their and Having a set of will a key component of the to be not only to the vocational higher education and academic and the education that with development, but also to required by governmental regulatory the these may be as a framework around which an or Transfusion Medicine and training program should be and The major identified are as in terms of knowledge of basic and relevant the principles of blood and Transfusion clinical blood blood social and However, one needs to that the elements listed for each of the four groups of within these do not a and may need to be with elements to professionalism, stewardship and leadership, of development, of and the education for the development of a set of outcomes, one that all the of the major or at least by of students laboratory professional and and nursing and can be in To students who to be involved in the of blood and/or transfusion of on a for the and the can be listed (Table To who are involved in the of blood and transfusion of on a for the and the can be (Table To laboratory who are involved in the of blood and transfusion of on a for the and the can be listed (Table To nursing personnel involved in the collection of blood from or transfusion of on a for the and the can be listed to which transfusion and patient and appropriate should be to the as listed in Table All and learning areas be underpinned by and professional and quality and safety Education in transfusion medicine is a set of and that student and to knowledge and the The to which knowledge and and leadership principles are on the for the needed and This to all including and Transfusion the safety of clinical includes blood transfusion at the for which a quality procurement or system needs to be based on and standards as a to guarantee health and patient clinical with knowledge is the government leads on the infrastructure and environment and for learning, educational vocational schools, and their can on a and practical education for their students and can practice when working toward an of continuous development and of quality As the in education with their leadership and should have the to and and can that educational and These can into the national education and for peer learning among education institutes and their the primary will be the responsibility of national there are several areas a approach be local role players, and education and professional or societies should build an appropriate component into the model framework a into all learning, any student or need to be for poor include and curricula or failure to at the right besides poor access to technology and other may to to the while students and However, one needs to be in as the and socioeconomic are and The to their to and and for their and The have no of The is not for the or of any information by the than should be to the for the

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