Integrating Immunotherapy and Bone Marrow Transplant Clinic Operations Policies for FACT Accreditation

Abstract

Topic Significance & Study Purpose/Background/Rationale Our Blood and Marrow Transplant (BMT) center is part of an NCI-designated cancer center that performs nearly 500 transplants a year. Historically, it was a free-standing hospital/clinic and in 2001 became part of a larger clinical alliance. BMT Physicians manage clinical care and research. Standard Practice guidelines were established with physicians based on the need for standardized care and to educate rotating medical personnel. In the last 25 years BMT care has transferred from hospital to the Ambulatory Clinic. BMT Ambulatory Nurse Management recognized standardization of Operational Policy was essential. This work became the basis for creating the policies required for Foundation for the Accreditation of Cellular Therapy (FACT). Methods, Intervention, & Analysis The BMT clinic managed patient care and staff orientation when chimeric antigen receptor (CAR) T-cell therapy first began at our institution. The Immunotherapy (IMTX) Clinic is now separate from the BMT Clinic but many clinical care guidelines remain similar. It was determined that the IMTX clinic would fall under the BMT FACT accreditation standards, as our needs for accreditation are intertwined. BMT maintains Operations Standards for adult/pediatric inpatient/ambulatory care across three geographic sites of practice. IMTX operations guide adult inpatient/ambulatory care across two institutions in our alliance. Findings & Interpretation BMT and IMTX maintain Operations Standards by review through the Transplant & Immunotherapy Clinic Operations Team (TICOT). TICOT membership includes all departments providing services to BMT and/or IMTX patients and in each institution with patient care involvement. Policies each have designated owners and are distributed a month prior to the meeting when due for revision. At monthly cross-institutional meetings, policies are collaboratively reviewed and approved for the central policy data base. Discussion & Implications Changes in 2015 transferred policy management to the BMT Nursing Supervisor with BMT Medical Director oversight. The IMTX clinical staff is responsible for reviewing policy and addressing the differences to cover IMTX FACT requirements. BMT/IMTX designated CNS reviews policies to assure alignment with FACT standards. Nurse leaders most familiar with clinic operations are critical to the process of policy creation, implementation, revision and maintenance for the best standards of care and practice in BMT/IMTX cellular therapy care delivery.