EBMT Accreditation

Guidelines on EBMT Accreditation

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Aim of EBMT Accreditation

The aim of EBMT accreditation is to provide an indication of the quality of a Clinical HSCT Programme based on experience in terms of the number of new patients transplanted each year. Length of experience of the programme is also a factor taken into consideration.

Eligibility

Only Full EBMT Member Centres are entitled to apply for EBMT Accreditation. Full membership requires clinical transplant programmes to commit to submitting a minimum of MED A data on all patients on an annual basis. The duty is to report all consecutive haematopoietic stem cell transplants and follow-up data.

Centres applying for accreditation must also confirm their willingness to accept an EBMT audit/on-site visit and to adhere to WMDA and EBMT guidelines.

How to apply for EBMT Accreditation?

Complete the Accreditation for Blood and Marrow Stem Cell Transplants Form then return it to the EBMT Secretariat Office admin@ebmt.org Fax: +34 93 453 1263, together with copies of the EBMT Activity Survey for the last 2 years.

1. Counting transplants:

For the purpose of EBMT Accreditation the terminology used in the 3rd edition of the FACT/JACIE standards is to be adopted i.e. reference to number of 'New Patients'

Definition of New Patients: this refers to an individual undergoing the specified type (autologous, syngeneic or allogeneic) of transplantation for the first time in the Clinical Programme whether or not that patient was previously treated by that Clinical Programme with another type of transplantation.

On this basis:

- an auto followed by an allo within the same programme will be counted as 1 allo transplant and 1 auto transplant

- an auto followed by an auto within the same programme will be counted as 1 auto transplant

- an allo followed by an allo within the same programme will be counted as 1 allo transplant

Accreditation for allogeneic transplantation:

A minimum of ten (10) new allogeneic patients will have been transplanted each year for the last two years

Accreditation for autologous transplantation:

A minimum of ten (10) new autologous patients will have been transplanted each year for the last two years

2. Reporting transplants to the EBMT Registry

In order to qualify for EBMT accreditation it is obligatory to report to the EBMT Registry Minimum Essential Transplantation data (MED A) on all transplants performed over the last two years.

The number of new patients indicated on the accreditation application form will be cross-checked with the data submitted to the registry. Up to a 10% discrepancy in numbers reported will generally be accepted in processing EBMT accreditation applications.

Accreditation is granted for a three year period. Centres who qualify for accreditation will be sent a letter confirming their accreditation status per type and date of expiry. Where a centre fulfils the minimum requirements in terms of New Patients transplanted, but has not reported the data to the EBMT Registry, they centre will be granted Provisional Accreditation for a period of 6 months, by which time the data must be reported to the registry in order to be granted full accreditation per type.

3. Accreditation by team or centre (CIC)

The majority of EBMT Member centres are listed as single Clinical Programmes and will apply for accreditation on this basis. In some cases CICs have been split into various teams (auto/ allo; adult/paediatrics, etc.) either operating as separate Clinical Programmes or as a Combined Programme.

Where a CIC is split into teams, the team can either apply for separate accreditation or accreditation as a Combined Programme. In order to be accredited as a Combined Programme the centre must provide evidence that they operate as a Combined Programme, for example:

- common UPN list
- joint location
- joint staff
- common transplant coordinator
- common waiting list
- shared on-call
- joint training programmes, etc.

The accreditation status will be reflected accordingly in the EBMT Membership List: http://www.ebmt.org/ebmt/members/search4b.htm

.4. JACIE Accreditation:

EBMT Accreditation should not be confused with the accreditation programme of the Joint Accreditation Committee ISCT-EBMT (JACIE), which is a more elaborate process requiring implementation of a quality management system based on the internationally FACT-JACIE Standards.

For full details visit: www.jacie.org

JACIE accreditation means that a centre in principle qualifies for EBMT Accreditation in terms of numbers of patients transplanted. However, this is not an automatic process as EBMT Accreditation also requires that a centre:

• is a Full EBMT member
• commits to following EBMT and WMDA guidelines
• is reporting MED A data to the EBMT registry
• accept on-site audits

For additional information, please contact the EBMT Secretary.