Saturday, October 23, 2010

'Get back' Jo Jo (Musings on cognitive dissonance)

This blog is about competing blood safety standards and a current conflict that caused me to muse on cognitive dissonance. The title comes from a catchy 1969 Beatles song with silly lyrics.

Cognitive dissonance (CD) is a fascinating thing. I've experienced it several times over the years, ie., the uncomfortable mental conflict that arises when holding incongruous beliefs simultaneously. An example is the conflict that many nicotine addicts feel knowing that smoking is bad for them, yet at the same time managing to convince themselves that it is not that bad, even believing it is "good" for them in some ways (e.g., helps to cope with stress, fit in with peers, etc.)

Currently I'm experiencing CD that started with the
The letter requests a meeting to discuss AABB's concern about TJC's creation of a separate set of blood standards for hospitals. Excerpts:

"AABB was both surprised and dismayed to see that The Joint Commission has determined not to incorporate AABB standards into its most recent proposed standards, but rather to draft a separate set of blood standards applicable to hospitals accredited under The Joint Commission's laboratory accreditation program."

"We do strongly believe that the proliferation of overlapping, but potentially divergent, standards for transfusion services and blood banks is a disservice to hospitals and will actually decrease patient safety as hospitals work to adhere to two separate sets of standards. Further, the time and resources that will be required to ensure that the proposed standards do accurately reflect AABB standards, now, and in the future, are significant."
As mentioned in the letter, AABB standards have existed since 1958 and are widely adopted within the USA and worldwide. I do not know why TJC decided to set up another set of blood standards that do not incorporate AABB standards. The US blood bank community already has an array of compulsory government regulators and voluntary accrediting bodies, including FDA / CBER, AABB, CAP, FACT, and TJC.

That said, regarding the new TJC regulations and their impact on hospital laboratories, AABB-accredited or not, I have no idea about the range of opinions that may exist within the USA. Nor will I wade into the morass of competing blood standards and regulations in the US.

Instead, this blog muses on the cognitive dissonance that unexpectedly occurred after reading the AABB's TJC letter.
For those who do not know, TJC operates accreditation programs for a fee to subscriber hospitals and other health care organizations (> 17,000). Most state governments recognize TJC accreditation as a condition of licensure and Medicaid (health program for low income individuals / families) reimbursement. Like all voluntary accrediting organizations, AABB also charges users for its inspection and accreditation services.
The two competing thoughts:

  • Thought "A": AABB standards are exemplary and, of course, AABB is right in saying, "What the hey! Slow down and reconsider these new TJC standards. This is nuts and could harm patients!" They said it more respectfully, of course, but that's the core message.
  • Thought "B": Yes, all that's true, but AABB has a big investment in its standards and a vested interest in preventing anything that threatens to undermine their primacy. Many of its activities revolve around standards, especially the standards and associated accreditation activities, as well as AABB Consulting
Indeed, standards are arguably the AABB's prime line of business, more important than its role as a professional association. The AABB standards are its main brand. Think of AABB and what do you think of? Standards. If American, think of blood safety standards and what comes to mind? The AABB. Even its mission statement incorporates the term standards:
  • AABB advances the practice and standards of transfusion medicine and cellular therapies to optimize patient and donor care and safety.
In a nutshell:

  • Thought A: AABB is clearly right and has the moral high ground because it's fighting for patient safety.
  • Thought B: AABB is motivated by self-interest and fighting for survival of its main business line.
What to do with the cognitive dissonance that arises? CD theory proposes many ways to reduce CD. Dilbert has several CD-related beauties:
The coping mechanisms in the Dilbert cartoons are discussed in

So, let's see. I could reduce dissonance by thinking as follows (a few examples, some tongue in cheek):
  • "AABB may be motivated by self interest, but it does such good work, I don't care."
  • "TJC is out of line, dead wrong." (I don't know TJC's rationales and would like to hear its viewpoint first.)
  • "AABB does good work. But what it proposes is in its self interest and has to be taken with a huge grain of salt."
  • "TJC is a good organization. It must know what it's doing. I just don't know what the justification is yet."
  • "AABB has jumped at the chance to accredit everything going. It wants to dominate the TM standards world, evidenced by removal of 'American' and 'blood banks' from the name. They are power hungry and will fight to the last standard standing."
For now, the questions remain. Which position is closest to the truth? Who cares? Should we all care?


Interestingly, for years the Canadian Society for Transfusion Medicine has produced
In 2004 the Canadian Standards Association came out with a new set of blood standards, revised in 2010:
This resulted in the need for CSTM to revise its standards to incorporate CSA standards. So with TJC and AABB, some aspects seems like deja vu all over again (to quote Yogi Berra).

At the time I wrote about the impact on hospital transfusion services:


  • "While regulations and standards share many similarities, they differ in one fundamental respect: regulations apply standards through the force of law and provide penalties for noncompliance. Standards, in and of themselves, are never legislative tools. To have the force of law, standards must be incorporated into the regulations.
  • Health Canada is currently developing new regulations specific to blood and blood components intended for transfusion under the Food and Drugs Act. Health Canada will use CSA Standards as one of several tools employed to develop new federal regulations for blood and blood components. Based on the Standards, a goal of the proposed regulations is to outline clear and intelligible requirements, allowing for timely updating as new technologies / products / issues emerge, and achieving greater harmonization in Canada related to blood collection, handling and post-market surveillance.
  • A review of Z902-04 is currently underway [ by Health Canada] to determine which parts can be referenced in the new regulations. Some sections of the standards fall outside of Health Canada’s jurisdiction and will not be referenced in the new regulations."
  • Since the 2004 article was written, CSA Z902-04 has come and gone, replaced by CSA Z902-10, and still no regulations for hospital transfusion services have materialized from Health Canada.
  • CSTM is a relatively small organization yet has had to invest much time and energy to revise CSTM Standards for Hospital Transfusion Services to comply with CSA Z902-10.
Where does all this leave organizations that had been using CSTM Standards? Where does it leave the CSTM Standards?


In the USA, AABB is 'dismayed' that TJC chose not to incorporate AABB standards into its most recent proposed standards and strongly believes that proliferation of overlapping, potentially divergent, blood standards is a disservice to hospitals and will decrease patient safety.
  • Is AABB clearly right? Does it have the moral high ground because it's fighting for patient safety?
  • Or is AABB motivated by self-interest and fighting for survival of its main business line?
  • Are both statements true?
  • Does any of this matter?
Readers can decide for themselves. Perhaps the issues will become clearer as events unfold.

But it's obvious that anyone with AABB accreditation (nearly 2000 institutions, the vast majority in the USA, and no doubt including all of the large transfusion service laboratories) - and any institution thinking of becoming accredited - would be unhappy to say the least. If unchanged, TJC's action will cost AABB-accredited institutions time and energy that could be better spent elsewhere.

In the meantime, the song that comes to mind is this irreverent Beatle ditty, sung here by Paul McCartney in live performance:
Maybe The Joint Commission ('Jo Jo') should get back to where it once belonged?

And for a fun change of pace, since summer has come to an end, at least in my corner of the globe, from AndrĂ© Rieu's 2004 concert in Cortona, Tuscany, a lovely version of

  • The Rose (Carmen Monarca, Carla Malfioletti, and Suzan Erens)
As always, the views are mine alone. Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice.