Quality without a mandate: An exploratory national survey of perioperative autologous transfusion accreditation barriers

BACKGROUND: Perioperative autologous transfusion, encompassing intraoperative cell salvage (ICS), acute normovolemic hemodilution (ANH), and autologous component production, is integral to patient blood management. Association for the Advancement of Blood and Biotherapies (AABB) has published comprehensive quality standards, yet perioperative accreditation remains profoundly underutilized; fewer than 10 U.S. institutions are currently accredited. No prior study has characterized these barriers. METHODS: The AABB Perioperative Accreditation Committee administered a six-item electronic survey to AABB members in August-September 2023, addressing services provided, program oversight, quality control (QC), governance, and accreditation barriers. Fifty-seven complete responses were analyzed using descriptive statistics. This study met criteria for Non-Human Subjects Research self-determination. RESULTS: Seventy percent of respondents (40/57) reported providing perioperative services. Only 60% expressed a positive level of comfort with perioperative program oversight and patient safety; 28% were neutral and 12% were uncomfortable. More than one in four (28%) confirmed the absence of formal QC or did not know whether any was performed. No single discipline dominated governance, and 25% reported fragmented, unclear, or absent oversight. The most frequently cited barrier was that accreditation is not required, endorsed by 53%. CONCLUSIONS: Perioperative autologous transfusion programs in the United States often operate without the quality oversight applied to every other blood component service. The dominant barrier is not cost or complexity but the absence of external accountability. Existing oversight through The Joint Commission, the College of American Pathologists (CAP), the Centers for Medicare & Medicaid Services (CMS), and AABB's Blood Bank and Transfusion Service (BBTS) accreditation does not extend to perioperative operations in any program-specific sense. Practical frameworks exist; adoption requires action from professional societies, hospital leadership, and regulatory bodies.