BLOOD SERVICES

OPERATING MANUAL

Revised September 2019

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FOREWORD

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 TABLE OF CONTENTS
1. Introduction 1
2. Acronyms 2
3. License / Authorization to Operate a BSF 3
4. BSF Personnel Requirements 3
5. Headship of the BSF 4
6. Operations in PRC Blood Service Facilities 5
Blood Donor Registration and Screening 5
Blood Collection 6
Blood Testing 6
Blood Issuance 9
7. Technical Standards 10
8. Physical Facility / Work Environment 11
9. Blood Bank Supplies 12
10. Financial Policies 14
11. Submission of Reports 16
12. Blood Delivery Fee 17
13. Blood Bank Equipment Maintenance 17
14. Training 18
15. Notification and Counseling of Blood Donors 19
16. Participation in Researches 20
Duties and Responsibilities of BSFs 20
17. Blood Donor Recruitment and Retention 20
18. Blood Samaritan Program 21
19. Blood Donor Screening, Counseling and Collection of Blood 22
20. Testing of Blood Units 22
21. Storage of Blood Components and Reagents 23
22. Issuance and Transport of Blood and Its Components 24
23. Centralized Purchasing of Supplies 24
24. Quality Assurance 25
25. Administrative Duties 26
Annexes 28
Administrative Order No. 2008-0008-A 29
Administrative Order No. 2010-0028 31
Department Circular No. 2012-0198 40
Department Circular No. 2013-0132 42
Department Circular No. 2018-0039-A 46
Department Circular No. 2018-0405 72

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1. INTRODUCTION

1.1. The Philippine Red Cross Blood Services operates in accordance

with the following:

1.1.1. National Blood Services Act of 1994 (Republic Act

7719)
1.1.2. Manual of Standards for Blood Service Facilities
1.1.3. Department of Health Administrative Orders
1.1.4. Philippine Red Cross strategic directions and
objectives
1.1.5. Philippine Red Cross Administrative Memorandums
1.1.6. Guide to the Preparation, Use and Quality
Assurance of Blood Components (published by
the Council of Europe)
1.1.7. American Association of Blood Banks Technical
Manual
1.1.8. World Health Organization on Blood Safety

1.2. Copies of the National Blood Services Act and of the

Manual of Standards have been distributed to all PRC
Blood Service Facilities.

1.3. This Operating Manual shall serve as a guide for any PRC
Blood Service Facility and will be the basis for monitoring
and evaluation of BSF anywhere in the country.

1.4. This Manual, will be updated as often as necessary, in part

or in whole. Notification on revisions will be done through
the issuance of Administrative Memo or Blood Services
Circular.

1.5. The words “SHALL” and “SHOULD” indicate a requirement and

must be complied.

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2. ACRONYMS:

BC Blood Center
BCU Blood Collecting Unit
BS Blood Station
BCU/BS Blood Collecting Unit/Blood Station
BSF Blood Service Facility
BPF Blood Service Facility
DOH Department of Health
NBS National Blood Services
NBC National Blood Center
NHQ National Headquarters
NRL National Reference Laboratory
NVBSP National Voluntary Blood Services Program
OPCEN PRC Operations Center
RITM Research Institute for Tropical Medicine
RMT Registered Medical Technologist
RN Registered Nurse
TLT Trained Laboratory Technician
ULT Under-board Medical Technologist
TTIs Transfusion-Transmitted Infections
PAMET Philippine Association of Medical Technologist
PNA Philippine Nurses Association
PBCC Philippine Blood Coordinating Council

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 3. LICENSE /AUTHORIZATION TO OPERATE A BSF

3.1 Every Blood Center shall obtain a License to Operate and

every Blood Collecting Unit/Blood Station shall obtain an
Authority to Operate.

3.2 Obtaining a license/authorization is a function of every

BSF. In cases when the license/authorization is withheld
because of deficiencies, the concerned BSF shall ensure
that the deficiencies are corrected within the next 15
days, otherwise it should voluntarily cease to operate
in that capacity. Information on this decision should be
given to NBS immediately.

3.3 Every BSF shall furnish the National Blood Services a

copy of the license/authorization renewal.

BSF Medical
Classification Pathologist Physician Technologists Nurses Phlebotomists
Blood Center 1 (Head) 1 6* 1 2
(shall work (RMT or
on shifts to RN or TLT
cover a 24- or UMT)
hour
operations**
Blood 1 (Head) 3) 1 2
Collecting (shall work (RMT or
Unit/Blood on shifts to RN or TLT
Station cover a 24- or UMT)
hour
service***)

4. BSF PERSONNEL REQUIREMENTS

4.1 In accordance with DOH requirements, qualified and

trained personnel shall man Blood Service Facilities.
The qualification and minimum number of personnel
are defined in the DOH Inspection Tools for Blood Center
and Blood Collecting Unit and Blood Station.

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 * refer to DOH Department Circular 2018-0405 or the
Revised Personnel Requirements for Blood Centers

** 24-hour operation – the BSF is open and in full

service of its operations 24 hours a day, 7 days a
week.

*** 24-hour service – the BSF is open for a minimum of

8-hours in daytime and shall and must arrange a
system that will cater all the blood needs during
night time.

4.2 Additional personnel shall be hired based on the

output of the BSF. Annually, every medtech in a
Blood Center is expected to produce 1,000 units while
every nurse is expected to produce 2,000 units.

4.3 Every medtech/nurse in a BCU/BS is expected to

produce a maximum of 2,000 units per year. One (1)
physician is needed for every 5,000 units of collection
in one year; 1 clerk for every 10,000, 1 driver for every
5,000.

4.4 A blood service facility shall designate one trained

Donor Recruitment Officer and one qualified Quality
Assurance Officer.

5. HEADSHIP OF THE BSF

5.1 Blood Service Facility standards require that a pathologist

heads a blood center and that a physician heads a
blood collecting unit/blood station. Hiring a full-time
pathologist would be impossible for a PRC Blood Center
the services of full-time and/or part-time physicians
shall be obtained to take their places while the Heads
are not available. Pathologists should be required to
visit the Blood Service Facility at least once a week.

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 5.2 All P R C blood service facilities shall have a physician
trained i n blood banking who will accept
responsibility over the BSF in the absence of a
pathologist, while BCU/BS should have a licensed
medical technologist who will accept responsibility
over the BSF in the absence of the physicians.

6. OPERATIONS IN PRC BLOOD SERVICE FACILITIES

6.1 Donor Screening and Selection

6.1.1 Every BSF shall use the official NBS Blood Donor
Interview Sheet. It will accept only voluntary
blood donors without remuneration, without
regard to gender, rank, race, color, creed,
religion, and political persuasions. The blood
donor medical assessment guide which can be
found in the DOH issued Manual of Standards in
2011 will be the reference guide for the
acceptance and deferral of a blood donor.

6.1.2 All potential blood donors shall be ABO- blood

typed and pass the required screening process
which include but not limited to age, hemoglobin
determination, blood pressure, physical
examinations and other health conditions,
medical and social history.

6.1.3 All PRC BSFs shall repeat the ABO blood typing,
now including the Rh type, in its own laboratory
and will use the method prescribed by the DOH
Manual of Standards which is the tube method
or a higher platform whenever available.

6.1.4 BCU/BS blood samples if found to be ABO

discrepant or typed Rh negative shall be sent
and referred to the nearest PRC Blood Center for
ABO and Rh confirmatory blood typing using the

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 method provided by the NBS before the final
labeling is done.

6.2 Blood Collection

6.2.1 No blood collection shall be done unless the

donor has been declared fit to donate by a
physician who should be within 100 meter-
distance from the BSF during and 10 minutes-
past the blood collection process. Such
physician shall accept responsibility for
whatever problems that may arise from the
blood collection procedure.

6.2.2 Phlebotomy and blood collection shall be

performed only by a trained phlebotomist who
is either a registered nurse or registered medical
technologist or other medical personnel allowed
by law and should use only the prescribed
blood collection materials which include but not
limited to blood bags and apheresis kits,
whenever available.

6.2.3 The physician and phlebotomist shall always

observe the blood donor during and right after
blood collection procedure for any signs of
discomfort. When necessary, the donor should
be managed for adverse reactions in donating
blood. Refreshments and/or rejuvenating fluids
should be given to every blood donor after the
donation process.

6.3 Blood Testing

6.3.1 All donated blood shall be tested for the five(5)

mandatory screening tests by the DOH which
are HIV, HCV, HBsAg, Syphilis and Malaria. These
tests should all be an enzyme-linked
immunosorbent assays(EIAs) platforms or higher

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 in conformity with the NVBSP Technical
Committee recommendations, strategies,
methodologies and algorithms for testing
blood for transfusion-transmitted infection
under Department Circular 2013-0132 and the
World Health Organization’s recommendations
on screening donated blood published in 2009.

6.3.2 BCU/BS shall not release unscreened blood

units. Each BCU/BS should be networked to a
Blood Center where it wil l refer bl ood
samples for testi ng . The BCU/BS should be
responsible for bringing the blood samples (for
testing) to the blood center. Patients or their
relatives should not be allowed to bring blood
to the blood center for testing.

6.3.3 The standard testing fee is P60.00 which includes

the cost of manpower, transport and other
utilities such as water, electricity, etc.

6.3.4 The testing blood center shall i s s u e written or

printed t est results to the BCU/BS after all
the testing are done and complete

6.3.5 The Blood Centers, given the tasked to test

blood samples from the BCU/BS shall release the
test results preferably within 24 hours but not
later than 48 hours from the date and time the
samples were received.

6.3.6 Blood units with initially reactive test results shall

be discarded however sample of which should
be repeated in duplicate to determine the true
result of the screening test and be referred to
TTI-NRL if necessary as required by DOH
Department Circular 2012-0198 (Guidelines for
Referring of Blood Units for Confirmatory Tests to
NVBSP-NRL at RITM).

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6.3.7 Blood samples with repeatedly reactive test
results except for HBsAg and Syphilis should be
referred to TTI-NRL(RITM) for confirmatory
testing.

6.3.8 HBsAg and Syphilis should only be referred to

TTI-NRL based on the conditions set forth by
DOH Department Circular 2012-0198 “Guidelines
for referring of blood units for confirmatory tests
to NVBSP – NRL at RITM”. Blood samples that fall
within the criteria of this department circular
shall be considered as basis for counseling of
donors.

6.3.9 The medical technologist sh all send the blood

sample for referral and shall use the TTI-NRL
confirmatory testing request form to the
Research Institute for Tropical Medicine. The
sample quantity, labeling and packaging for
transport must be within the required criteria
set by RITM so the sample/s may become
acceptable for confirmatory testing. The TTI-NRL
request form should be properly accomplished in
duplicate, 1 copy for RITM and a file copy for the
sending BSF. All PRC BSFs shall refer samples to
RITM based on the instructions stated in PRC
Administrative Memo No. 60 series of 2012
“DOH guidelines for referring of blood units for
confirmatory tests to RITM and PRC NBS
guidelines for sample referral”. Blood samples
for referral may also be sent directly to RITM or
through NBC.

6.3.10 In general, all Philippine Red Cross Blood Service

Facilities shall follow the prescribed “Standard
Blood Testing Algorithm”.

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6.4 Blood Issuance

6.4.1 All blood issuances shall be based on the

presented hospital blood request form
complete with patient’s name, diagnosis, blood
product and type, number of units and hospital
name with the requesting physician’s signature
and license number.

6.4.2 The PRC blood request form shall be

accomplished by the BSF nurse or medical
technologist before issuance of the blood unit, as
a supplementary document for the issuance.

6.4.3 For blood issuances through hospital network, it

shall be based on the purchase order (PO)
submitted by the hospital blood station after
determining the blood requirements or
consumption of the transfusion facility. On a
regular basis, blood and blood products to be
issued will still depend on the inventory of PRC
BSFs

6.4.4 The cost of all blood and blood products of the

Philippine Red Cross are regulated by the
Department of Health. The BSF shall in its own
discretion provide humanitarian assistance to
those who cannot afford to pay (indigency
program) the processing fees. This assistance can
come in the form of discounts or chargeable to a
sponsoring agency partner eg. PCSO fund, blood
samaritan program, etc.

6.4.5 In principle, the Philippine Red Cross shall not

accept “returned” blood after this has been
released or issued to a patient. No return policy is
exercised to ensure the safety of the recipient
wherein the quality of our blood products might
have been compromised because of uncontrolled
storage conditions once the blood units are

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 removed from our preservation and storage
facilities. However, as a humanitarian
organization, the policy does not stop the BSF
in exercising its compassion and comprehension
on the reasons of the return therefore any
“returns” should be decided by the BSF based
on their routine practice, whether it would
accept the blood unit or not.

6.4.6 Contested blood units are those that were issued

or released to a patient but were later returned
to the BSF because of the following conditions:

a) discordant laboratory test results from that

of PRC BSF;

b) quality control checks or product

specifications such as over/under weight,
lipemic or chylous, icteric, etc., blood units.

6.4.7 The BSF shall require the hospital of its official

laboratory findings. Refunds or replacement
should never be processed until the outcome of
the confirmatory test results of an authoritative
body such as the DOH-NVBSP National Reference
Laboratories or validating the findings from its
own laboratory, the Head and QA Officer. This
does not however prevent the BSF in issuing
another blood unit, for humanitarian reasons, but
with a corresponding payment of blood
processing fee.

7. Technical Standards

7.1 The Philippine Red Cross follows the Standards set by the
DOH in the operation of Blood Service Facilities. These
Standards are embodied in the DOH Manual of Standards
which is given to every BSF. Each BSF should ensure that
Standards are complied with.

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 7.2 The Council of Europe Guide to the Preparation, Use and
Quality Assurance of Blood Components, AABB Technical
Manual and WHO on Blood Safety provide details in the
proper preparation and storage of blood components and
should be used as additional references to the Manual of
Standards.

8. Physical Facility/ Work Environment

8.1 Services shall be provided in an environment that

promotes safety, has adequate space, meets the needs
of clients, service providers and other stakeholders and
conforms with the current Manual of Standards of the
Department of Health. B e guided with the revised
DOH BSF Inspection Tools Checklist (Department Circular
2018-0039) and PRC Guide to Set-up a Blood Service
Facility.

8.2 Blood Centers shall have a minimum floor area of 150m 2

while BCU/BS should have a minimum floor area of 100m 2
however, the number and size of equipment and number
of people in each section of the BSF should be considered
to allow adequate space for the movement of people
working in the BSF.

8.3 The BSF shall ensure that the orientation of functional

areas such as donor areas (screening, interview, medical
and blood collection), processing, testing and distribution
conform to good manufacturing practices (GMP). These
areas should be separated from each other and protected
from tampering, contamination and damage.

8.4 The Blood Service Facility shall also ensure compliance

with existing environmental laws and local ordinances in
the management of their generated wastes. Among
these environmental laws are Republic Act 9275 or the
“Clean Water Act of 2004” and Republic Act 9003 or the
“Ecological Waste Management Act of 2000”. These laws
mandate the industries to abate, reduce or prevent air and
water pollution.

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 8.5 The BSF, in compliance with the environmental laws, shall
not discharge wastewater and other effluents
directly into the drainage system and bodies of
water. The BSF is encouraged to install a sewage treatment
plant(STP) in its facility and to adopt systematic,
comprehensive and ecological solid waste management
program to ensure proper segregation, collection,
transport, storage, treatment and disposal of solid waste.

8.6 Solid wastes should be segregated properly in accordance

to the prescribed environmental laws. Infectious materials
such as used blood bags, test tubes with blood samples,
needles, etc. shall be autoclaved first before disposing or
handing these to final disposition area or to a waste
contractor. People handling waste should always wear
personal protective equipment when handling
biohazardous wastes.

8.7 PRC BSFs shall designate a Pollution Control Officer and a

Biosafety Officer to implement these laws and other
pertinent laws concerning health, safety and environment.

9. Blood Bank Supplies

9.1 The following blood bank supplies are purchased centrally

and should therefore be requested from NHQ-Blood
Services utilizing the NBS Requisition Form for Supplies:
a) Blood bags
b) Test reagents
c) Anti-sera
d) Blood lancets
e) Blood labels
f) Blood donor cards
g) Blood typing cards
h) Blood donor interview form
i) Blood request form
j) CuSO4 crystals

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9.2 For chapters that have implemented “hubbing”, shall
follow the additional guidelines in making requisition for
supplies.

9.2.1 Blood Collecting Units/Blood Stations shall

request only supplies for blood collection and
issuance. These include blood bags, typing
sera, blood lancets, blood donor interview
sheet, copper sulfate solution, blood request
forms, donor cards, blood labels, and blood
typing cards.

9.2.2 Blood Centers shall file separate request for

reagents to be used for testing of samples
from BCU/BS. This should be done after
consulting the BCU/BS to determine their target
for the following month.

9.3 Hubbing is recommended because it allows volume

testing and therefore more efficient use of reagents.
Since blood testing is a highly technical skill, only a
proficient medical technologist ie. with HIV and other
TTIs Testing Proficiency Training from RITM shall
perform it. Hubbing and centralized testing are in line
with the quality systems promulgated by the World
Health Organization, the International Federation of Red
Cross and Red Crescent Societies and the DOH.

9.4 Receipt of supplies shall be acknowledged by signing the

Acknowledgement for Delivery Receipt (ADR) form and
returning the form to NHQ-Blood Services within 2 weeks
from time of receipt. The ADR Form comes together
with the shipped supplies and includes information on
the quantity of items received. Any discrepancy in
description or quantity should be reported through a
notation in the ADR and a call to NBS supply staff.

9.5 All reagents/supplies in the manufacture of blood

undergo evaluation at the National Headquarters by the
NBS Quality Assurance Unit.

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 9.6 Reagents/supplies which are obtained by donation may be
used provided they are the same as the
reagents/supplies currently in use by PRC. If not the
same, a sample shall be provided to NBS for
evaluation prior to use. In case of reagents for testing,
only those reagents which are included in the list of
reagents recommended by the Technical Committee of
the National Council for Blood Services should be accepted
for evaluation.

10. Financial Policies

10.1 Policies and procedures particular to the Blood Services

are summarized as follows:
10.1.1 In accordance with the New Cost Recovery
Scheme for the Blood Services (Administrative
Memo #32 s 2015), the following policies shall
be strictly complied with:

a) Implementation of the Blood Processing

Fees based on the allowable service fees
authorized by the DOH.

b) Every blood unit corresponds to a blood

processing fee obligation to NHQ. The
Blood Samaritan Program, thru its
solicited funds subsidizes the BPF of
indigent patients. The Program should be
fully implemented and maximized for
cost recovery.

c) Appropriate sharing of costs and

remittance of BPF based on actual
expenses incurred at NHQ in terms of cost
of supplies, shipment, handling, etc. For
every unit dispensed, the chapter BSF shall
remit an obligation to NHQ based on the
following:

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 Unit Dispensed Obligation to NBS
Whole Blood (450 ml) Php 850.00
Packed Red Blood Cells Php 1,076.00
Washed RBC Php 1,076.00
Platelets, fresh frozen plasma (FFP), cryoppt.) Php 200.00
Apheresis-derived platelets Php 11,000.00
Leukocyte-reduced red cells (L-PRBC) Php 1,400.00
Leukocyte-reduced platelets (L-PC) Php 300.00
Leukocyte-reduced FFP (L-PRBC) Php 300.00

d) Centralize purchasing of supplies

e) Strict monitoring and control of use of
supplies

10.2 Please refer to Admin Memo #32 s.2015 for the

Guidelines on the New Cost Recovery Scheme.

10.3 For the National Blood Centers, all BPF collections shall be
remitted to NHQ.

10.4 BPF remittance in payment of obligations to NBS

should be deposited through local Metrobank branches
to Savings Account No. 3-151-51347-7, which is the
main depository account, placed at Metrobank Anda Circle
Branch Manila. In a Memorandum of Agreement with
Metrobank,

10.5 transaction fees shall be waived. Please refer to Admin.

Memo #2 series 2004.

10.6 Handling of Blood Processing Fee collections:

All BPF collections shall be deposited daily and remittance
to NHQ shall be made on the 10th day of the following
month. BPF collections intended to pay obligation to NBS
should be deposited in Metrobank Savings Account No. 3-
151-51347-7 or should be sent to NHQ together with
the other remittances but should be declared as BPF
collection, to delineate them from other resources such
as Fund Campaign, etc.

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11. Submission of Reports
11.1 Monitoring and evaluation are a very crucial part of
ensuring quality in the Blood Services operation.

11.2 At times when an extraordinary increase in blood demand

arises, as in cases of Dengue alert/outbreak or insurgencies,
additional reports maybe required to enable monitoring of
response.

11.3 The following reports shall be submitted regularly:

Report Date/Time of Submission Remarks

Inventory of Blood Daily (to be Consolidated by NBS
submitted by then to submitted to
chapter BSF to NBS PRC OPCN
at 9 am and 4 pm)
 Service Delivery report Monthly (Day 5 of
BS Form 323 the following
 BS Form 324 List of month)
Indigents
 Pledges for Blood
Donation

DOH-NVBSP and PRC- Quarterly, Day A copy of quarterly

Revised Forms (BM 01- 5 of the reports should be
BM- 08) following submitted to the
month corresponding DOH
Center for Health
Development and
Regional Blood Service
Coordinators on the
same day.
Form 325 (data on Annually, Day A copy of BSI reports
recruited donors) 5 of the should be submitted to
DOH-PRC Blood following the corresponding DOH
Safety Indictor month Center for Health
(BSI) Form Development and
Regional Blood Service
Coordinators on the
same day.

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12. Blood Delivery Fee

12.1 Clients who want to avail of blood delivery service shall be

charged an additional P1,000.00 as delivery fee. (First 30
kilometers to and additional P 50.00 per kilometer).

12.2 Blood units requested by a BSF from another BSF to

serve their locals or augment their blood inventory shall
be charged an additional P500.00 to cover the logistic
costs.

13. Blood Bank Equipment Maintenance

13.1 Equipment maintenance shall be part of the quality

management system of the blood bank, necessitating a
clear policy statement on the maintenance of
equipment in general and supported by Standard
Operating Procedures (SOP). The aim of equipment
maintenance programme is to ensure the maximum
working life of the equipment.

13.2 Preventive maintenance has the following specific

objectives:
a. To reduce the frequency of down time of the equipment
b. To increase its useful life
c. To ensure its safety
d. To reduce its operating costs
e. To determine its weak points
f. To reduce the cost of repairs

13.3 Standard operating procedures (SOPs) have been

developed taking into account the manufacturer’s
recommended preventive maintenance programme
(please refer to your SOP’s distributed in 2006)). Key to
the success of preventive maintenance is compliance by
all concerned, especially in the area of record keeping.
Preventive maintenance is reported to extend the life of
equipment by 1.5 to 2 times as well as saving around 30%

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 of repair bills.

13.4 All BSF shall contract a service provider that would render
preventive maintenance and calibration for all its blood
bank equipment after warranty periods have lapsed on the
equipment.

14. Training

14.1 The BSF in coordination with the National Blood Services

s h a l l provide trainings on Donor Recruitment, Blood
Collection, Blood Testing, Component Preparation,
Storage and Handling of Blood, Quality Assurance,
Apheresis and BSF Management.

14.2 The BSF shall support and encourage its technical staff to
attend other venues of trainings, symposia and workshops
such as those given by PSP, PAMET, PNA, PBCC, RITM, etc.,
for staff development and skills acquisition.

14.3 Training for BSF personnel shall be provided at the

National Headquarters (National Blood Services and
National Blood Centers) or by the Regional Blood
Centers. The National Blood Centers shall provide
training on all aspects of blood banking while the
Regional Blood Centers training shall provide training to
develop capability to operate Blood Collecting
Unit/Blood Station.

14.4 All BSF personnel should undergo training before the

end of the first year of service in PRC.

14.5 Training for personnel lasts for 2 weeks – 4 weeks, and

may be extended depending on the results of the final
evaluation or depending on additional skills which have to
be acquired.
e.g. apheresis.

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 Personnel Blood Center BCU/BS
Physicians 2 weeks 2 weeks
Medical technologists 4 weeks 2 weeks
Nurses 2 weeks 2 weeks
Non-technical staff 1 week 1 week
(clerk,
bookkeeper,
cashier, encoder,
etc.)
15. Notification and Counseling of Blood Donors

15.1 Pre-donation counseling shall be provided to determine

the individual’s suitability to donate blood. This should
also provide donors the opportunity to ask questions and
understand the reasons for donor deferral.

15.2 Post-donation counseling shall be given to donors whose

blood have been found not fit for transfusion because of
positivity to any of the tests for transfusion-transmitted
infections.

15.3 Except for Hepatitis B and Syphilis, notification to the

donor shall be done after the confirmatory test result
indicates POSITIVE. Confirmatory testing for Malaria, HIV
and Hepatitis C virus should be done at TTI-NRL-RITM.

15.4 For Hepatitis B and Syphilis, donor may be notified after

repeatedly reactive results are obtained (Refer to DOH
Department Circular 0198 s.2012; DOH Dept. Circular
2013- 0132).
15.5 Notification shall be done by sending a registered mail
addressed to the blood donor himself.

15.6 Pre and post counseling shall be provided by an HIV and

AIDS counselor, licensed social worker, licensed health
practitioner such as physicians and nurses trained for this
purpose, or a DOH licensed healthcare provider as stated in
R.A. 11166 or the Philippine HIV and AIDS Policy Act of
2018 under Article IV section 31.

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 15.7 Donors whose test results are repeatedly reactive to
hepatitis B and confirmed positive to Hepatitis C shall be
referred, after counseling, to a gastroenterologist for
further evaluation and management. Those with
repeatedly reactive results to malaria and syphilis shall
be referred to the appropriate infectious disease specialist
and those c o n f i r m e d positive to HIV shall be referred
to DOH Treatment Centers/Hub with organized HIV-AIDS
Core Team (DOH-HACT), refer to DOH Admin Order 2009-
2006 or any HCT Facility recognized by the DOH, refer to
DOH AO 0028-2010.

16. Participation in Researches

16.1 Conduct of research in blood banking is strongly

encouraged. A copy of the research proposal should be
submitted to NHQ. Before publishing the results, a copy
of the paper should be provided to NHQ to allow for
discussion and to avoid dissemination of misinterpreted
PRC data.

16.2 In cases when other institutions will require PRC data

for research, the aforementioned requirements also
apply. In addition, a written request should be given to
PRC.

16.3 Ethics in research should be strictly observed.

DUTIES AND RESPONSIBILITIES OF BSFs

17. Donor Recruitment and Retention

17.1 Each PRC BSF shall designate one Donor Recruitment

Officer as required by the DOH Bureau of Health Facilities
and Development. He/she shall be responsible for donor
recruitment and retention so that blood collections will be
achieved as targeted. A DRO can be a registered nurse or a
registered medical technologist.

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 17.2 Conduct an effective public education, advocacy and
marketing campaigns for the promotion of voluntary
blood donation program.

17.3 Carry out the donor recruitment and retention plans and
programs of the Philippine Red Cross (PRC).
Implementation of such plan shall be done by the
identified Donor Recruitment Officer staff of the chapter.

17.4 Donor recruitment program shall target volunteer blood

donors from low risk population who meet defined
selection criteria.

17.5 Implement and execute strategies on donor recruitment

and retention relevant to targeted low-risk population to
maintain efficiency and sustainability and adequacy of
blood supply. (Pledge 25, RC 143, community voluntary
blood donation, students in colleges and universities,
etc…)

17.6 Recruit at least 2% of the total population in each barangay,

town, city and province.

18. Blood Samaritan Program

18.1 Implement an active Blood Samaritan Program to

improve access of indigent and charity patients to safe
and quality blood supply. (Liaison and solicitation of
financial assistance from local government units, private
companies and individuals for Blood Services indigent
clients.)

18.2 Report on a monthly basis to the National Blood Services

(NBS) and PMER the donations received under this
program and the utilization of said funds.

18.3 Blood referral of legitimate indigent clients to a blood

service facility.

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 18.4 Report on a monthly basis to NBS beneficiaries of this
program. (List of Indigent patients and a copy of its blood
requests).

19. Donor Screening, Counseling and Collection of Blood

19.1 Donor screening shall include medical interview, pre-

donation counseling, blood typing, hemoglobin
determination and physical examination of donors
following the Standards on Donor Screening.

19.2 Blood shall be collected from healthy, voluntary, non-

remunerated blood donors properly interviewed,
examined and screened prior to blood donation.

19.3 Collection of blood may be conducted in the premises of

the BSF or during mobile blood donation activity.

19.4 Mobile blood donations shall be conducted in

schools/universities, government or private agencies,
shopping malls, business establishments, factories,
barangays, churches, communities, among others.

19.5 Mobile blood donations shall be regularly and properly

organized so that sufficient stocks of blood are sustained
and periods of oversupply/shortage are avoided.

19.6 Technical personnel who screen blood donors and collect

blood shall undergo sufficient training to assure the
quality of blood collected.

20. Testing of Blood Units

20.1 All blood units collected (in-house and from hub BSFs)
shall be tested to five (5) TTIs at the blood center using
the prescribed methodology and reagents by the
Technical Committee of the National Council of Blood
Services. The PRC NBS shall monitor compliance of
blood service facilities to quality standards. The BC is

22
 required to participate and pass the External Quality
Assessment Surveys (EQuAS) by the NRL.

20.2 All blood units for transfusion must and shall test non-
reactive for the following: Hepatitis B & C, Syphilis,
Malaria, HIV 1& 2 and Hepatitis C prior to issuance. In
addition, blood typing (forward and reverse in tube, gel or
plate method) must be done on each unit.

20.3 Every donated unit found initially reactive to any of the

five (5) TTIs shall be retested twice using the same test
format. A repeatedly reactive donated blood unit shall be
sent directly to the (RITM) for confirmation using the
prescribed NVBSP-NRL referral form.

20.4 When a donated blood unit is confirmed positive for any

of the transfusion-transmitted Infections (TTIs) by the
NRL, the donor shall be recalled for counseling and
referred to t h e H I V - A I D S C o r e T e a m
(HACT) for appropriate management and
counseling.

20.5 HIV-positive cases shall be referred for confirmation,

counseling and management in accordance with the
Flow Chart of Accredited HIV Testing Centers.

21. Storage of Blood Components and Reagents

21.1 The BSF shall have a clear demarcation of stored blood

products under controlled temperature required for each
type of products.

21.2 The BSF shall have a temperature-controlled storage areas

for reagents and adequate dry areas for other materials
and supplies.

21.3 The BSF shall regularly monitor the temperatures, external

and internal, of the cold storage equipment.

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 21.4 The BSF shall practice the policy of “first in – first out” to
avoid or minimized outdated blood products.

22. Issuance and Transport of Blood and its components

22.1 The BSF shall have a system of issuance and transport

of blood and its components following the standards set
by the Department of Health.

22.2 Blood units shall be inspected thoroughly before they are

packed for distribution.

22.3 The BSF shall practice biosafety and biosecurity at all times.
Unauthorized persons should have no access in restricted
area of the BSF such as the laboratory, blood storage area,
etc.

22.4 Cold chain shall be followed during transport and

distribution of the blood products. Components
ordinarily stored at room temperature (+20°C to +24°C)
shall be transported also at +20°C to +24°C. Blood
products stored at +2°C to +6°C shall be transported at
+2°C to +10°C. Frozen components shall be transported
with dry ice to maintain in frozen state.

22.5 Blood units shall be packed and distributed using blood

transport boxes.

23. Centralized Purchasing of Supplies

23.1 Supplies to be purchased at NHQ shall include all

reagents for testing, for blood typing, blood bags,
apheresis kits and lancet.

23.2 NHQ shall provide the standards printed forms for Blood
Donor Interview, Blood Donors Membership Card, Blood
Typing Card, Blood Label and Blood Request Forms.

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 23.3 Request for blood supplies for one month use shall be
forwarded directly to NBS at least two weeks before the
expected day of acceptance.

23.4 Such requests shall be evaluated using the following

parameters:
a) Quantity of blood collection
b) Quantity of units dispensed
c) Amount of BPF remittance and other BS revenues
(this should be equivalent to the expected BPF
remittance stated in the BS Monthly Report)
d) Quantity of remaining supplies and expected
blood collection for the month ahead

23.5 Requests to be forwarded to NHQ should include an

inventory of the remaining stocks at the time of request.

24. Quality Assurance

24.1 The BSF shall establish a Quality Assurance System

consistent with the Standards of the Department of
Health.

24.2 Each PRC BSF shall designate one Quality Assurance

Officer as required by the DOH Bureau of Health
Facilities and Development. He/she shall be responsible for
maintaining the quality assurance system of the facility
by means of monitoring and evaluating the performance
of each operational processes of the facility and if
necessary conduct an internal quality audit so that
continual improvement can be initiated.

24.3 Each PRC BSF shall adhere to and religiously practice the
policies and standard operating procedures as required by
the Department of Health and the Philippine Red Cross.

24.4 Each BSF shall ensure that the license to operate(LTO) or

authority to operate(ATO) is valid and updated. The BSF
Head and the QA Officer shall prepare for renewal of such,

25
 3 months prior to filing an application for renewal and
have been filed 3 months before expiry with the Health
Facilities and Services Regulatory Bureau.

24.5 The BSF’s quality manual, standard operating procedures,

work instructions and other quality related documents
shall be controlled, current and updated and shall ensure
that obsolete documents are properly archived and/or
disposed. The QA Officer shall take lead in monitoring
these quality related documents.

24.6 The BSF shall regularly conduct quality internal audit to

detect possible nonconformities in the BSF’s routine
operations. The QA Officer shall ensure that the results of
such audits be reported to the BSF Head so that
preventive and corrective actions can be taken and thus
prepare the BSF for any upcoming external audit such as
the DOH annual inspection visits.

24.7 The BSF shall regularly conduct a Management Review of

its quality management system, at least annually or after
each internal or external audits to ensure its continuing
suitability, adequacy, effectiveness and alignment with the
strategic direction of the Philippine Red Cross Blood
Service.

25. Administrative Duties

25.1 The BSF Head shall formulate an integrated yearly budget

of blood service facility and chapter based on plans and
programs of the PRC. Coordinate with the Blood Service
Head regarding blood services budget.
25.2 The BSF Head and persons authorized by him/her shall be
responsible for the daily collection of blood processing fee
(BPF) and;

25.3 Shall regularly remit blood processing fees to NHQ according

to the prescribed obligations on remittance.

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25.4 The BSF Head shall implement PRC Administrative
memorandum issuances in accordance with policies, e.g.

1. Supplementary and Extra Compensation- Per diem rates,

meal allowances

2. Career Development - attendance to blood bank

convention, symposium, training, partners’ meeting,
etc.)

25.5 Remittance of salaries of blood bank personnel to NHQ.

In addition to the above obligation to NHQ, an additional
remittance to cover the salaries of blood bank personnel
from every PRC BSF is expected. The amount shall depend
on the actual payroll for the Blood Services staff.

25.6 Maintenance, improvement and expansion of BS facilities,

equipment and services. Surplus funds from the Blood
Processing Fees after the payment of BS operating
expenses and supplies shall be used for the purpose above.

25.7 Hiring of blood bank personnel.

The Chapter Administrator shall assess the behavioral
competency while the BSF Head shall evaluate the
technical competency. The two competency quality
indicators are basis prior for final recommendation to HR
office.

25.8 Administration of Personnel (Attendance, uniforms,

identification cards, proper housekeeping).

25.9 Implementation of Career Movement (re: promotion &

merit).

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