The International Anaesthesia Research Society state that " PBM is not an intervention per se: It is not about transfusion thresholds, appropriate transfusion, intravenous iron, or any other specific therapeutic intervention. Rather, it is the application of the principles of good clinical medicine which include, first of all, diagnosis, followed by the consideration of appropriate patient-specific therapeutic options for management of that patient's diagnosis with patient engagement, shared decision-making, informed consent, and clinical follow-up"." This overall approach is most likely to improve patient experience and clinical outcome" (1). 

Establishing a PBM strategy needs leadership and support at all levels, from national and regional government policymakers to executive management and health professionals from various clinical disciplines within hospitals, and active participation by patients. Patients are at the centre of PBM and active participation of patients in the planning, implementation and evaluation of PBM programs is essential. 
The World Health Organization (WHO) supports PBM and published a policy brief titled “The Urgent Need to Implement Patient Blood Management”; it noted that the PBM paradigm has not been universally employed, and they recommend that implementation of PBM become a global health priority (2). They identified several priorities for action at international, national and hospital level; they also highlighted potential barriers and enablers to implement PBM. 

The cornerstone of a PBM program is the multidisciplinary team

Patient blood management (PBM) improves patient outcomes by improving the patient's medical and surgical management in ways that boost and conserve the patient's own blood (3). The National Blood Authority (NBA) Australia also provides guidance on its use in the elective and emergency pathways.

For PBM to be effectively considered and implemented, it is essential that all healthcare professionals and key stakeholders involved in patient care are engaged in both the planning and delivery processes. This includes at a national (Health Authorities, Health insurances) and local hospital level (Hospital Executives, key Healthcare professionals such as Medical, Nursing and Scientific staff). Equally important is the involvement of patients and community representatives, which helps ensure that any changes remain patient-centered—an established principle in Patient Blood Management (PBM) and across all models of care. 

These stakeholders play a central role in shaping and implementing the decisions and policy changes required to establish a PBM program within a hospital or hospital system, and are directly affected by the outcomes of these changes. 
 

Chapter 1 Figure 1.png

Figure 1. Taken from the World Health Organization (WHO) Policy Brief: The Urgent Need to Implement Patient Blood Management (4).

Key enablers at a national/regional level: 

Government commitment: Strong political will and leadership to prioritize PBM in national health strategies (2)

Develop and implement national PBM policies and guidelines: Supported by department of health and executives

Define key areas for action: In accordance with your own regional /national socioeconomics and potential benefits

Integration into Health systems: Embed into health service delivery plans, electronic health records, clinical pathways (2)

Define the framework: Include governance structure for communication, resources required to allocate funding and personnel to support implementation

Identify professional and clinical standards: these can be used to assess participation and compliance

Develop guidelines and tools: To support implementation and monitoring that can be adapted locally by hospitals

Education and training: Establish national programs to train healthcare professionals in PBM principles and practices (2)

Data and monitoring systems: Establish a national PBM audit program to track PBM outcomes and compliance
Key barriers to implementing PBM at a national/regional level

Lack of Political Commitment: Limited prioritization of PBM in national health agendas and absence of dedicated funding.

Fragmented Health systems: Poor coordination between national blood services, hospitals, and public health authorities.

Insufficient Policy Frameworks: Absence of standardized national PBM guidelines and protocols.

Limited Data Infrastructure: Inadequate systems for monitoring transfusion practices, outcomes, and PBM compliance.

Workforce Gaps: shortage of trained professionals in transfusion medicine and PBM principles.
Key enablers to implement PBM at a hospital level

PBM implementation requires change in culture, behaviour, structural adjustments in health service delivery and redirection of scarce resources. HTC's that are product-centered should be restructured as hospital PBM committees with a focus on Patient Management. Engaging with clinicians and involving them with the development of guidelines is a good starting point to motivate the change in practice and champion PBM (2). 
The following enablers collectively support the successful implementation of PBM, placing the patient at the centre of any decision making. 

Health economics

  • Identifying Main PBM Issues: Focusing on key issues in the hospital. 
  • Holistic Implementation: Embedding PBM into existing systems for sustainability. 
  • Culture and Capacity Building: Maintaining and evolving PBM practices

Policies and Guidelines 

  • National/regional transfusion and PBM guidance supported by the Hospital Transfusion committee (HTC)
  • Adopting guidelines from other SABM, AABB, EMA: Promoting harmonized practices
  • Clinician Engagement: Involving clinicians in the development of guidelines. 
  • Algorithms and Patient-Centered Approaches: Using evidence-based algorithms. 
  • Standards Alignment: Aligning with national and international standards. 
  • Simplified Guidance and Bundles: Providing clear and concise guidelines
  • Digital Tools: Using alerts for transfusion decisions and setting clear goals. 
  • Substitution Potential: Replacing low-value techniques with evidence-based ones. 

Skill Mix and Infrastructure 

  • Job Roles and Leadership: Ensuring the right mix of skills and leadership supporting HTC and
  • Executive Support: Gaining support from executives and finance. 
  • Business Cases: Developing business cases for PBM initiatives. 
  • PBM Practitioners: Roles for transfusion practitioners and nurses in hospitals. 

Multidisciplinary Team (MDT) Members and Champions (motivators)

  • Stakeholders – Includes finance, administration, laboratory staff, medical staff, nursing staff IT, pharmacy, and PBM group members
  • Champions/motivators - Identify clinical champions in key disciplines to implement and encourage PBM practices
  • Terms of Reference (TOR): Clear roles and responsibilities for stakeholders
  • PBMG network: for sharing best practice within the community

Education and training

  • PBM education program - Hospital-wide, including induction training for new staff,
  • Learning from other Trusts and Hospitals – avoid duplication of work 

Communication Channels:

  • Committees/ Groups – Patient Engagement, PBMG/PBM network, stakeholder forums, patient safety forums, regional groups, other hospitals
  • Hospital-wide awareness - Clear messages: posters, intranet, newsletter

Patient Involvement 

  • Patient Information and Consent: Involving patients in PBM. 
  • Patient Involvement in PBMG: Ensuring patients are part of the management group. 

Audit Programs 

  • Continuous Audit Program: Regular audits with feedback and quality improvement plans (QIP).
  • Data and Metrics: Using local and national data for evidence. 
  • National Audit Advocacy: Supporting national audits to reduce costs and improve outcomes
  • IT Systems: that support audits, clinical decision-making, and instant feedback. 
Key barriers to implementing PBM at a hospital level

These barriers underscore the complex nature of integrating PBM as a routine standard of care, involving challenges related to education, awareness, financial constraints, organizational structures, and cultural norms. These barriers highlight the need for a coordinated, multi-level strategy to embed PBM into routine clinical practice.

Education and Training

  • Limited Training Opportunities: A lack of structured PBM education programs for healthcare professionals.
  • Low Awareness of Alternatives: Clinicians may be unfamiliar with or hesitant to adopt modern, evidence-based techniques.
  • Minimal Influence on Institutional Policy: Clinicians often have limited input into hospital-wide PBM strategies.
  • Skepticism toward Evidence: Doubts about the validity of newer evidence can lead to continued reliance on outdated practices.

Lack of Awareness

  • limited understanding of PBM: Among clinicians and hospital staff
  • limited patient engagement: Patients unaware of PBM options and not involved in decision making

Complexity and Stakeholder Management

  • Multiple Stakeholder Involvement: Coordinating across diverse professional groups with varying priorities and perspectives.
  • Differing Priorities

Economic and Organizational Challenges

  • Insufficient Funding: Limited financial resources allocated to support PBM implementation.
  • Lack of Institutional Backing: Minimal support from hospital leadership and administration.
  • Staff Shortages: Inadequate numbers of trained personnel, particularly physicians and clinical staff.
  • Human Resource Constraints: Broader workforce shortages across the healthcare system.
  • Need for SOP Development: Absence of established standard operating procedures tailored to PBM.
  • Inadequate Monitoring Systems: Lack of robust mechanisms to track outcomes and measure impact.
  • Leadership Engagement Gaps: Difficulty securing commitment from senior clinical and executive leaders.
  • Fragmented Collaboration: Siloed working practices hinder cross-disciplinary coordination.
  • Time Pressures: Limited protected time for staff to engage in PBM planning, training, or implementation.

Conclusions

Implementing PBM can feel overwhelming, whether you are just beginning the journey or working to embed an established program more deeply into clinical practice. The scope of PBM touches multiple disciplines, systems, and behaviors, making it a complex but essential transformation. PBM implementation will ideally shift focus from volume-based to value-based care with focus on quality.

However, by identifying your key priorities through structured gap analysis and focusing on achievable, high-impact changes such as updating a policy or refining a clinical process, you can begin to make meaningful progress. These “quick wins” often require minimal financial investment and can serve as a foundation for broader change.

Adopting a phased approach—breaking PBM into manageable pilot projects, allows for gradual implementation, evaluation, and expansion across departments or specialties. This strategy not only reduces operational strain but also helps build momentum and stakeholder engagement. By focusing on successive small improvements, which collectively lead to significant change, goals can be therefore discrete and measurable – ensuring steady progress and can provide clear metric evaluation.

Following the guidance on enablers and being mindful of common barriers can help you tailor your approach to your hospital’s unique context. Whether you're navigating limited resources, infrastructure constraints, or cultural resistance, incremental progress aligned with your health system’s goals can yield both clinical and economic benefits.

Ultimately, PBM is not a one-size-fits-all solution, it is a continuous journey of improvement, collaboration, and patient-centered care.

Resources

Many examples of how to develop and establish a PBM strategy and supporting tools and other materials for patients and staff are available. 
WHO has developed Aides-Memoirs on key topics in transfusion safety to convey important messages to ministries of health and health professionals around safe and appropriate clinical use of blood.

Title of resource

Resource link

WHO Guidance on implementing patient blood management to improve global blood health status (March 2025)

14h45_4 Mar_24025_PBM implementation guidance to improve the global blood health status

World Health Organization Policy Brief; The Urgent Need to Implement Patient Blood Management - 9789240035744-eng.pdf

 

21257_Policy Brief The urgent need to implement patient blood management

World Health Organization Patient Blood Management and Clinical Use of Blood

Health products policy and standards

 

Australian Blood Authority Patient Blood Management Guidelines

Patient Blood Management Guidelines | National Blood Authority

Australian Blood Authority

Patient blood management | National Blood Authority

National Blood Authority Australia

National Patient Blood Management Implementation Strategy 2017-2024 | National Blood Authority

National Blood Authority Australia

National Patient Blood Management Implementation Strategy 2017-2024 | National Blood Authority

PBM England – PBM Toolkit

Implementing PBM - Hospitals and Science - NHSBT

Association for the Advancement of Blood & Biotherapies (AABB) PBM Toolkit April 2021 

Patient Blood Management Toolkit

 

A Global Definition of Patient Blood Management Aryah Shander et al 2022 International Anesthesia Research Society - table 2 ABC toolbox for PBM

A Global Definition of Patient Blood Management - PubMed

 

 

7 Knowledge to Action (KTA) Framework modified for PBM implementation (Table 1)

Improving PBM Programs: An Implementation Science Approach: Anesthesia & Analgesia

PBM "Bundle" Strategy -A 6-block framework

The pillars of patient blood management: key to successful implementation (Article, p. 2840) - Sullivan - 2019 - Transfusion - Wiley Online Library

Systematic Behavioral Framework -Grol’s 5-Step Implementation Model used in the LISBOA study

De-implementation of expensive blood saving measures in hip and knee arthroplasties: study protocol for the LISBOA-II cluster randomized trial - PMC

 

References

  1. Aryah Shander et al 2022 International Anesthesia Research Society A Global Definition of Patient Blood Management
  2. Policy brief: The Urgent Need to Implement Patient Blood Management
  3. National blood Authority Australia  Patient blood management
  4. Section 7. Who will benefit from PBM and how. WHO Policy Brief The Urgent Need To Implement Patient Blood Management

The authors

Tracy Johnston

Tracy Johnston

Patient Blood Management Practitioner, NHS Blood and Transplant, London, UK

Josephine McCullagh

Josephine McCullagh

Vice Chair of the LTH subgroup, Consultant Clinical Scientist, Blood Transfusion, NHS England, London, UK

Divjot Singh Lamba

Divjot Singh Lamba

Clinial Transfusion Working Party Education Subgroup Co-Chair, Post Graduate Institute of Medical Education and Research, Chandigarh, India

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