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CRI Lab Quality Advisor

Adding New Staff to an Old Team
October 6, 2015 8:00 AM by Irwin Rothenberg

Sometimes, you have the good fortune to find qualified staff within a short time to replace those who have left, minimizing the disruption to your daily routine. More often than not, it takes a while to find the “right” person for your lab. In the meantime, the remaining techs have to take on extra shifts, work in other specialties or take on additional responsibilities. So, everyone’s glad when a qualified “newbie” has been hired.

This is the time to have a comprehensive orientation and training protocol in place not only for the purely technical responsibilities of the position, but to facilitate their integration into the working culture and value system of the laboratory. This is important for the smooth transition from being an “outsider” to an accepted member of the team. Institutional culture is a combination of commonly agreed upon values, behavior, performance and expectations for the work environment.

The institutional culture of the laboratory is characterized by expectations that peer behavioral and performance standards for work will be met. This not only refers to technical competencies, but also to social-interactive competencies such as whether it is okay to be connected to your iPod while working; the frequency of personal calls or texting; or rotational preferences. It also defines the consequences of not meeting these standards and how tolerant the rest of the staff is when these occur.

None of the examples above are meant to diminish the importance and right of individuals to be who they are, but to promote how vital it is to have an awareness of your “mini-society.”

Culture is also defined by the type and direction of communication. Is yours a top-down or a bottom-up lab? The former is where decision making primarily flows from supervisors and managers to staff; the latter is where staff participation in decision making is encouraged and appreciated. If a new employee is unaware of this dynamic, there can be problems.

Of course, these dynamics are not usually incorporated into job descriptions or the Human Resources handbook, but a lack of awareness of group dynamics can contribute to an uncomfortable work environment. An assigned mentor who can provide both cultural and technical orientation and training will increase the probability of successfully retaining the newly hired member of the laboratory team. 

Laboratory Testing: Reflecting Our Changing Society
September 18, 2015 5:54 PM by Irwin Rothenberg

As laboratory professionals, our focus on quality begins by looking inward at our operational processes -- from specimen collection to result reporting. But the application of this work is then externalized, sent to the ordering physicians and applied to their patients.  The way we perform and report our work and its effect on patient care ultimately affects the greater community.  This we already know, and it is one of our strongest motivators to maintain the best quality possible.  What we may not see as clearly is how changes in the world around us are constantly impacting our own work environment, challenging established routines and time tested views of our profession.  

While change brings up thoughts of new tests, new instruments, new procedures and more training, it can also require conceptual re-orientation of what we are achieving.  An example of this is the emergence of genomics and genetic testing, enabling the rise of personalized medicine. Our test results contribute to the development of individualized treatment protocols

But we also live in an era where laboratory testing has become intertwined with political, social and technological change to a degree unheard of in years past. Laboratory testing has always been in the epicenter of efforts to control and monitor disease outbreaks, such as HIV (with all the attendant societal issues surrounding it). Now, we are in the midst of an epidemic of illicit drug usage, particularly prescription pain killers like opioids and opiates.

This category of laboratory testing is the fastest growing not only in the United States, but in the UK, Japan, Germany and other European countries. Illicit drug users now exceed 315 million globally, approximately 6.9% of the global adult population. Imagine the unmet need for additional laboratory testing: drug screening, confirmation and monitoring. Progress in dealing with this epidemic cannot be made unless our work is accurate and reliable.

Additionally, we cannot help but be part of preparation and planning regarding the possibility of bioterrorism. Whether we are in public health, the hospital, the physician office or reference laboratories, we will be involved.  Our concerns range from disseminated Anthrax to Yersinia pestis (plague) to everything in-between. The importance of the quality of our work extends far beyond immediate patient treatment to a new and higher societal level.


1. Drugs of Abuse Testing Market-Global Industry Analysis, Size, Share, Growth,Trends and Forecast to 2018.

Assess the Quality of Your Waived Testing
September 2, 2015 9:30 AM by Irwin Rothenberg

According to CMS, there were 229,815 laboratories in the U.S. , in 2012, of which 150,256 were Certificate of Waiver sites. Stated another way, this means that some 65 percent of laboratories in the U.S. do not have any routine oversight. The number of waived tests has grown from just 9 tests in 1993 to 119 analytes using more than 5,400 test systems. From diabetes management and monitoring anti-coagulant therapies to screening for infectious disease, waived tests are now an integral part of patient care. Laboratory professional groups have long recognized the need for increased oversight of these waived tests, and unfortunately, evidence is mounting that significant quality problems exist in the largely unregulated labs relying on these.

According to a report from the Centers for Disease Control and Prevention, for example, 31-43 percent of waived labs do not follow manufacturer’s instructions. Some other examples of notable problems among the more than 150,000 waived testing sites in the U.S. include:

-              More than 20 percent do not routinely check the product insert or instructions for changes to the information
-              More than 20 percent do not perform Quality Control testing as specified by manufacturer’s Instructions
-              Nearly half do not document the name, lot number and expiration dates for tests performed

How can we deal with these issues using direct action that produces relevant measurable results within discrete time frames? I suggest the following five activities as effective strategies to assess the state of your waived testing, which engage your staff in this campaign for excellence:

1. Self-assessment of the waived testing performed
2. Competency assessment of staff performing waived testing
3. Proficiency testing for your waived test menu
4. Quality assessment of how your laboratory handles waived testing issues
5. Continuing education for your staff engaged in waived testing

Any or all of these can be carried out independently of the rest; you can choose which to use for your determination of quality performance; and all can be compartmentalized and measured within discrete time frames or events, including continuing education.=

The idea is that, to improve the quality of your waived testing, you choose the activities most suitable to your laboratory that achieve relevant measurable results and provide information you can act upon and measure improvement over time. Choose assessments that motivate and educate your staff. This promotes buy-in and commitment to continuous improvement.

Don’t Be Careless About Lab Safety
July 13, 2015 1:50 PM by Irwin Rothenberg

One of the top priorities for every laboratory should be the safety of its employees facilitated by creating a culture of safety consciousness, education, organization and accountability. Managing safety is more than having a top-down list of dos and don’ts, viewing educational videos, providing protective wear and having policies for incident management. A safe lab environment requires an ongoing active involvement by everyone. It’s about having strategies for prevention, an awareness of your individual laboratory environment and the potential for accidents and taking responsibility when action is needed.

So, while there are universal guidelines for safe laboratory practices, each laboratory’s policies and procedures should reflect particular considerations of hazards arising out of the use of its own instrumentation, testing requirements, physical structure, workflow and traffic patterns.

We are all familiar with the general safety guidelines:

- Always wear appropriate personal protective equipment.
- Wash your hands after working with potentially hazardous materials and before leaving the laboratory.
- Do not eat, drink, smoke, handle contact lenses, apply cosmetics or store food for human consumption in the laboratory.
- Follow the institutional policies regarding safe handling of sharp objects.
- Take care to minimize the creation of aerosols and/or splashes.
- Decontaminate all work surfaces before and after work and immediately after any spill or splash of potentially infectious material with an appropriate disinfectant.
- Decontaminate all potentially infectious materials before disposal.
- Report any incidents that may result in exposure to infectious materials to appropriate personnel (e.g., laboratory supervisor, safety officer).

However, an effective safety program must also incorporate the (now) standard phrase, “If you see something, say something.” Too often I have heard people say that they were aware that there were “problems” (such as a slippery spot in the break room, a loose leg on the phlebotomy chair, an unstable shelf above their work area, etc.), yet said nothing, assuming someone else would notice it and fix it. Take personal responsibility before someone gets hurt.

We must also remember that following safe practices is a choice. Management can provide all the education and protective equipment in the world – but an employee deciding to ignore safety rules will do so. Every individual makes the decision to follow the guidelines or not. Ensure anyone seen acting in an unsafe manner is taken aside, coached and not allowed to continue that way. Anyone repeatedly ignoring safety guidelines and putting fellow staff in jeopardy should be encouraged to choose a different place to work.

Finally, emphasize that safety awareness doesn’t end at the laboratory exit, but encourage the same safety-consciousness throughout your facility. 

Cultural Competence
June 25, 2015 3:55 PM by Irwin Rothenberg

The term, “creating a culture of…” has become the cliché of the 2000s’ ethos of competent management. It is no longer enough to lay down the rules, train your personnel and maintain documentation. Now, we must create an all-enveloping world of understanding, communication, compassion and comfort with the organization’s operating standards. This new modus operandi applies to all organizational settings -- whether offices, factories, retail, education, healthcare, etc. We are all enveloped by our new cultures.

In the laboratory, we talk about the “culture of quality,” but we can also be more specific and feel good about our “culture of customer service,” our “culture of safety,” our “culture of personal responsibility” and our “culture of teamwork.”

Contrary to what you might be thinking at this point, I heartily support this evolution of organizational behavior and standard setting. Just as we are undergoing a revolution in the technology of how, where and when we communicate and relate to each other, we are finding that this is changing everything related to human interaction. It isn’t just the smart phone or the use of social media or the ability to message each other 24/7; it’s the idea that we all now have the ability to create instant communities wherever we are.  When we are in the laboratory, we are immersed in our laboratory community; in the office, we are immersed in our office community; in the gym or spa, we are immersed in our exercise community; and, with family, we are immersed in personal community.  

So, when you read about your laboratory creating a “culture of [whatever],” buy into it because this is the future of all organizational and societal aspiration.  

For laboratories in particular, it is no longer enough to just set down the standard operating procedures and do the technical orientation and training. Today’s generation of laboratory professionals are already accustomed to operating in different organizational cultures. 

Effective managers will already have embraced this and understand that successful laboratories will have to create cultures of their own. This means that the old models of hierarchical management will no longer work. The new cultural models are driven by two-way communication and the acknowledgment that all input, including new employees,’ should be listened to and valued. If this is not the case, you will have a difficult time retaining new, younger, energetic staff.

Urine Drug Screen Reports Can Change a Life
May 27, 2015 4:40 PM by Irwin Rothenberg

As a laboratory procedure readily performed in physician office settings, the simplicity of urine drug screening belies its importance and impact as the test results can be used to monitor patients' medication compliance, detect drug abuse, provide evidence in legal/forensic cases and improve workplace safety.

Urine is the preferred specimen for drug testing primarily because it is non-invasive. Urine specimens may contain detectable levels of a drug over an extended period and at much higher concentrations than in blood. Urine may also contain higher levels of drug metabolites than blood, providing further evidence of drug use.

Immunoassay procedures, such as ELIZA or RIA, are performed first as a screening method. If the immunoassay is negative, no further action is required, and the results are reported as negative. If the sample is positive, the more specific GC-MS is used as a confirmatory test to identify individual drug substances or metabolites and quantify the amount of the substance. Confirmatory tests, such as GC-MS, should be utilized prior to reporting positive drug test results.

Below is a summary of the many reasons that urine drug screens may be ordered:

-              Pre-employment
-              Suspicion of drug abuse (e.g., unexplained negligence/impairment/behavior)
-              Random testing outlined in employment contract
-              Military service
-              Sports participation
-              Legal/criminal (e.g., post-accident, parole, date-rape)
-              Drug-therapy compliance monitoring
-              Drug abuse rehabilitation monitoring
-              Postmortem investigation

Because of the personal, occupational and legal implications that accompany drug testing, family physicians who perform urine drug screenings must be confident in their ability to interpret screening results and respond appropriately to that interpretation. Ordering and interpreting urine drug screenings requires an understanding of the test procedure, the detection times for specific drugs and the common reasons for false-positive and false-negative test results. False negatives are uncommon but can occur as a result of low drug concentrations in the urine, tampering and in other situations. Possible reasons for false-negative results include:

-              Dilute urine (excess fluid intake, diuretic use, pediatric sample)
-              Infrequent drug use
-              Prolonged time since last use
-              Recent ingestion
-              Insufficient quantity ingested
-              Metabolic factors
-              Inappropriate test used
-              Elevated urine lactate
-              Tampering:

Although immunoassays are very sensitive to the presence of drugs and drug metabolites, specificity and accuracy varies depending on the assay used and the substance for detection. This limitation may result in false-positives from substances cross-reacting with the immunoassay. Many prescription and nonprescription substances have been reported to cross-react with immunoassays and cause false-positives. Most have only been documented in case reports. The frequency of false-positives varies depending on the specificity of immunoassay used and the substance under detection.

In short, the importance and impact of urine drug screen results on the life of the individual tested requires a heightened awareness of both the strengths and limitations of the methodologies used.

Trending… EQC to IQCP: All Aboard!
April 16, 2015 1:29 PM by Irwin Rothenberg

Concepts of what makes for effective quality control have continued to evolve since the original requirements were defined by the Clinical Laboratory Improvement Act of 1988, and became effective in 1992.   At that time the minimum requirement was established as testing two levels of external control materials each day of patient testing.  However, CLIA Interpretive Guidelines have always allowed for an alternative to daily external Quality Control requirements as long as “equivalent quality testing” is assured.  Since 2004, this alternative has been Equivalent Quality Control (EQC).    Even though many laboratories implemented EQC without difficulty, there were a number of potential errors that could lead to inaccurate results that were not detected by the test system’s internal controls or by the EQC qualifying studies.  Out of these concerns,   the concept of quality control based on Risk Management was developed.  CMS named this policy the “Individualized Quality Control Plan” (IQCP). 

Presently, we are in the midst of a two year transition period, during which laboratories have the time to study and learn about IQCP; and to decide whether to move forward to develop and implement IQCP.  To have an acceptable IQCP in place is not a simple matter, and during this time, laboratories can continue to utilize EQC as their QC option.

However, on January 1, 2016, EQC will no longer be an acceptable option by CMS, and it will either be IQCP or returning to the current CLIA quality control standards.   If you wish to move ahead with IQCP, now is the time to master the concepts and applications of IQCP, and begin implementation.

If you are not familiar with the concept of Individualized Quality Control Plans, here are a few key points:

-              IQCP is a QC program based on the individual risk factors involved in the performance of each test in your laboratory.  IQCP consists of a Risk Assessment, a QC plan; and a Quality Assessment process to monitor the effectiveness of the IQCP.

-              IQCP is voluntary; but it can be applied to all non-waived clinical laboratory testing except within the specialties of Pathology including  Histopathology; Oral pathology; and Cytology

-              You must follow manufacturer’s requirements for QC if they are equal to, or exceed CLIA QC standards.    If however, the manufacturer’s QC requirements are less than CLIA QC requirements, you must follow the more stringent CLIA requirements UNLESS you implement IQCP to validate that the risk level is acceptable.

-              There is no grandfathering in of test procedures presently using EQC; all IQCP must be newly developed for each test involved.

-              The Laboratory Director is responsible for deciding whether the laboratory will utilize IQCP; the development of the IQCPs; and approval of the IQCP before putting it into use.

There are many sources of information available that provide both basic information about IQCP, as well as implementation tools. 

These include:

Strong Staff Morale: Your Umbrella for the Perfect Storm
March 24, 2015 12:21 PM by Irwin Rothenberg

The next thirty years comprise a perfect storm scenario for laboratory medicine in terms of meeting professional staffing needs:

-              Millions more people will be insured and able to access the healthcare system far more comprehensively than ever before, including laboratory services.

-              Millions of baby boomers adding to the post-65 year old demographic, requiring more frequent and intensive healthcare, including laboratory services.

-              Significant numbers of boomer clinical laboratory professionals are part of this retirement tidal wave, contributing to the shortage of available staff.

-              The continued rapid development of advanced technology such as molecular genetics, requiring ever more sophisticated instruments and advanced training by staff.

-              Increased competition from other healthcare professions that are able to promise and deliver on better working conditions, higher compensation and greater recognition.

-              Lack of adequate funding for enough schools and graduation capacity to provide the needed numbers of laboratory professionals.

Through all these challenges and stresses, the backbone of the laboratory operation continues to be, and will always be, the dedicated, competent, hard-working laboratory professionals who staff all shifts, multi-task and respond to callers impatient for test results. Those who handle all of this should not be taken for granted. If you lose a good employee, replacement might not be possible for an extended period of time.

A good laboratory manager knows that to retain good staff, you must offer them more than just wages and benefits:

-              Chat with your employees, always greet them by name. Be friendly. Be willing to listen. Create a sense of family among your staff. You cannot reduce the daily stress of testing, emergency situations, time pressures, dealing with difficult people, etc. -- but you can humanize the environment.

-              Recognize achievements, even if they are routine. If they day has gone well, say so. If the lab received a compliment, note it. If the lab achieves a mile-stone (say, a great inspection by your accreditation agency), celebrate it.

-              Recognize and celebrate personal mile-stones, such as birthdays and employment anniversaries.

-              Support your staff by providing educational opportunities. Hold regular meetings and encourage all staff to talk about issues in their work areas and how improvements can be made. Be current on performance evaluations.

-              Be transparent. Keep your staff informed of all happenings, both good and bad. This can open up new avenues of discussion, problem-solving and team-building.

These are a few basic, yet effective strategies to humanize the workplace and to enhance the sense of being a valued part of the healthcare team. Improved wages and benefits may not be within your control, but these actions are, and they reflect your leadership skills.

Effective Laboratory Medicine in the Era of Individualized Healthcare
March 2, 2015 10:30 AM by Irwin Rothenberg

We live in an age of increasing individualism facilitated by technology that allows immediate access to information in the format, the setting, and the time of our own choosing. This change is occurring as rapidly as we can adapt to it, accompanied by social media-facilitated feedback, commentary and communication. These are new manifestations of individual empowerment. All phases of our society have been impacted and are adapting, willingly or otherwise, to this new world. The healthcare profession, including laboratory medicine, is no exception.

We, as laboratory professionals, are at the nexus of these changes -- not only in terms of information technology as discussed above, but also in terms of advances in molecular diagnostics that are facilitating the development of personalized (i.e. individualized) medicine. The latter, through the decoding of the human genome and genetic mapping, allows the tailoring of medical treatment to the individual characteristics of each patient, through all stages of care, from prevention, diagnosis, treatment and follow up. The result is a leveraging of both information and biomedical technology to empower individual participation through all stages of medical care.

How does this affect us?

As the healthcare industry starts to reengineer healthcare delivery to accommodate these new advances and demands, providers on the front lines of change recognize the need for increasing patients’ engagement in their own health care. This means that patients must be more involved in the self-management and the modification of their own risk factors. Educating patients about the meaning of their laboratory tests promotes this goal. When the patient understands the reasons specific tests are ordered; what the results mean; and how they are utilized in the diagnosis, treatment, and monitoring of their conditions, the more likely it is that the patient will do what is needed to attain and maintain a healthier state.

Patient education can be provided in many ways:

•             The physician directly
•             Laboratory staff and other office staff who have the education to provide this information, such as nurses
•             The Reference laboratory -- either directly, if the patient visits, or by hard copy / on-line
•             Laboratory Information sites, such as Lab Tests Online or Health Network Laboratories
•             Laboratory testing Information online provided by major clinics and hospitals.

The importance of patient education about laboratory testing is heightened even more by the increasing acceptance of laboratory test orders originated directly by patients without a doctor’s order. This is now permitted by several states with more added every year. This is another manifestation of patient empowerment. When patients order their own tests, they must have the correct and complete information to understand what the results mean; when it is necessary to follow up with physician visits; and even when to seek immediate help.

Pre-emptive Causal Analysis Applied to Change-Decisions
February 16, 2015 12:23 PM by Irwin Rothenberg

We are most accustomed to using (root) cause analysis in the context of incident management investigations -- that, by tracing the sequence of events backwards, and asking the what, how and why questions, we can determine the true cause of these events. This allows us to respond in the most effective manner not only to correct the damage already done, but to put changes in place to prevent a re-occurrence.

However, we should not restrict our application of causal analysis just to incident management situations, where application is retrospective. Root cause analysis is a useful preemptive tool when considering any changes considered for your laboratory operation. As you well know, not all problems rise to the level of an Incident, and not all issues are negative. Many issues simply occur out of evolving needs, but they all may require changes in how the laboratory operates. 

Here are some scenarios to illustrate evolving needs:

1.            Physicians on staff are requesting new endocrinology tests and that these should be performed in-house, but the present chemistry analyzer cannot perform these. Buy a new instrument ?

2.            More test requests are coming to the laboratory earlier in the day with pressure to get the results out sooner than previously; staffing may not be adequate to handle this need.

3.            You have a new LIS and you are having performance issues with staff not doing all the documentation required when reporting stat results, panic values and other calls to nurses or physicians.

All of the above have obvious “common sense“ responses: meet physician needs with new instrumentation, hire more staff, and perform more training -- if only it were that easy! -- but there are other factors to consider, such as cost, efficiency, shift responsibilities and institutional resources available. This is where preemptive root cause analyses are needed. By asking the right questions, delving into the real origins of these issues and including discussions with all parties involved, you can develop solutions that satisfy both the needs of the physicians and the resource limitations  of the laboratory and institution.

For examples of some of the questions:

1.            Why is it necessary for all these new tests to be performed in house? What is the projected volume? Is it sufficient to warrant investment in new instruments? Or is this a turnaround time issue?  

2.            Why are test orders coming in earlier? (Perhaps a root cause is that test results presently are not available in time for afternoon rounds; if so, why are test results delayed? Would it be a staffing issue? An instrumentation issue? Test reporting problem? )

3.            Why is your staff having problems with documentation? Is it a lack of training? Time? The clarity of the procedures involved?

Once these questions are answered, you may find that your responses are not the obvious ones first considered. Delve into the causal factors of all issues; once you get to the true cause, you can then arrive at your decisions with greater confidence that the issues have been effectively addressed.

Personalized Medicine: Opportunities and Challenges For The Laboratory
January 12, 2015 5:16 PM by Irwin Rothenberg

The development of personalized medicine holds the promise of radically changing the practice of medicine from reactive to proactive. Historically, medical treatment was initiated as a response to the symptomatic onset of diseases -- and, because we haven’t fully understood the genetic and environmental factors that cause diseases such as cancer, Alzheimer’s and diabetes, our efforts to treat them have often been imprecise, unpredictable and ineffective.

Personalized medicine is changing this paradigm; it is defined as the tailoring of medical treatment to the individual characteristics of each patient during all stages of care, including prevention, diagnosis, treatment and follow up. This approach relies on understanding how a person’s unique molecular and genetic profile makes them susceptible to certain diseases. Scientists advanced the cause of personalized medicine with the decoding of the human genome.

New gene-based and other molecular diagnostic laboratory tests can also be used to determine the benefits and harms for an individual of taking certain medications. These tests are known as companion diagnostics. Information on an individual’s drug metabolism, for example, can yield information on who might benefit most from a drug and those at risk for atypical adverse reactions. Tests can also inform the optimal dose or treatment frequency needed to achieve a desired therapeutic effect in an individual patient.

The advent and continuing evolution of personalized medicine also offers significant challenges and opportunities for laboratories.

- Since personalized medicine can define the risk of developing specific diseases, the challenge will be for laboratories to work with physicians to integrate traditional diagnostic testing into specific risk assessment profiles. These individualized test profiles will be key in supporting personalized prevention and diagnosis efforts.

- Personalized medicine often begins with the primary care physician. In addition to ordering traditional diagnostic tests, primary care physicians will be ordering genomic-based tests that they are far less familiar with. Laboratories can add value to the physician's practice through education to physicians, nurse practitioners and physician assistants.

- By providing interpretations of genomic test results, laboratories will strengthen their role of consultant, influencing the management of patients and related clinical outcomes. Thus, lab managers will need to join the healthcare delivery team and play a role in patient management.

- The challenges that labs will face in offering panels of new tests for early disease detection are many. New offerings will likely affect every function of the lab, including staffing, processing, equipment purchases, results reporting, billing, validation and continuous education and training.

Difficult Employees
December 17, 2014 9:52 AM by Irwin Rothenberg

One of the inevitable experiences of managing a workforce is dealing with difficult employees. In the broadest sense, we mean those who have demonstrated a lack of responsible behavior; but in a laboratory, where the continuum of work goes well beyond specimen testing (analytical) to include interaction and communication with the public (pre and post-analytical) as well as with other professionals, the concept of difficult must include the lack of professional behavior as well. This applies to all levels of laboratory staff from phlebotomists to supervisors.

The term, “difficult,” can result from very tangible, measureable occurrences, such as not meeting performance requirements and goals, not adhering to official policies and procedures and acting out in ways that have resulted in official complaints or have otherwise been observed and documented. Often, this can be serious enough to be considered harmful to the reputation of the laboratory. However, “difficult” can also be a very subjective term – to include behavior that is considered unpleasant, exhibiting attitudes that hurt morale (including the quaint term “trouble-makers”) and include disrespect to fellow staff as well as management.

Of course, there are many reasons employees may be, or become, “difficult,” and management should attempt to discern why this is occurring. There may be personal and/or health reasons; stress factors, such as the lack of proper communication to the staff of new expectations; lack of organization; lack of adequate training; and lack of preparation before major changes in operation are introduced.

Well-managed laboratories (and their parent organizations) should have in place a clearly defined process for dealing with difficult employees, escalating from verbal discussions and delineated expectations for change thorough counseling, warnings and documentation of progress or failure all the way to termination.

All this seems quite straight-forward, but as in all things human, complications can arise. Subjective components of this determination must be handled especially carefully. In these cases, one must ask, “Is there another side to this? Are we dealing in perceptions rather than reality? Are there other possible reasons for any change of behavior? If there are health or emotional issues, can these be addressed differently, such as through Employee Assistance Programs?” Discussions with the employee involved should at least offer an opportunity for clarification.

Now for the kicker: suppose the employee in question is the most productive (technologically) in the lab, and that termination would definitely affect the productivity and, yes, even the quality of testing performed. With all else being equal, how much should this enter into your decision to terminate your employee? Should you pre-emptively ensure that you have resources to back up this loss? Or should you attempt to isolate this person and allow them to work with the least interaction with your other staff (“Moving you into a position that ensures a better match between the needs of the lab, and your skills and experience (not to mention your personality.”)?

What do you think?

Just Do It!
December 1, 2014 11:51 AM by Irwin Rothenberg

One of the refrains I hear at every professional gathering is how so many of our issues would be resolved if we could just get the word out about our profession -- that is, if we could just educate other healthcare professionals about our work. If we could just educate the public about how important laboratory testing is; that our work is the basis for 70 percent of all physician medical decisions; that, with 13 billion tests performed annually, we directly affect healthcare decisions for millions of people.

All in all, we are eternally searching for the pathway, the right strategy, that will deliver us from this obscurity; that, once this is achieved, we will emerge into the sunshine to assume our rightful place of public recognition and appreciation. From that place, we will gain traction for better compensation, better working conditions and, as a result, larger numbers of younger people will flock to our profession with the knowledge that they can realize their desire to help people, become part of the healthcare continuum and be properly recognized, compensated and appreciated.

Well, guess what?  Unless we personally take the initiative and pro-actively reach out, Nirvana will always be a yearning away.

What can you do as an individual? What can you do as an experienced member of our profession? You can get out and speak! So many of us belong to other groups in our lives, whether related to hobbies, politics, religion, exercise, social, whatever -- we all interact with “the public” apart from our profession as friends and fellow group members. This opportunity to act is staring us in the face.  Think about it. We can speak to various groups of people who really are the “general public,” but we would not be speaking to them as strangers, rather as friends, neighbors, colleagues, fellow religionists -- peers!   We would be speaking and possess the credibility of familiarity and friendship.  This is where we could really talk about what we do with passion, with knowledge, with care, to our audience.  We would not only be informing them about our profession in a way that helps us get the word out, but helping them to understand better their own experience with, and benefits derived from, their laboratory test interactions.

All we need is to…. just do it!

Different Shifts, Different Worlds -- Part 2: Factors To Consider
November 13, 2014 11:51 AM by Irwin Rothenberg

In the previous blog, we discussed the factors that make one shift different from another, and how an awareness of these differences is important for the proper management of the workload and staffing for these shifts.  Since each shift is part of the continuum of the lab operation for that day, when chronic problems are happening on a particular shift, it is important to determine if the problems are centered within the shift, or are interrelated to the shifts that precede or follow as well. 

Below are some of the many factors that need to be considered when performing a root cause analysis of problems that may occur on any shift:


- Total workload per person

- Total workload per person compared to other shifts

- Training and Competency of staff working each shift

- Permanent staff / shift ?  or does the staff rotate to/from other shifts

- Presence or availability of supervisory staff during the shift

- Awareness of personality differences and conflicts between shift staff

- Evaluations: are they designed for the specific tasks and responsibilities for each shift and performed by supervisory personnel who are familiar with the operations of that shift?

Policies and Procedures

- Appropriateness of instrumentation for different workloads and test menus

- Shift specific policies governing routine and STAT orders, including which tests are included in each category, and expected turnaround times.

- Support when needed during each shift

- Policies for performance of quality control, calibrations, and maintenance during each shift

- Policies for test management when expected testing cannot be performed on each particular shift

- Inventory control

Internal Communication

- Shared work between shifts: policies governing testing already underway when next shift begins

- Availability of policy and procedure manuals, other resources on every shift.

- Ability for all staff  to participate in laboratory meetings and continuing education

- If rotating staff: proper training for work on each shift.

External Communication

- Communication with other departments that interact with the laboratory: ER, ICU, Radiology, Respiratory Therapy, Outpatient.

- Expectations of Physicians, Nursing staff and other professionals for turn around times for STAT and routine orders

- Have nurses and others external to the laboratory been trained on proper specimen collection, labeling and handling?


- Listen to and act on all complaints and other feedback from lab staff, physicians/nurses, and patients as soon as possible.

- Proficiency Testing needs to be performed by each shift

- QA each shift

- Review workload changes annually to adjust staffing levels and instrumentation if appropriate.

These are not all the factors to be considered, of course, but for effective corrective actions and the maintenance of quality standards, these make a good start when getting to the root cause of chronic problems occurring on different shifts.

Different Shifts, Different Worlds -- Part I: Consistency Between Shifts
October 20, 2014 11:38 AM by Irwin Rothenberg

Have you noticed that when you work a different shift, it almost feels like you are working in a different lab? Whether we compare day/evening, evening/night or night/day interfaces, we often have different priorities, different responsibilities and different ways of communicating with our clients. The outside world views the laboratory as a cohesive operation, whether 24/7 or 9/5, and expects the same level of quality, turn-around time and staff expertise, regardless of when testing occurs.

Of course, while many labs are busiest during the day, especially those that serve physician offices, group practices, and hospitals, there are many that are busiest in the evening or on the night shift, such as reference labs, or Walk In / ER Clinic labs. Test volume is the single greatest determinant of how the lab is organized for each shift: it determines test menus, instrument needs, staffing size and specialty experience, extent of automation for specimen handling, tests performed, results reporting, and documentation. As a result, determinations are made as to when it is best to perform instrument maintenance, calibration, quality control, performance specifications, and staff training.

Of course, just because another shift may have fewer staff, a limited test menu, and a different set of priorities, doesn’t mean that there should be any less effort to ensure that the staff is properly trained on any changes to the lab operation. The continued evolution of laboratory information technology has made maintaining consistent record keeping among all shifts easier to achieve, and monitor. But just because of these advances in technology, we cannot overlook the need to constantly monitor staff competency, especially for those who work alone, or nearly alone, on their shifts. On many late shifts, there may be no supervisor on site, and there is the possibility that the expected competency may not be maintained. Also, over time, each shift develops its own culture, and in small ways, may individualize how some procedures are performed.

 Of course, determinations of the type and variety of work to be done on any shift are made based on how busy the staff is during their shift, and many labs choose to add responsibilities rather than reduce staffing if the workload is unpredictable. Many labs will have the night shift prepare and/or run the quality control prior to the day staff coming in; or have the evening shift perform some of the routine instrument maintenance. Any shift might check inventory. All these determinations should be done through a realistic assessment of what can be achieved in the way of routine work, in light of the priorities set for that shift.

Through it all, regardless of what shift is involved, efforts must be made to encourage a sense of community, trust, competency and communication among all staff. If the lab staff is fragmented, or feels that other shifts are treated in a better manner, this will definitely impact the quality of work, as these issues can lead to distrust, miscommunication and lack of teamwork.

 Next Blog: Part II: Issues Between Shifts



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