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Press Start: Lead an Empowered Life as a Clinical Laboratorian

Is this Quality or Just Habit?

Published January 18, 2014 12:36 PM by Glen McDaniel

 

The Director of Nursing hotly defended her staff. They had in fact performed quality control on the point of care glucose meters per policy. They had dated and initialed the appropriate line on the sheet. What was the lab complaining about? What did the state inspector mean by citing them?

 

Let me back up and explain. A few years ago I was associated with an organization where nurses performed glucose and urine pregnancy point of care testing. The nurses were trained to perform quality control and to document QC as well as maintenance on a log sheet. However it was a constant battle to ensure compliance. One day the state came in and found a couple instances were QC was performed, but were out of range. There was no corrective action documented, yet patient testing was performed.

 

The Director of Nursing could not grasp the concept of running QC to indicate acceptable performance of the test system. In her mind, QC and maintenance were just tasks to be checked off a list. Over the years, I have come to realize that many concepts we medical laboratorians consider fundamental are alien to those in other professions, including nurses.

 

I have also noticed that as laboratorians we also do some tasks by rote without thinking whether they are logical or not. Some recent examples I have seen with clients: performing 3 levels of QC daily for low volume tests that the lab performs maybe twice weekly. Another client performed correlation on all 82 of their (identical) glucose meters instead of using a representative sample as recommended by CLSI. A small laboratory performs quality control on their chemistry analyzer each of three shifts. Yet another , strapped for space) uses valuable refrigerator space storing their urine samples for a week. Why? Their policy says, "patient specimens are stored for 7 days."

 

How much of what we do is based on ensuring quality and how much is simply checking off a task on a list? With the increased sophistication of laboratory instruments is it still logical to perform the sort of validation studies traditionally required by CLIA? How often should methods be revalidated?

 

Another area that needs consideration is reporting results. Increasingly physicians are pleading for decision limits or cut-points instead of a "normal range."  Maybe our reference intervals should provide more information than normal/abnormal, or low-normal-high.

 

As laboratorians we are very concerned with quality, but I suggest we periodically look at our long list of “tasks” and reconsider which ones contribute to quality and enhance patient care, versus those which are just something on a list and no longer serve a useful purpose.

 

Is there a task or process in your lab that has passed its prime or that you perform without knowing exactly why you do it?

 

2 comments

The one thing that drives me crazy are how we do our manuals. We have different colored manuals for different topics- procedures, safety, quality, HR and so on.

Then we make several copies of each one so that there are copies of binders everywhere. My manager says we have copies so that they are readily available to staff as needed. I say it takes too much time to find and update all those books, especially since she and the pathologist signs each policy individually. If you revise or add a policy you have to find maybe 5 books and then pull the old procedures and save those in another binder.

I have suggested keeping our procedures online. You go to one place to update them and they are still available to staff.  My manager says no that CAP says procedures must be signed every 2 years ( I don't believe that). She also says if computers are down the procedures are not available to staff which is another CAP requirement.  How often are all computers down?  I even suggested a compromise: computerize procedures and have ONE paper copy as a backup. She still says no.

That is one thing that the manager claims is being done because of lab standards and I say she just does not want to change her old habits.

Anonymous MT January 20, 2014 10:12 PM
NJ

POCT is always a problem. I think California has the most stringent laws in the country and yet it is difficult getting nurses to follow the regulations. I think POCT works better if there is a POCT Coordinator who is a CLS and not a nurse.

Issues that I have notice relate to older folks in the lab who want things done "the old way" even if they have no real reason. I worked at one place where almost everything on computer was printed off, checked, signed and put into boxes. They were then sent off to be stored for 5 years. We had all this paper even when both the Joint Commission and CAP surveyors told us we only needed to keep most files for  2 years and if it's on the computer we don't need to print it out.

Another place I worked we would create all these computerized worksheets for manual tests and then enter patient name and results on the computer. We could just find the order and put in this result and be done. Instead we went through this extra step. No one knows why we did it, but it was a rule so we did it.

Bob Jernigan, MLS (ASCP) January 18, 2014 5:32 PM
San Francisco CA

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