Less is More: Time to Discontinue Redundant Processes
laboratorians we tend to be masters (and mistresses) of multitasking and
completing tasks. Ever wondered why we have so many checklists, worksheets and
forms? Computerization has simply moved some of that documentation to a new
so as scientists we do need to have checks and balances, we must document, we
must meet regulatory requirements. However too often we have become slaves of “always doing
something and writing it down.” We proudly use “if
it’s not documented it wasn’t done” as a mantra.
few years ago, I reviewed some point of care (POC) documentation on the nursing
floor of a hospital and found out that for an entire week, quality control was out on several tests,
yet the nurses performed patient testing daily anyway. The Director of Nursing
defended her nurses by saying her nurses followed the laboratory policy of “performing
QC daily.” It took several attempts to convince intelligent healthcare
providers that the laboratory did not simply want them to complete a task to be
checked off on a list. They had to go one step further and evaluate the each QC result
to make sure it was in range/acceptable; or troubleshoot and correct the
problem until the QC was in range. Then (and only then) should patient results
am not suggesting that any laboratorian would be guilty of such an act, but it does point out how task-obsessed we can be. We sometimes
have procedures or old practices that have long outlived their usefulness
and logic. I consulted for a laboratory that had worksheets for every test,
although some instruments were interfaced with the LIS. Other manual test results were
entered directly into the computer along with the QC result. Yet they had all these reams of manual worksheets. Asked why, the over-worked
staff responded in various ways: the state required it, it was a CAP standard, or
they needed to be able to pull monthly volumes of each test performed. As I
drilled down, one honest person finally admitted, “We have always done it that way so I
don’t want to be the one to break the pattern, just in case.” Just
in case of what?
lab I know of has a policy that requires that 5 different "licensed individuals" check blood for transfusion: an MT/MLS rechecks the phlebotomist, another
MLS verifies the correct units are documented and tagged, an RN (not even an LPN)
signs out the blood at the blood bank with an MLS, and then cross checks the unit with another RN before the blood
is hung. That sounds pretty safe, but it
is a very labor intensive process. Worse it does not do what it purports to do.
Supposing the phlebotomist draws the wrong patient (that’s not checked),
suppose the first MLS tags the wrong unit of blood (the second MLS visually
verifies the blood type and unit numbers not the actual crossmatch), the nurse
signing out the blood again does the same thing (just verifies the numbers in
the sign-out log matches the units in her hand. The nurses hanging the blood
cannot verify that was in fact the patient the phlebotomist drew. So a long, complicated
process with lots of paper and several signatures does not always ensure quality.
of quality assurance should be to examine processes on a regular basis to see
what purpose they actually serve: clinical, quality, regulatory, financial, or something
else. Can you get volumes or data from the computer instead of hanging on to a
manual 15 year old worksheet for example? Could you simplify that bloodbank process while ensuring greater greater patient safety?
as well as regulatory agencies like CAP constantly revisit issues like the need
to run QC: how many levels and how frequently. What documents need to be maintained
and for how long? Is any process causing undue hardship, eating up too much
staff time and is too labor intensive?
we try to reduce costs, do more with less and try to bring some relief to an
older, tired and overworked workforce, we need to re-examine processes for
redundancy. If you cannot give a valid reason related to patient care, quality,
regulatory or financial requirement, then rethink that process you are hanging on so tenaciously. Even processes that
need to be continued still need to be examined to see if they can be revamped
or streamlined in some way. Some processes can be discontinued, modified or documented in
simpler ways or via an electronic format (versus paper).
a worklist to complete or because we have always done it this way are no longer
valid reasons for retaining and perpetuating those long-standing process.