In a few days the country will be celebrating Thanksgiving,but this festive holiday means different things to different people. To many it will be a day off from work, a time to spend with family, to over-eat and drink too much. It will be a time when family members get to show off their favorite recipes, critically assess relatives they haven't seen all year and, if lucky, enjoy a long weekend. To others it signals the start of the Christmas shopping season and an opportunity to start eagerly stimulating the econmy!
It is pretty easy to forget how Thanksgiving started as a celebration of a successful harvest by the Pilgrims, that over the years there have been different days of thanksgiving based on historical milestones, or that the day itself was not always a permanent national holiday.
Many incorrectly think of Thanksgiving as a uniquely American holiday. I once mentioned to a colleague that I was headed to Toronto to celebrate Canadian Thanksgiving with family and friends. I told him the celebration was on the 2nd Monday in October. He replied in utter consternation, "Why do Canadians celebrate Thanksgiving? What are they grateful for and why are they celebrating on the wrong day?"
So the idea of giving thanks on a particular day has a checkered history; but reduced to its basics, it is a time to be grateful for all the blessings we have individually, as a nation, as a family, and as a profession. It is formal recognition of the gratitude we should feel all year long.
As a profession we should be grateful for the opportunity to serve, the ability to make such a valuable contribution to the health of this great country. We have a long way to go in terms of recognition (pay, independent practice and licensure, for example) but we have also come a very long way, especially technologically.
While many can kick back and enjoy a long weekend of feasting, fellowship and foootball, many of you, my colleagues, will be away from family and friends; working as you do all year long. You will be supporting the health of the country. For that, I am personally grateful. You will be using your expertise, competence, knowledge and critical thinking skills to make crucial decisions that often mean life or death. For that, I am immensely grateful.
Whatever you are doing this Thanksgiving and however you choose to celebrate it, enjoy it and be safe. And, please take a moment to acknowledge those achievements, qualities, individuals and blessings for which YOU are grateful.
Just a few short weeks ago, Ebola was the talk of the
town. Both the lay public and healthcare professionals seemed consumed with the
topic. Entire cottage industries were born to supply Ebola-proof personal
protective equipment (PPE) and to teach Ebola safety.
There was a CDC conference call almost daily to
update (and modify) guidelines. Hospitals diverted lots of resources to train
their staff and to provide PPE in emergency departments and many patient care
areas. The nation’s largest airports started screening visitors originating in Western
Several very enterprising merchants ramped up
production of Tyvek-looking full body suits in time for Halloween.
Now, Ebola is rarely even mentioned-at least on the online
sites that I visit and the healthcare organizations that I work with. So what
First, the cases in the USA seem to have got less
and those being treated in the US (except in one Texas hospital) have all had favorable outcomes. They were all
released, essentially cured.
Conversely, why the earlier panic? Again it’s conjecture
but there are several possibilities:
-This decades-old disease was now infecting Americans
so it suddenly became new, serious, significant and important to Americans
- The media pushed the fact that it was largely
fatal, and as much as they explained how it was spread through intimate contact with body fluids, the public chose to
concentrate on the fatality rate and the fact that PPE use as described by the CDC might not be 100% fool-proof
-There was an election looming and this was too
tempting a drama not to exploit for political purposes. Who would be best at coping with this “foreign
disease?” How tough should sanctions be: travel bans? Quarantine? What would
each candidate do to protect you?
Now the election is over, the US has an Ebola-czar
and there are currently no patients being treated for Ebola in the USA. So
Americans have tended to turn away as if bored with a prime time melodrama and its drawn-out plot.
But the battle continues elsewhere. According to the
World Health Organization (WHO) more than 14,000 have become infected and over
5,000 have died since the 2014 Ebola outbreak in March.
One doctor infected in Sierra Leone is on his way to
be treated at the Nebraska Medical Center’s Biocontainment Unit, which like
Emory University in Atlanta and National Institutes of Health have a perfect record of treating patients using
appropriate infection control protocols and targeted treatment by dedicated
medical lab scientists, doctors and nurses.
There are 3 principles that come to mind. In healthcare,
actions should always be based on science. We should be concerned about
healthcare issues regardless of who is affected. Finally, healthcare delivery should
not be politicized or overdramatized for political reasons. The Ebola scare is
instructive because the public reaction violated all 3 rules.
This is a shame.
My dad was so proud of the fact that he worked for the
same employer for 40+ years. He was never late, was rarely sick and sometimes
went to work despite the fact he was under the weather. He thought he was
indispensable and that his employer really valued him. To him loyalty to one
employer was huge.
He received a small pension - not even the metaphorical gold watch, or a cake and punch party - when
he retired riddled with aches and pains.
How things have changed. It is now very clear that employers
have no loyalty to employees who are typically viewed as “elements of
production” and therefore costly and replaceable.
Several years ago, the American Management
Association (AMA) conducted a survey of 6,000 participants across the United
States. The survey asked employees 2 questions:
1) Do you get enough recognition at work?
2) Would you do a better job if you got more recognition?
There was no equivocation in the answers. Over 97%
of the respondents said "no" they didn't get enough recognition at
work, and 98% replied "yes" they would do a better job if they
received more recognition. This means that employees think recognition is very
important, but that they don’t receive nearly enough from employers.
The typical employee (inside or outside of
healthcare) will have several jobs in their lifetime, sometimes even changing
professions. Laboratorians are no
exception and have come to realize that employers have no loyalty to them, and
will gladly cut an employee loose for a variety of reasons including preserving the
That does not mean that the employee-employer
relationship has to be adversarial. However it is important to realize that you
work for yourself first and foremost. In
every job you should learn as much as you can, develop new transferable skills
and keep your resume current. Consider a reasonable work-life balance.
A flexible, nimble employee is a good
employer of him or herself. To be a good self-employer, you should be open to
change, cross training, taking on new projects and practicing constant networking.
Learn as much as you can, and acquire skills that no one can take from you.
Position yourself as a valuable individual professional, not merely as an
employee of ABC Laboratory. It is easy
to get comfortable in a job, but at least once a year, update your resume with any
new skills you have acquired. Look at job ads and decide, in an ideal world, which
one would you go for. Practice writing a cover letter. List the professional colleagues
you would like to act as your professional reference if necessary.
This exercise is as much a matter of
psychology as practical preparation. If you suddenly have to make a change
(voluntary or not) you will have a leg up if you are prepared, sale-able and have
a current resume. Faced with change, you
will then have real options to make the move that is right for YOU. Your employer
will be OK and will move on without you. Trust me.
It seems that experiences always occur in groups. Recently I had 3 separate but similar experiences that made me decide to write this blog.
Laboratorians on an online forum were discussing recent issues that their particular labs faced with nursing, such as specimen draws above an IV, many hemolyzed specimens, abuse of stat; the usual. In each instance several respondents said, “Tell the pathologist.” The same sentiment was echoed for a physician over-ordering uncrossmatched O negative blood.
The discussion continued with each example apparently designed to show an even more ridiculous "pathologist issue" that laboratorians are confronted with.
“One so called doctor wanted to know which hepatitis B test to order. Another genius asked me what was the difference between a PT and anti Xa test”
“What do you do when a doc insists on ordering a bleeding time for his pre-op patients?”
"Check this out, one doctor asked how could the current b-HCG be less than the prior result when the patient is still pregnant as confirmed by ultrasound."
Some questions were tricky. But there was also a fair amount of agreement that even the most casual question regarding selection, use or interpretation of a test should be referred to a pathologist.
“I am just a tech.” said one comment. “The pathologist gets the big bucks,” said another. “I did not go to medical school,” said a third.
This discussion made me think about a coupleother recent experiences I had regarding essentially the same issue. About a week ago, an MLS around my own age was opining to me how lax and unsupportive pathologists are these days. I asked her for more details. She gave me a list of annoyances, mostly breaches of common laboratory practices, such as frequency of ordering the same test, ordering boutique tests from private laboratories and insisting they be sent out, or demanding that specimens be retrieved from storage for add-on tests long past the recommended time period. One physician realized that specimens were discarded after 5 days and now demanded that “his specimens” be maintained for 7 days for add-ons.
"In the old days, a pathologist would just call and set them straight," she says. "Not these young guys who just want to do quick biopsies, a little histology and nothing else. They are friends with the doctors and don't care about the lab."
That piqued my interest so I asked for more specifics. “I have told our pathologist about these problems and he does nothing,” she said. Have you talked to the physicians yourself and pointed out that these are violations of laboratory policy? Have you had your technical manager attend a medical staff meeting and educated doctors? Have you shared your Test Utilization Policy? Have you involved Quality Assurance or Risk Management? No, no, no she said.
“Have you told the pathologist the extent of the problem?” She admitted she had talked to him once, giving him examples and she expected him to act if he really cared. It is not really within the purview of a laboratorian to talk directly to a physician, she said.
The other example I was told about was even more baffling. In a community hospital a group of MLS/MLTs were assigned to review procedures that were long overdue for review. Their review policy called for a biennial review but some had not been looked at in close to 5 years. They wanted to do the right thing. They went the extra mile of verifying best practices with local sister hospitals, checked with specialists in the hospital about cut points for troponin, use of glucose tolerance test for gestational diabetes and updating the glucose range from 70-110 mg/dl which is what the current procedure listed. They also developed a list of critical test ranges based on physician input.
A new pathologist on staff objected to any change in procedures despite the fact the change would reflect current best practices. They provided justification, but he would not budge. It was unclear why he was resistant to changes that were clearly justified, but he made it clear he had the final say.
I cannot fault anyone mentioned in any of the examples above for consulting their pathologist in his/her role as medical laboratory director. However, does every annoyance, breach of policy or question about laboratory practice have to be referred to a pathologist? As professionals is there a point we can decide it’s within our scope (and body of knowledge) to answer questions or resolve problems. It should not be difficult to re-state what current policy is or to explain the principle of a test or give guidance on selection of a test.
A couple of months ago, I wrote two blogs: What do doctors want from the laboratory? Parts 1 and 2
discussing a major study which found that clinicians really do want more from the laboratory. Furthermore providers think we are more than prepared (educationally and intellectually) to provide answers and give guidance but we hesitate to do so.
The pathologist certainly is one tool in our arsenal, but should not be used as an excuse for not stepping up and offering answers or resolutions to problems that are fully within our capability.
It is extremely important to get back to basics in whatever
we do. This simple edict is so often ignored because- well, because it is so
basic. We tend to go for the complicated and glitzy. I thought about this
truism when the CDC issued its new
more rigorous guidelines this past Monday.
There is nothing really complicated about the guidelines at
all. What is remarkable is that these guidelines have been used with thousands
of Ebola patients for years in Africa. The group Médecins Sans Frontières (MSF) or
Doctors Without Borders has treated hundreds of Ebola patients under
horrendously primitive conditions for years with very few cases of
provider-infection by using very basic guidelines similar to these finally
adopted by the CDC.
We like to think we have the best healthcare system in the
world, the most sophisticated equipment,
and the most knowledge. We are reluctant to modify our more high-tech rituals;
we certainly do not like to borrow ideas from less developed countries. CDC
first issued Ebola guidelines in 2008 and again as recently as August of this
year. But we have a situation where 2
American nurses using CDC guidelines became infected on American soil. The CDC
admits they have not been able to identify any specific breach in protocol
so it’s possible the problem was the ineffectiveness of the protocol itself.
According to CDC Director Dr. Thomas Frieden, the new,
MSF-type guidelines are based on 3 principles:
-healthcare workers should be rigorously trained in both
donning and doffing PPE
-there should be no skin exposure at all
-each episode of donning and doffing should be supervised by
a trained monitor
Looking at the protocol in more detail, consider how basic
certain steps and concepts are
1. Full coverage
of the body, no neck or face exposed as in previous guidelines
2. Use of face
shields versus goggles that leave skin exposed, fog up, and may be adjusted
inadvertently with contaminated hands
gloved hands and soiled PPE with a
virucide during and after removal
4. Use extra
covering such as aprons if the patient is producing excessive body fluids like
vomiting and diarrhea
5. Use a “buddy”
monitor to observe, coach, and correct in both the donning and doffing of PPE
to ensure there are no shortcuts or violations of protocol
6. Hand washing,
hand washing, hand washing
7. Staff should be
trained, practice and be familiar with the protocol before they have to
actually use it
It is worth noting that as scientists with highly
sophisticated instrumentation at our disposal, specimen processors, auto
verification and the like we sometimes give up autonomy and abandon critical
thinking. Nothing is a substitute for ensuring the right specimen is collected
from the right patient, the right test is performed, the result makes sense,
and the correct result gets back to the right decision maker in a timely
No matter what our
instruments say, we can over-ride technology and should still go with the
basics whenever there is doubt. Or if there is a problem of any sort. Or as
part of troubleshooting. Or if we have a gut feeling.
Technology and established protocols are great helpmates.
But I cannot think of one instance in which going back to the basics is not a
sound principle by which to operate.
Just a few short months ago Ebola was a disease in a far away continent. The greatest fear was that with our internationally mobile population a case or two might slip into the USA. Then 2 Americans in Liberia contracted the disease and were flown back amongst great fanfare to Atlanta's Emory Hospital where they were treated for several weeks, during which they obtained various experimental treatment. They both recovered and were discharged from the hospital.
But then there was another case in the US, and then another. The CDC has also been receiving calls from emergency rooms all over the country. Epidemiologists and health scientists assess symptoms on the phone and advise whether patients should be hospitalized and isolated, hospitalized and treated supportively, or treated and sent home. Sometimes specimens are drawn and tested for the Ebola virus, sometimes not.
A man who traveled from Liberia to Texas, presented to the emergency room with flu-like symptoms. He was misdiagnosed and sent home. A few days later he returned to the hospital, was admitted and died of Ebola several days later.
The World Health Organization (WHO) estimates there have been over 4,000 deaths from the current Ebola epidemic, and has called this the biggest epidemiological challenge since AIDS .
Several countries including the US have started assessing travelers at the larger airports and denying them travel if they appear to have been exposed to Ebola (or have flu-like symptoms and are traveling from certain areas).
The US hospitals that have treated Ebola patients tend to have entire isolation suites, often with a dedicated care team. In one hospital I know of, specimens were handled exclusively in a point of care lab, samples for further testing were specially bagged and sent off to the CDC. Equipment was sterilized and samples were incinerated or specially disposed of. That is great for a couple of patients, but how will the typical hospital handle suspected Ebola cases coming through their emergency rooms? It is conceivable to have more than one patient at a time.
Laboratories need to know what tests to perform for diagnosis and retrospectively on someone who might have died suspiciously.
Infection control practitioners and risk managers might be building protocols right now, but is the lab involved in the planning? How would your lab handle the sample of a suspected Ebola patient sent for a CBC and electrolytes and crossmatch, for example?
I would like to hear how you personally feel as a scientist in terms of your own comfort level and how well prepared do you think your lab is to handle your first case of Ebola?
Why do we run quality control in the laboratory? The simple, obvious answer is to ensure that the entire test system working together is able to produce reliable results. The rub lies in the concept of reliability. So we run QC based on manufacturer’s directives. But how does the manufacturer come up with its recommendations for a kit, set of reagents or an analyzer?
Then we also run some QC based on regulatory requirements (accrediting agency, CLIA, best practices, state) or based on our organization’s policy. The mandate is to go with the most stringent requirement in each case, but all with the notion of ensuring that the results we produce are reliable.
So if we run quality control for an entire chemistry profile on analyzer ABC once per shift, how sure are we that every patient result generated for the next eight hours is reliable? Some of our confidence comes from studies done on that instrument, using those reagents. We know that statistically, even with the best instrumentation, we cannot absolutely guarantee 100% accuracy 100% of the time.
Over the years several advancements have been made that have helped to increase our confidence that our results are accurate, precise and reflect medically significant values. Technology has become more robust, with more internal checks and balances, reagents have increased sensitivity and specificity. The analytical measurement ranges (AMR) of most tests have increased; as has precision. Once again these factors help to make us more confident that time after time the result we receive is pretty close to the real thing.
It is because of all this progress that CLIA is introducing new QC standards using a protocol called the Individualized Quality Control Plan (IQCP). Why do we have to blindly follow the old 2 levels of controls with every run or every 8 hours if the state of the art is such that our systems have been proven over time to produce reliable results? Available as a voluntary option under CLIA, IQCP is designed to give labs greater flexibility in customizing their own QC program based on their particular environment.
The rub is that you cannot simply decide to move to IQCP, a system some might see as less demanding and less expensive. Your lab must do a risk assessment evaluation to study what QC regimen you can “get away with” under CMS regulations.
IQCP was launched in January of this year and labs that choose that option have been given 2 years to make the transition to IQCP and verify how their lab is operating under that option. IQCP applies to all non-waived testing, except Pathology. Labs will need to provide sufficient data to show a credible analysis/assessment was done.
Has your lab been contemplating IQCP? What have they done so far? How do you personally feel about IQCP?
The concept of Pay for performance (P4P) is based on the use of
incentives to encourage and reinforce the delivery of evidence-based clinical
practices in health care; with the goal of better outcomes.
As the cost of healthcare has skyrocketed, major payers have
adopted P4P as a way of curtailing costs while improving quality of care. The
theory is that if providers all adopt proven standardized methods of care,
patients will have better outcomes at overall reduced cost to the payers. As an
incentive, adherents of the P4P are paid more, while non-adherents are paid
Not only Medicare, but some commercial managed care plans as well,
now pay based on performance or outcomes. More commonly payers penalize providers
(usually through reduced payments) for not meeting certain set treatment guidelines. The
P4P movement is not new, but the Affordable Care Act (ACA) has a significant
pay for performance component as well.
Each year, Medicare looks at its total payment to providers
(doctors, hospitals, laboratories, for example) and tries to tweak their
payment schedule to reduce total cost to Medicare. The rate of hospital readmission is a target indicator
that is used to indicate suboptimal treatment or clinical relapse. Readmissions
are expensive so Medicare pays reduced reimbursement for readmitted patients.
Laboratory testing will continue to play a significant role in “proving”
whether a provider should be paid the full reimbursement, a bonus or be
penalized in some way. For 2015 there will be reduced payment for certain hospital
acquired conditions. Central line associated blood stream infections and
catheter-associated urinary tract infections will prompt reduced payment for
providers. In 2017 Methicillin Resistant Staphylococcus Aureus (MRSA) infection
and Clostridium difficile infections will be added as criteria of performance.
Medicare also penalizes healthcare organizations that do not
report indicators like infections, falls,
pressure ulcers and the like in a timely fashion.
Many chronic conditions like diabetes, obesity, hyperlipidemia,
hypertension and others will also incorporate regular laboratory tests as best
practices for their diagnosis and management. Not performing the correct tests, not testing
with the right frequency, or obtaining results that suggest non-adherence to
treatment will result in reduced payment.
While the laboratory might not be directly involved in selecting
these tests, it is important to know why they are being ordered. It is also
important to stand ready to manage utilization (over testing is costly and may
not be reimbursed) and the interpretation of test results.
to a recent press release, American Medical Technologists (AMT) has partnered with the American Kidney Fund (AKF) to foster and
promote collaborative work focusing on the role of allied health professionals
in the prevention and treatment of chronic kidney disease and end-stage renal
“Throughout the partnership, AMT will help raise awareness
of kidney disease through professional and public education and communications.
AMT will also raise funds to support the American Kidney Fund’s programs and
services” the statement reads. I hope other professional MLS organizations will
also get onboard.
is very good news and a logical partnership. Medical laboratory science plays a pivotal
role in the diagnosis and monitoring of renal disease, from impaired function to
chronic renal failure (CRF). Laboratory tests guide clinical decisions from pre to post renal transplant assessment
and monitoring. As professionals we ought to take a more active role in disease
prevention, management and education of the public.
requests to AMT to elaborate on the role they will play and specifically how
they will include/co-opt medical laboratorians have gone unanswered. However, according
to the press release AMT will play at least 2 roles-education and fund raising.
urge you to join this and similar efforts to contribute to the nation’s health
in a more public way while showcasing the expertise and social conscience of
medical laboratory science profession will be featured on the Leading
Edge, an award-winning program on public television that examines impactful
subjects and helps to educate the public about topics they might not otherwise
know about; or know very little about
glitzy, professional video prepared by ASCP does a great job of explaining the
MLS profession and highlighting the role medical laboratorians play in quality
healthcare. Especially encouraging is the fact that the speakers include not
only pathologists but medical scientists /medical technologists as well. Several times the script specifically references medical lab scientists and also makes
use of the much touted fact that more
than 70 percent of medical decisions depend directly on laboratory tests.
piece jointly produced by ASCP and the Leading Edge production team also
emphasizes that although not generally know most diseases have a component that
lends itself to the use of laboratory testing in diagnosis, treatment and
management. “Essentially 100 percent of the patients entering hospitals across
the United States today are dependent upon the work of the medical laboratory
team,” says one of the speakers, Lynnette G. Chakkaphak, MS, MT (ASCP).
is admitted that medical lab professionals have the expertise to weigh in
authoritatively on test utilization and interpretation.
is a well done piece that we can all be proud of. It is balanced, accurate and
professionally executed. It is slated to be broadcast on PBS sometime this month. Please
share this video and the information
about the upcoming program with your colleagues as well as friends and family.
the last blog we discussed a CDC survey addressing the difficulties many
providers face in ordering and interpreting laboratory tests. The providers admit to
having significant challenges in both ordering tests and interpreting laboratory test results. They
routinely seek help from various sources, with the laboratory being at the bottom of the
list. Further they agree laboratory consultation would be a logical adjunct in helping navigate the information maze, but
they don’t go that route for several reasons; none related to the ability or
expertise of the laboratory.
the area of test interpretation, physicians find the following most useful:
followup with patients face to face, review of patients’ histories and consulting e-references. Asked why labs fall way down on their list of consults, the
respondents indicate among other inconveniences of calling the lab is the long time it takes to
get someone on the phone who is able or willing to answer questions.
physician gave this example of I what he terms inefficiency, ” I called the lab to ask about
the swab needed for a particular culture I wanted to order. It took several
minutes before I got somebody in microbiology who knew what they were talking
about to give me an answer." He emphasized that doctors have very little time
to spare hanging on the phone or being transferred to several people to receive simple
physician pointed out that many physicians are not even aware that the lab
might have high-level resources to help them when they need it. Labs need to
make it known when they offer such services, he emphasized.
seems, therefore, like labs need to offer consultative services, make it known to
physicians that such services exist and also make the process more convenient
analysts discussed the use of information technology (IT) to automate certain
functions that would both facilitate consultation and force physician behavior
towards better utilization management.
in which IT could be useful include reflex testing, trending, interpretive
comments and physician order entry (POE) with electronic prompts (test definitions, suggestions,
soft stops and hard stops). These require medical staff leadership upfront but, once in place, can provide valuable education and help to manage behaviors basically on auto-pilot.
interesting concept discussed by co-author Paul Epner, a consultant interested
in the link between lab services and patient outcomes, is that of offering
trend reports of various providers. For example, IT can easily track and compare the
ordering practices of various providers. Do all cardiologists in a practice
order tests with the same frequency? Does one order CKMB while the others order
troponin? Does one physician order expensive reference tests which could be done on an outpatient basis? Who orders daily profiles when individual tests would suffice? Physicians can be pretty competitive and critical, so this type
of report can help in guiding test utilization as well.
laboratory should monitor physician calls: what do they want to know? What do
they seem to have most problems with? How fast does the lab resolve physician
concerns? Are resources available in terms of best-practices literature or an expert in the laboratory? These are always prime areas where stepping up and offering help would be appreciated and contribute to physician satisfaction as well as better patient care.
according to this survey, there is concrete proof that physicians do need our help, and would gladly consult with us. In fact
most would be grateful for our help. But we have to stay current in MLS to be comfortable providing factual information, we must be willing
to help, we must make it known to physicians that help exists, and we must respond to requests (or evidence of knowledge deficit) in a timely
manner. Since we are all busy, we should utilize automated aids when possible. In both the short and long term, IT is a powerful, but vastly
underutilized, arrow in our quiver.
anyone reads my writing knows I am a huge proponent of a more independent practice
model for Medical Laboratory Scientists (and MLTs to a degree). A component of
that model would be closer interaction with physicians and a willingness and
ability to consult with physicians offering advice and information on medical
when I make this bold assertion, I receive one of four reactions:
blank stare. What are you talking about?
am a tech, not a doctor. That suggests discomfort, lack of preparation or lack
is the one who went to medical school. This might be an unwillingness to use
valuable time “teaching” professionals who should already have that knowledge.
There might also be a willingness to give up information freely to someone who
would then use it without giving credit.
don’t need our help. This last one may be a combination of the above or simply incredulity that doctors
would “stoop” to asking for help in any way
studies crossed my desk in the past couple of weeks; both vindicating my
long-held viewpoint and in fact giving in objective terms when and how doctors
would need help from the laboratory.
The first study was
more of a survey conducted by the CDC’s Clinical Laboratory Integration into Healthcare
Collaborative (CLIHC). The survey
evolved from several focus groups conducted by CLIHC and sent to over 30,000 primary
care practitioners (PCPs). They had a 5.6 percent response rate, that is 1,768
PCPs responded (Journal of American Board of Family Medicine 2014; 27:268-74).
Of the findings, 2
struck me pretty significantly. Even though PCPs
see a large number of healthy patients including younger people and well adults, they
reported ordering laboratory tests in 31 percent of their patients. Further, they had
difficulty ordering tests and interpreting results in 15% and 8.3 percent of patients
respectively. Those percentages might seem small, but the authors of the study point
out that there are more than 300 million PCP visits in the US annually. That’s
a lot of patients potentially having the incorrect test ordered or results
To further place this in context,John Hickner, MD,
lead author of the study who is professor and head of clinical family medicine at University
of Chicago Medical School, said in Quality Improvement terms (e.g. LEAN) even a
1% error is unacceptable, yet this study shows a total error of over 20
percent. “This is a big problem,” Dr Hickner says.
Another huge area of
concern for doctors is the cost of tests. They receive pressure from hospital
administrators and patients to contain cost, but they have no idea how much different
So how do physicians
typically cope with knowledge gaps in these areas? They use e-references, refer
patients to specialists (you handle this!) or use curbside consults (John what
do you think of this patient's results?) Specifically asked about consulting
the laboratory they said that lab consults would be very valuable and would be
welcome. However they do not do it
because it is not offered. Despite the perceived lack of that option, an
optimistic and persistent 6 percent of doctors do still try to consult the lab, however.
I would welcome feedback
about your opinions on these findings and I will continue discussing the findings
of this important study. I will also describe the second (totally separate) study
I mentioned in my introduction. Some
questions to ponder: specifically why do physicians think lab consults are not
available? Do those intrepid souls who seek out the lab find the lab helpful? Do
they ever change their mind after speaking to a laboratorian?
We’ll discuss those
and other questions in my next two blogs.
the workforces ages we find many Baby
Boomers (born 1946 to 1964) are retiring and the workforce is increasingly
made up of younger individuals. The interesting thing about different generations
working together is that values and even work ethics will vary. Oldsters (Boomers
like myself) tend to assess younger workers as being sloppy, unprofessional and
reality, though, is that very often younger laboratorians and other workers
just don’t see themselves as “married” to a job the way Boomers are.They are
early adopters to technology and tend to eagerly welcome new “toys” in the lab
rather than see them as just additional instruments to learn, maintain and
generations tend to live by the axiom, “We work to live, not live to work.”
They realize they are very likely to have several jobs during their work life
and do not have unwavering loyalty to any one organization. But that does not
make them unprofessional slouches. In fact we raised many of them to be the independent individuals
- Generation X: Defined as the
generation born between 1965 and 1980, members of this group are more
likely than their predecessors to have been raised in single-parent
households or by two working parents. Having grown up playing video games
and using computers, they may see technology as allowing them to work
smarter and tend to use technology in daily life: to schedule, make goals,
tote files around, make presentations and communicate.
- Millennials: Born between 1981
and 2000, members of this group are also known as Generation Y or
Generation Next. As noted in a 2007 Pew Research report Millennials have been “shaped by an unprecedented
revolution in technology and dramatic events both at home and abroad.”
Gen Y is more diverse, racially and ethnically, than
previous generations and is often seen as being more tolerant on various
issues, the Pew report found. For Millennials, the line separating their work
life and leisure time may be less defined and they may be more likely to move
from one job to another with no qualms.
Generation Y individuals are much more likely to entertain and accept
divergent views and are less conformist. They might question rules and find it
logical to make exceptions to rules based on specific circumstances. They also
expect management to understand why the need for work-life balance might prevent them from
sacrificing for the good or convenience of the organization.
Whether you are the manager or peer of a member of an intergenerational
team, it helps if you are willing to accept certain realities without being too
judgmental of those not exactly like yourself. Different perspectives prevent the
stagnation of group think. So the “young ‘uns” may be different, but that also
means they offer different benefits, making the entire team stronger.
So, how do you cope with that Generation X or Millennial for the good of your laboratory? A University
of Notre Dame business school pamphlet offers the following suggestions.
- Value individual strengths: Lose the stereotypes that come with labeling groups of people.
Instead, maximize the potential of each member of your team by
understanding and appreciating his or her background, skills and goals.
- Provide training: It’s not enough
to simply assemble an intergenerational team and expect it to work
flawlessly and seamlessly. Provide awareness training and allow employees
to learn about their differences, as well as their similarities.
- Create partnerships: Establish
mentoring partnerships among the generations. For example, team a
tech-savvy Millennial with a baby boomer who values technology but needs
some hands-on training.
- Be flexible: Acknowledge and,
if possible, accommodate various work styles. That may include offering
flexible hours and work-from-home options. It might also involve catering
to different food and drink preferences in the company cafeteria, or
providing wireless connections for employees’ personal mobile devices or
charging stations for their electric vehicles.
If you follow these suggestions, what is generally perceived as an annoyance
and a negative can be turned into a huge benefit.
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.
overutilization of laboratory tests continues to be the bane of laboratory and
hospital management. Overutilization is troublesome for several reasons, of
-Laboratory professionals are frustrated
by clear misuse of tests and sometimes needless repitition of previously
performed tests e.g. daily profiles or repeat of send out tests before the
original are on the chart
-Hospital management are acutely aware that
overutilization increases costs. Organizations that receive a per diem rate
from Medicare or a managed care policy, for example, are just eating into their
profit margin with every service (including laboratory test) that they perform.
patients are not discharged as scheduled in order to perform additional tests or to
wait for test results. Some tests are not necessary; others are important but
can be performed on an outpatient basis.
-Physicians do not benefit from
overutilization because they have to address any abnormal results that turn up
during the process. They also are under pressure from administration to keep
costs down and to discharge patients ASAP.
-Patients are inconvenienced and suffer
discomfort when subjected to frequent lab draws, and they may have a heightened
sense of anxiety while waiting for “yet another test result.” They do not always
understand why a result will vary from day to day and worry needlessly.. One
cause of idiopathic anemia is frequent blood draws while in the hospital.
what is a laboratory to do? Since physicians drive test ordering it is
important to get physician input and to co-opt physician champions to tackle
the problem. If you have a strong, knowledgeable pathologist that helps. But
even absent such a person, it is possible for the laboratory to gather
information regarding the points raised above and also refer liberally to independent sources describing best
practices in laboratory utilization.
method that a few laboratories have adopted successfully is the use of formularies
similar to drug formularies. It is a common concept that just about every hospital
pharmacy has a formulary of “acceptable and available medications.” Physicians
must pick from that list. Any deviation must be approved by a committee-or at
least be honored only after detailed justification and documentation.
information technology folks play a significant role in forcing physicians to
stick to formularies. If they try to order an off formulary drug-or even an
off-label drug available in the formulary- they may receive a soft stop or a hard
stop in the computer system.
same concept can be used for laboratory testing. If a physician orders some
tests (no longer available, inappropriate, very complex, very costly, ordered too
frequently for that patient) they can receive the same hard or soft stop.
Either the test is not allowed at all, or the ordering physician needs further documentation
and approval in order to have that test done.
is very likely (as happens in pharmacy with off-formulary and off-label use of
medication) that some physicians will protest, be slow adopters or will call the
laboratory directly for an explanation of rationale; or even to over-ride the
hard stop. They will pull rank and try to be exempt from the rule. Pharmacists
are very adept at fielding such calls. In order for laboratory formularies to
work it is important for laboratorians to be equally knowledgeable and confident
when speaking to possibly frustrated and aggressive physicians.
today’s climate of high cost, innovative operational methods and
overutilization of lab tests that this is an approach worth pursuing.