Stepwise Success

Read This, Read That

2008-05-22T18:22:00Z

My oldest son has become an avid reader, bringing back my own memories of reading Way Down Cellar, The Wonderful Flight to the Mushroom Planet, and The Phantom of Walkaway Hill. So, when he asked me one day why I don't read--as in novels--my answer surprised me. "I read a lot at work."

It's a simple answer to a complex question. Reading--any reading--involves comprehension to connect new information to what is already known. According to The National Institute for Literacy, monitoring comprehension by asking questions while reading is one effective strategy. Pausing to reflect ... makes all the difference.

But we aren't sitting in an armchair on a lazy Sunday afternoon reading the weekend paper. We are constantly reading emails, paper memos, posted notices, bulletin boards, financial reports, faxes, information system reports, spreadsheets, regulations, policies, procedures, patient charts, physician orders, reference texts, package inserts and magazines (even blogs!). Sometimes, all in the same day. And we are expected to produce accurate and timely test results using this information.

A concept of information literacy has emerged. The library, the reference text and the periodical are eclipsed by concepts such as business, computer, health and media literacy. To be "information literate," you need to be able to find what you need and decide if it's any good. A National Forum for Information Literacy was created in 1989 to tackle our "increasingly fragmented information base."

This implies two things. One, what we read being accurate or even relevant decreases with volume; we have become speed readers. The second is "information overload," coined by Alvin Toffler almost 40 years ago in Future Shock. More information adds to stress and the likelihood of forgetting--or not seeing--something important.

It's enough to make me want to curl up with a good book.

The Speed of Information

2008-05-12T18:02:00Z

My old boss used to say, "Any delay is too long." He was talking about programming iterate functions on a computer, but it's true for many things. We all hate to wait.

But what are we waiting for?

In a healthcare system, the speed of information is crucial to patient care. Patient identification, physician orders, and laboratory test data are moving at speeds unheard of a generation ago. Barcode scanners, bidirectional interfaces, physician order entry, expert systems and autoverification are all designed to increase speed.

But ever-decreasing turnaround time makes acceleration the goal instead of always putting information in the hands of the physician in time to make a treatment decision. It's something many bench techs instinctively know: faster doesn't always make a difference to the patient.

The key to "speed" may be meeting expectations every time, suggesting that consistency defines expectations and paces performance. We understand this in the laboratory. A phlebotomy station is easier to staff if patient flow has fewer peaks and lulls. Multiple instruments are easier to load and result if turnaround times are reliable. And any manual process works more smoothly with fewer interruptions. Less variation is easier to work around.

According to this in Clinical Lab Products, many laboratories are adopting a "real-time" performance model without priority distinction. At one hospital this reduced Stat orders from 54 percent to 3 percent. This non-traditional approach to curbing Stat abuse works by improving turnaround times on all testing. More to the point, turnaround times are closer to each other if "batch and rack" testing is eliminated.

We should strive to control the speed of information. If we can do that, maybe everyone will wait a little less.

Your Culture

2008-05-05T16:44:00Z

Imagine in the near future, a job applicant asking, "What is your culture here?" Your first thought is Duh, it's a laboratory.

But with the pressures on healthcare, you may already be hearing plenty of talk about your organization's "culture." Even if you haven't, it exists and is important. In a way, it affects everything within your work environment.

A culture can be thought of as a set of values that guide behavior of employees. Does the culture in your laboratory reflect your hospital's values? How effectively does senior management influence the behavior of employees? One measure may be how closely behavior aligns with the organization's mission, vision and values.

Here is advice for applicants regarding corporate culture: "The bottom line is you are going to spend a lot of time in the work environment--and to be happy, successful and productive, you'll want to be in a place where you fit the culture." The author suggests asking key questions about how decisions are made, team building and behaviors that are rewarded. It suggests reviewing a company's annual report, Web site and to arrive early for an interview to observe employee behavior, demeanor and appearance.

For an applicant, it's smart shopping. For your laboratory, it points out the obvious: a happy, productive environment is a deliberate choice made by employers. A culture is planted, nurtured and occasionally weeded. As an industry shortage looms, these workplace environment issues will become more critical as people have a choice where to work.

Such applicants are really asking what kind of place is this to work? Perhaps, it's another sign the value of work is changing, as I've written here. But it's important to imagine cultural clues an applicant perceives during an interview.

Think about your answer to the interview question posed above. Think about what your answer would be now versus where you would like to see your laboratory. Are they different?

Other Managers

2008-05-02T15:07:00Z

Becoming a manager means changing your peer relationships. Instead of competing with another work silo, you now need their cooperation. It is essential to transition from the subordinate-supervisor relationship to this new peer setting to complete projects and achieve success.

A new manager can't do it alone. As this article from the Harvard Business School suggests, seeking assistance is essential to growth--superior and lateral, internal and external. Building relationships in an organization helps ensure success. And while your experience is different from a nursing manager, advice and emotional support are invaluable.

To be sure, "intractable" attitudes are hard to schmooze away. Nurse managers can perceive themselves as more qualified or authoritative. Other departments with more access to physicians can isolate your laboratory. But it's often what happens on the floor that can determine your success in dealing with other departments. It's what makes building relationships with other managers so critical.

For instance, when a physician complains about your laboratory at a nursing station, is your department defended? Incident reports can offer clues. If a nurse manager writes up an adverse treatment event as "The lab did it!" there probably isn't much time spent defending your laboratory. This is a relationship problem as well as a system failure. Fixing the latter won't help the former.

One solution is to develop lateral relationships. Seek out counterparts in other departments to ask for advice, share information or just chat. Social settings--even the hospital cafeteria--are non-threatening environments in which to meet. I make a point to walk through nursing stations at least once a day to see what's going on and if I can be of help with anything. It helps make my job easier. And maybe--just maybe--the laboratory is defended once in a while.

Understanding Tests

2008-04-28T17:20:00Z

It is the laboratory scientist's responsibility to make a test choice clear for the physician. We can be expected to reasonably interpret an order that doesn't match a menu name (AST for SGOT, for example). Other times, a questionable order is a methodology choice. A simple telephone call to the provider, a pathologist or a reference laboratory can clarify ambiguity.

The FDA and the Institute for Safe Medication Practices (ISMP) recognize the error potential of ambiguous abbreviations. Their education focuses on medications, but it isn't a stretch to apply this to the laboratory. Reference laboratory test menus, in particular, can create a bewilderment of choice.

Less often, a test report isn't clear or is difficult to interpret. There are even those times when the provider hasn't ordered what he thought he ordered.

As this small study published in a British biochemistry journal suggests, not all physicians are equally up to speed on laboratory tests. Junior doctors--similar to American interns--order a majority of laboratory tests, but nearly one in six admitted not being able to fully interpret the results.

How can laboratories help? A proactive approach can help make a laboratory, regardless of size, an approachable and responsive resource.

A laboratory newsletter is an excellent way to let providers know what the laboratory offers. Reference materials such as specimen collection charts, media guides and directory of service booklets are invaluable for providers and office staff.

Much of this material can be on a hospital Web site, emailed or distributed on a CDROM. Test synonyms in computerized physician order entry (CPOE) systems are helpful. Finally, it's useful to periodically survey providers to make sure a particular service responds to their needs.

As engaged professionals we can help improve patient care. We need to build partnerships that help providers understand laboratory test menus and reports.

The Press

2008-04-18T13:49:00Z

I sometimes wonder why an evening newscast devotes so much time to what the weather might do and so little to all the neat stuff happening under all that weather. Then it hits me like an extra of the Times. The news is a mile-wide, inch-deep phenomenon. Journalists can't know everything, especially if understanding isn't condensable into a ten-second sound bite. The common ground of most stories, then, is human misery.

Which makes the weather a story of hope, I suppose. Still, I often cringe:

"The number of MRSA cases in Maine is hard to pinpoint because hospitals are not required to report them to the state." Portland Press Herald
"... advocates for improved screening argue that the MRSA legislation is necessary because hospitals are moving too slowly in screening patients." The Baltimore Sun.
"MRSA is responsible for more deaths than AIDS in the United States." Columbia Tribune
"Ten patients a day killed by C. diff bug." The Telegraph
"The proportion of death certificates mentioning Clostridium difficile (C diff) rose by 72%." The Guardian

Hospitals, apparently, are cesspools. And if a bug in the hospital makes us sick, it must be because that bug is there and not here--not because we are sick to begin with. Hospitals struggle not only with containment but control, almost impossible in a public environment where handwashing is the biggest unknown. For microbiologists, it's old news.

But for patients, it's frightening. These stories manage to offer just enough information without perspective to scare most sane people. "Flesh-eating bacteria" says it all.

As healthcare professionals, we should be proactive with the general press to educate the public. A local column explaining what new services are offered at the hospital, a newsletter, patient brochures, and even a blog are excellent vehicles.

How do you handle the press? Are you involved with your hospital's marketing? And if so, are you successful in informing and reassuring the public, making you a caregiver of choice?

Sell Your Success

2008-04-07T13:55:00Z

I knew a Lieutenant Colonel in the Air Force who regularly walloped me at cribbage. His secret was a mean pegging game that he lost no time explaining to me--in excruciating detail--after each win. Laughing, he would say, "You can only gloat when you're ahead."

The good Colonel had a point--not to gloat, an ugly word connoted with malice--but to sell success while we can. Accomplishments should be celebrated and advertised to make others aware of your laboratory, something to think about as National Medical Laboratory Week approaches. Does your laboratory sell success?

There are two very good reasons for doing so.

First, selling success allows your staff to take pride in their work. Consider your hospital's efforts to celebrate nurses, for example. How much space is devoted in hospital newsletters, on bulletin boards, and in press releases to the success of these visible caregivers? How many service excellence awards are given to nurses for exceptional patient care? How often are the skills, education and credentials of nurses highlighted? Nurses afford this self-celebration.

Tell other departments about a drop in cost per test, a decrease in turnaround time or new technology. Highlight new certification, attendance at a seminar or professional affiliations. Chances are, the rest of the hospital doesn't have a clue what happens in your laboratory. Letting them know says, "We're great too!" and sends a message to staff that it's OK to feel proud.

Second, selling success allows others to take pride in your laboratory. As part of a healthcare team, the laboratory recognizes its own role in the success of other departments. The reciprocal is true, of course. Other departments should be allowed to bask in the unique success of the laboratory--finance for negotiating a cost-saving contract, human resources for helping recruit the best people and nursing for their complementary role in patient care.

To be recognized, you must be recognizable. Taking time to sell success will elevate your laboratory and motivate staff. Just don't beat the nurses at cribbage and gloat about it.

Quick and Dirty, Part Four

2008-03-25T14:04:00Z

We've seen that the lowly batch file can help capture quality data with little programming. Let's examine how this batch file works. Here it is:

@ECHO OFF
ECHO 1 - Smith
ECHO 2 - Jones
ECHO 3 - Doe
ECHO .
SET /P CHOICE=Enter choice
SET /P ACCT=Enter account
ECHO %CHOICE% %ACCT% %DATE% %TIME% >> NODX.LOG

ECHO--this "echoes" what immediately follows, usually to the screen.

SET /P--SET assigns an "environmental variable," used by Windows to track directory names, file locations, devices and so on. But they can be used on the fly in batch files, too. Adding /P prompts the user. Thus, CHOICE is a variable that stores what the user types in after the prompt Enter choice.

Variables need a percent sign (%) on either side. Note %DATE% and %TIME%, already defined by Windows. What's tricky is the ">>" just before the file name. This redirection operator tells Windows to append the ECHO to a file. Without a redirection, the ECHO defaults to the screen.

The graph shows our initial raw data collection, imported into Excel. Note the peaks, which represent real-time interruptions for our phlebotomists and the offices. Most importantly, they are patient delays. This kind of data helps make quality data relevant.

I encourage you to play around with the batch file or share your own success. It's quick and dirty--and it works.

Quick and Dirty, Part Three

2008-03-19T16:44:00Z

Recently, 3-hour long evening classes were locally offered to managers to learn Microsoft Word. That seems excessive for a fancy typewriter, except that Word 2003 for Dummies is 432 pages. Technology meant to save us so much work shouldn't be this complicated.

Comparable effort to explain how to use a sheet of paper, pen or even a real typewriter would be absurd. This bloatware blight creates software that is harder to write, harder to debug, and just plain harder to use.

But a program of a few lines is easy to write, bug-free and usable. For our problem of collecting quality data at point of entry, we need a way to capture the interruption (requisitions without a diagnosis) without creating another. A batch file equivalent of a paper log sheet does just that.

And here it is:

@ECHO OFF
ECHO 1 - Smith
ECHO 2 - Jones
ECHO 3 - Doe
ECHO.
SET /P CHOICE=Enter choice
SET /P ACCT=Enter account
ECHO %CHOICE% %ACCT% %DATE% %TIME% >> NODX.LOG

Be sure to add a space at the end of the "Enter" prompts. Then, cut and paste it into Notepad and save as NODX.BAT.

Double-click the batch file icon. It lists a menu of last names and prompts you to enter the number matching the name and patient account number. The information is added to a file called NODX.LOG, a text file readable by Notepad, Word or Excel.

If this batch file is added to the Windows Start Menu or Quick Launch bar, a phlebotomist can collect data in a few seconds--including date and time. NODX.LOG can reside anywhere on your network.

You can easily add names, prompts and even write to multiple files. Next, I'll explain how.

Quick and Dirty, Part Two

2008-03-17T16:15:00Z

(Read Part One.)

The beauty of a quick and dirty solution is its simplicity. I'll admit it isn't always preferable--many times it amounts to a hack--but if it works, it works. Data mining problems don't necessarily need cumbersome, complex or paperwork solutions. And that's where DOS comes in.

DOS (rhymes with "toss") stands for Disk Operating System, originally a series of I/O (input/output) routines that allowed a user to communicate with the computer. It is a non-graphical, command-line interface instead of the GUI (pronounced "gooey"), or Graphical User Interface, of Windows.

On the Windows Start Menu is a program called "Command Prompt" that brings up a window of white text on a black background with the cursor blinking to the right of something like C:\Document and Settings\User> (the so-called "C:> prompt"). Type dir and press Enter, and you'll get a list of files. That's DOS.

Here's the good part. A batch file "batches" DOS commands to run automatically. I'm often amazed at their power, given the bloatware available.

Here is a simple example:

@ECHO OFF
ECHO Hello World!
PAUSE

Type or cut and paste the above into Notepad and save as HELLO.BAT. (You'll need to change Save As Type to "All Files" and add the .BAT extension.) To run this batch file, open the folder where it is saved and double-click its icon. A window pops up that says this:

Hello World!

Press any key to continue...

Back to our problem: how to collect quality data real time. Batch files can display a message as in our trivial example. But they can also ask for input, change it and write it to a file with just a few lines of code. Next, I'll show how.

Quick and Dirty, Part One

2008-03-13T17:21:00Z

As a programmer on the coast of Maine 20 years ago, I liked a quick and dirty solution--the inelegant, simplistic, but often workable idea. Scientists call this lex parsimoniae or Occam's Razor (after a 14^th century English logician), which states the simplest solution is best, all things being equal. It surfaces in Toyota's Lean philosophy, pushing the automobile giant ahead of General Motors.

In the next few entries I'll describe such a solution.

Here's the problem: requisitions without diagnoses generate telephone calls or faxes to doctors' offices, causing delays. If the office isn't open, the patient may be turned away. Data has to be collected that answers at least the following:

What time of day does the disruption occur?
Who is the ordering physician?

Requisitions can be tagged and tallied at day's end, but this invites transcription error. An information system "marker" can be used--a dummy test, location or other tag--nice if a user does it and patient billing doesn't mind. Or a paper log can be kept--ugh.

Above all, we need good data--complete and accurate as possible--and process disruptions corrupt data proportionally. Minimal disruption is also crucial to maintain patient throughput at a busy phlebotomy station; we are especially interested in interruptions at busy times. Before we start fitting solutions to the problem, we need to imagine what the ideal solution is.

Data is captured at point of order entry
Minimal extra steps
Collection is novel and easy
Data is easily mined

A lowly DOS batch file--quick and dirty--does the job. Next entry, I'll describe what that is.

Fire Plans

2008-03-11T15:30:00Z

The Hindu reports a fire at Railway Hospital in Perambur, the fourth largest city in India, that began from a spark generated by a window air conditioner. There were no casualties, although the laboratory runs parallel to the hospital's children's wing. And at Royal Marsden Hospital in London, a fire in a research laboratory spread to engulf a large section of the hospital as reported here. Only one patient and two firefighters suffered smoke inhalation.

These are recent, not isolated, cases. Fire is always a danger, and hospital laboratories have specific hazards that put you and other employees at risk. These include flammable chemicals, compressed gases, and combustible materials. On-call staffing policies can increase the risk of a fire going undetected. Crowded equipment can create a setting with unseen crushed or frayed electrical wiring that is a serious risk.

OSHA requires employees receive annual fire extinguisher training--a good idea--and all employees should understand fire science and prevention. Paradoxically, fire extinguishers are not designed to put out fires--large ones, anyway--but are for rescue and evacuation. That's why they are located near exits and in egress corridors. A fire extinguisher could just save your life.

Not only should laboratory employees understand fire extinguishers, but there also needs to be an evacuation plan. It's not uncommon for laboratories to have rooms tucked away beyond main corridors. You may not be able to hear overhead pages in all areas. What happens if there is a fire? How do you account for everybody in your laboratory, and how do you keep them safe?

Drills are key to reinforce training. Make sure laboratory employees know the location of extinguishers, how they are used, and what happens when there is a fire. Your maintenance/safety department or local fire department can help.

Focus on Your Weaknesses

2008-02-26T16:15:00Z

In an interview, I was asked, "What are your strengths and weaknesses?" This generic question--too vague to tease a useful response--echoes our tendency to expose our strengths and shield our weaknesses. The question implies admitting to a weakness is a virtue as well as an expectation. While we all gravitate to activities, events and careers that allow our strengths to shine, we are supposed to be self-aware and honest enough to know what we can't do well.

But defining weaknesses can create a setting in which managers and employees are afraid to try something new. For example, if a manager excels at detailed analysis and tends to be introverted, he may avoid hospital politics and prefer e-mail to face-to-face interactions. This can leave the manager's behavior open to speculation--and the rumor mill, right or wrong, can be devastating. The manager, in turn, can feel frustrated and isolated; the laboratory staff can feel unrecognized.

Consider those in your organization with obvious weaknesses. Do their strengths make up the difference? A weakness coddled tends to attract the spotlight. He isn't good with people. She doesn't like computers. You can almost hear the " ... but" to justify the person's continued employment.

Truth is your strengths are what they are. They already carry you. If you are technically proficient, sensitive with patients, or a computer wizard, it's nice to enhance your skills, but this may happen anyway. Unless one of your strengths is self-actualization, it seems unlikely they will entirely excuse your failings.

But if you focus on your weaknesses (e.g., take apart an instrument, start community outreach, learn how to use a spreadsheet, etc), you can find unrealized opportunity. What have you got to lose? You may discover a new strength that leads to success.

A New Work Perspective

2008-02-19T17:03:00Z

Law and medicine careers may be losing self-respect, according to this article in the Dallas News. While these professions are still solidly supported by pay, security, schooling and responsibility, there is a sense that their status is waning.

Excerpt:

This decline, Mr. Florida argued, is rooted in a broader shift in definitions of success, essentially, a realignment of the pillars. Especially among young people, professional status is now inextricably linked to ideas of flexibility and creativity, concepts alien to seemingly everyone but art students even a generation ago.

"There used to be this idea of having a separate work self and home self," he said. "Now they just want to be themselves. It's almost as if they're interviewing places to see if they fit them."

Arguably, such a shift may be more noticeable in high-profile professions. There are a number of spins. For the laboratory, this means recruiting students who may have different assumptions than previous generations. There may have existed a want for a steady job, a prestigious career or a stepping-stone to other professions. "I just want to be myself" is a new paradigm.

I wear a dress shirt and tie at work, for instance. Why? Because it is my work self. My home self is different in many ways, dress being one example. Will the new generation of laboratory technicians and technologists be different?

It's easier for someone of my generation to dismiss this as a change in "work ethic," when there may be something more fundamental going on: a new perspective on the value of work.

If this is correct and professional status has become a matter of personal expression, then this changes what working in a laboratory means. This will echo in recruiting strategies and, ultimately, in how laboratories are managed to ensure the best patient care possible.

Encourage Dialogue

2008-02-08T19:40:00Z

Many years ago, a worried pediatrician followed me around one evening. I remember this vividly for two reasons. One, he looked a little like Tom Baker in Doctor Who minus a long scarf and bag of Jelly Babies. Two, working alone had never been so stressful. Juggling urine antigen screens, cerebrospinal fluid, and everything a busy ED lobbed at me was hard enough. The last thing I wanted was a shadow.

My laboratory manager said this: "Next time, tell that doctor to get out of the lab and let you finish your work."

I understand the need to avoid distractions that cause errors. But I wonder how this advice would have worked. "Doc, I need to finish my work. Please leave." This sounds polite, but it's "Get out" all the same. A physician worried about his patient won't take kindly to such rudeness. I wouldn't blame him.

As part of a healthcare team treating patients, the laboratory has a responsibility to find out what a physician wants. The smart solution is to open a dialogue. "What do you need first? How can I help you?" This invites the physician to share information that helps both of you work together to help the patient. And if the physician just wants to watch, so be it--maybe he can add information that will help you. But you have to ask. You have to engage yourself.

We not only have a responsibility to open a dialogue, the physician expects it. Yet too often, abruptness or perceptions interfere with what needs to be an open, professional relationship. And we've all been there--nothing puts you quite on edge. But greenness, gender or status are immaterial to a patient deserving the best care possible. There are any number of ways to open a dialogue.

"Get out" isn't one of them.