Managing supplies is complex. Contracts, par levels, shipping schedules, and storage issues are unique in a hospital setting, because the laboratory is largely self-contained. Your central warehouse may distribute gloves, sharps containers, and other common items, but chemistry reagents are yours to manage, for example. Added to this complexity is lot sequestration.
I’ve been pondering this as we approach switching coagulation reagent lots. Every year we dread this lot changeover. (Are we the only ones?)
Depending on the manufacturer and reagent system used, there can be significant drift in normal ranges that affect INR calculations and heparin sensitivity that affects therapeutic ranges and heparin protocols. A lot to lot change in coagulation is more complex than with other methods for these reasons, involving collecting at least 40 “normal” patients, performing a correlation between old and new lots, testing quality control, and possibly creating a new heparin curve. Ideally, this should involve multiple shifts and techs to simulate real use over time to include as many variables as possible.
It can be confusing, expensive, time-consuming, and frustrating. What a pain.
Maybe, your lab has found a way to make it painless. I’d love to hear about it. In the meantime, there are a few ideas that can make it easier:
- Normal countdown. We post a countdown number to track how many normals we’ve collected to get phlebotomists involved. There’s something about posting a number that works.
- Cholesterol testing. We offer a concurrent cholesterol test for employees who donate a normal sample for testing. This also gives us a chance to explain to people in the hospital what we’re doing and why it’s important.
- Calculations. I enter the data into spreadsheet templates and share the data often with the techs to give a real time sense of where we’re at in the process. This helps some techs see there’s an end in sight.
It’s just more to do heaped atop the daily workload. Perhaps, this is harder in smaller labs with more generalists where it’s a grind switching gears day to day. It’s rarely lots of fun.
NEXT: We’re Back in Junior High
It’s the same story at many labs: techs who have worked in the field or worked together at the same lab for decades. These techs know each other well. They know strengths, weaknesses, habits, and body language. They know who gives favors, who is a doormat, and who doesn’t budge.
If you’re one of these techs, you know what I’m talking about. You comfortably fit into your job and coworkers, and your job is still fulfilling after decades. It’s a good feeling to know what you know. I’ve talked to many techs who say they still love their job after 30 years. That really says a lot about our profession.
Our wealth of experience and professionalism should be used to mentor new techs.
A mentor is “someone who teaches or gives help and advice to a less experienced and often younger person.” This is a natural role for techs with experience, knowledge, and ethics that have stood the test of stress and time. Techs who know their jobs inside and out are natural teachers and eager to share their knowledge. Mentoring is an easy next step.
As executive and author F. John Reh writes for About, “One of the most valuable assets your career can have is a good mentor... This guidance is not done for personal gain.” We have all needed mentors. And some of us were lucky enough to have one.
I was very lucky to have two. As a new supervisor and later manager, a consultant guided me through thick and thin, guiding and helping me with many projects and problems. I still occasionally email or telephone her with questions, fondly signing emails with “Grasshopper.” As a writer I was fortunate to know and work for a novelist who recognized talent I didn’t see and encouraged me to write. He spent time reading my awful prose and coaching me when he could have been writing himself, an astonishing gift in a profession of introverts.
The most valuable lesson is the mentoring itself and what it means. How about you: did you have a mentor?
NEXT: New Lots, Lots of Fun
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is designed to protect a patient’s healthcare information from unauthorized disclosure among other things. Laboratories, for example, may do so “for treatment purposes without patient authorization, as long as they use reasonable safeguards,” by fax, email, telephone, etc. But what if the disclosure is unintentional?
As a department manager, I frequently review results, charts, and history for quality and workflow purposes. For example, I might review a history and physical of a person admitted from the ED who has had blood cultures drawn. It’s easy to run across test results and healthcare information for people I know personally in the community. It’s part of the job but falls within “treatment purposes.” We can’t help but see this kind of stuff in our professions, unless we work a city away.
I don’t have access to all information. I can’t look at results just because I know the patient. If it is within the course of my duties or work, that’s fine. I might, for example, review a urine culture on a close relative that I didn’t know had been collected as part of quality assurance. Like everyone else working at the hospital, I have to put a patient’s personal information aside and be discreet.
This can be difficult.
What if, for example, a tech delivers a result to the emergency room and discovers her husband has just arrived with chest pain? She sees the chart, sees his name on a computer screen, or hears a nurse or doctor mention the name. It’s impossible in these situations to remain objective. There’s no way the tech can return to the lab and work, obviously.
This is an interesting dilemma, since it is understood in normal circumstances that the wife would be at her husband’s side during this ordeal. HIPAA allows disclosure to a family member if the information is directly related to patient care or payment. But in this case the spouse learns of the event because of unintentional access to information that was impossible to ignore.
Has this happened to anyone? And how was it handled?
NEXT: Did You Have a Mentor?
I’ve blogged about management myths -- many aren’t trained to be managers, for example -- but not about loneliness associated with the job. I discovered for myself last year that as a manager I’m alone, the cart before the cliche of being lonely at the top. Your manager is alone, too.
A recent study from the University of Western Sydney highlights the plight of middle managers. Says study author Dr. Melissa Parris, “The study reveals the day-to-day work experiences of middle managers are leaving them feeling lonely, frustrated and isolated from friends.” In particular, Parris found, middle managers have a hard time distinguishing between being friendly and forming friendships in the workplace.
Lonely people are often unhappy, managers included. As Forbes points out, “Because the leader’s actions reverberate, one person’s isolation becomes a larger problem when it leads to poor decision-making, negativity, fatigue and frustration. And who wants to work for an unhappy person?”
Newfound isolation is especially jarring for those promoted from within. It’s devastating to be proudly promoted into management only to be shunned, ridiculed, and get “attitude” from friends and coworkers. These people know your flaws and too easily take advantage of them. It frankly makes me wonder why anyone would risk promoting from within.
I’m not sure coming in from the outside is any better. It can be impossible to make friends, at least right away, in a political minefield. A new manager is seen as a threat or savior by those who are afraid of losing influence or willing to exploit the situation for their own benefit. It’s a given that any new manager will be alone for a long while. This is even harder to deal with when moving to a completely new area.
I was lucky to make fast friends with the dietary director. We spoke the same language, laughed at the same jokes, watched the same movies, and shared many of the same ideas about the workplace. When he left for another job last year, it was rough. I never realized how lonely my job is until I was alone.
NEXT: A HIPAA Dilemma
We touch our patients. Our profession is not as hands on as some, but collecting blood samples and other procedures involves close contact and a physical touch. Here’s a question to ponder: how much do you touch your patients, and how much of that is deliberate?
Touch is our primary way to communicate compassion and other emotions. Berkeley psychologist Dacher Keltner describes a study in which students were separated by a barrier and could only use touch to communicate; one person stuck her arm through the barrier while the other tried to convey an emotion through touch. Remarkably, participants guessed right 60 percent of the time.
Touch has positive effects. Writes Keltner, “Research here at UC Berkeley’s School of Public Health has found that getting eye contact and a pat on the back from a doctor may boost survival rates of patients with complex diseases.” This succeeds in part because patients expect compassion from healthcare professionals.
This need to be touched, especially when at our most vulnerable, is part of our humanity. Yet our comfort with it is learned. According to Psychology Today, reasons include how much we were touched as children, temperature (people in warmer climates tend to touch more), and even religion (agnostics and atheists are more touchy).
Here in Maine where the temperature can swing 50 degrees during a winter’s day and many of the locals stay clad in tee shirts and jackets, I’d assume people would want to be touched to keep warm. While Mainers’ stoicism is tolerated in good humor, that doesn’t mean as patients they don’t expect our compassion communicated through touch.
I touch a patient’s forearm lightly while making eye contact before examining for a venipuncture site. I’ve always felt that a sincere touch can reassure a patient and let them know I won’t hurry. If the patient relaxes, drawing blood is easier, too. This is deliberate on my part, but I’ve observed a wide variety of contact from healthcare professionals. We seem shy to touch each other and don’t discuss its benefits. We don’t have a touch strategy. Maybe we should.
NEXT: Your Manager is Alone
Culture or not? is not a straightforward question. We tend to see specimen results while the rest of the team sees the whole patient.
Recently we talked to a hospitalist about a urine culture that had been collected by the ED as a reflex urinalysis prior to admission. Did he know it was positive?
He didn’t. He ended up theorizing about the dangers of needlessly treating patients and his concerns of contributing to antibiotic resistance.
“This patient isn’t symptomatic,” he explained. “She can be admitted from the nursing home with a positive culture and be put on cipro, return to the nursing home and eventually have another culture with the same results and treatment. Eventually, the bug becomes resistant and we’ve treated her for nothing.”
The ED doc had a different view. He said, “Often I find elderly patients don’t show clear symptoms. They may have less sensation, for example. I find if I don’t treat they return with a more serious infection or are septic, in which case they could crash.”
So, culture or not? The answer is less important than the lesson that our results aren’t interpreted in a vacuum and shouldn’t be reported from one. The more we know about what the physicians and nurses are looking for and why, the better we can help the patient. In this case, for example, we may have avoided expense and effort by communicating with the inpatient team sooner, recognizing that decisions often change.
As those who analyze specimens and report values used to make clinical treatment decisions, we should be on the front lines more often reviewing charts, verifying our reports are understood, and talking directly with doctors and nurses about collection and testing options. We should be a visible, approachable resource.
We tend to standardize processes, but patient care is dynamic. Traditionally we stay put behind doors testing and reporting, inside the black box with specimens going in one side and values out the other. I’m sure this makes report disclaimers, rejections, comments, and even test order appear arbitrary. Face to face communication can make the arbitrary purposeful.
NEXT: The Power of Touch
A lab receives a complaint from a surgeon that lab work was not done on a preop patient even though the lab requisition was faxed by his office staff to the OR.
The problem is potentially big. The paperwork was faxed sometime in the middle of the week, the patient drove to the lab the following Sunday to have the labs drawn for Tuesday surgery, but without an order the patient was sent home. Monday the physician calls to complain, and the patient drives an hour in a downpour to be drawn. By the afternoon a specimen with a positive antibody screen is couriered to a reference lab. Antigen negative units arrive by morning, but it’s close.
That morning the lab tells the OR blood is ready and explains the patient’s antibody. The OR had the requisition but says, “That isn’t our system and the office knows it. It’s their responsibility to fax the paperwork to you.”
It’s funny how tunnel vision is 20/20. Of course, it’s better for the office to fax everything to one number. And it’s better for the patient to make one trip.
Near misses happen in the best systems. Efficiency doesn’t imply adaptability. It’s easy to fall into a trap of making customers work for us to improve our productivity. It’s why we pay at the first drive through window. But why do we think this way?
Any workplace is a box. We all become obsessed with the details of maneuvering the maze inside, flipping switches to get cheese (unless some idiot has moved it), and avoiding electric shocks. It’s easy to forget that outside the box is a world that justifies the existence of the box, because we tend to interact with everything to get cheese or avoid shocks. At the end of the day we just go home and complain about how stupid everything in our box has been. Day in and out it’s all about the box and our weird life inside it.
It’s easy to forget that it’s all about the customer. I wish the customer didn’t have to remind us.
NEXT: Culture or Not?
We employed a temp doctor who loved terrible breakfasts. During rounds we would stop by the dictation room to update her on cultures and other issues, and she listened while inhaling a fast food breakfast sausage muffin egg and cheese thing wrapped in a baby space blanket. I can smell it as I write about it.
Lab techs aren’t any better, bringing in muffins, bear claws, bagels, donuts, and those muffin egg things. We’re all busy, and we all tend to eat on the go to save time. When stress comes to shove, it’s therapeutic to eat comfort foods.
But two hours later, everyone is drony, irritable, and jonesing for break. Could this be related to the quality (or lack) of breakfast?
Much has been published on the effects of breakfast on schoolchildren to justify funding meal programs and educate parents, although the data doesn’t appear conclusive. An article in Public Health Nutrition concludes that the effect of fasting on performance isn’t uniform and may be linked to the nutritional status of the children, but breakfast does have short-term effects on memory that may be linked to glucose levels. The American Journal of Clinical Nutrition agrees that definitive conclusions of the how breakfast affects cognition and memory are elusive, but eliminating it does interfere, especially with malnourished children. But the journal Pediatrics has this regarding a crossover trial of 104 students between 13 and 20 years:
Breakfast had no effect on sustained attention among high school students. Visuospatial memory was improved in male students. Self-reported alertness improved significantly in the entire study population. Male students reported feeling more positive after consuming breakfast, compared with the fasting condition.
It’s terribly easy for workers to pick up something sugary on the way to work to jack up energy and mood. And as the studies on nutrition in school children suggest, this may have short-term effects. Skipping breakfast seems like a bad idea all around.
I can easily imagine that breakfast affects alertness (and maybe the quality of work) at the bench. I’ll have to ruminate this over my next cup of coffee.
NEXT: It’s All About the Customer
We report an estimated GFR using the MDRD (Modification of Diet in Renal Disease) equation. Sometime last year we stopped reporting the value in patients over seventy, because it hasn’t been validated for that subset of patients. It can still be useful, but it can also be misleading. Curious providers can use online calculators, preferable to reporting a questionable value.
And while our information system is able to automatically add patient age into a calculation, it can’t access weight or any other parameter for other calculations such as the Cockcroft-Gault that modify an estimate for BMI.
That can be difficult to explain. I received a telephone complaint from a nurse at a nephrology clinic that we didn’t report an estimated GFR on a patient greater than 70. I explained why, but she was adamant.
“I don’t understand why you don’t report it,” she said. “All the other labs do it.”
This is more than a simple argumentum ad populum fallacy. Despite being given a logical reason for suppressing the number, she insisted over and over that “other labs” provide the result. Why not us? I can imagine her thoughts as she repeated herself: your lab is smaller and not as good as the others; you aren’t as current as bigger labs; you’ve created a general rule for a special circumstance e.g. a patient with little muscle mass over 70. Perhaps. We just adopted a different policy based on recommendations.
I don’t think her bias is condescending. I’ve heard too many variations of this “bigger is better” argument over the years to take it personally. It’s a peculiar blind spot of larger organizations. One could also say, “Smaller is faster,” I suppose. In smaller labs techs know their patients and customers. It’s easier to be a generalist in a smaller lab. And so on.
Still I’ll bet this nurse won’t ask the other labs why they “all” do it when we don’t. Our deviation is a source of irritation and a customer service issue, despite a report comment and my explanation for no result. And you know? She’s right.
NEXT: Eat Breakfast, Work Smarter
I knew an old country doctor who ordered lab tests to confirm what he already suspected. Dewey would say it’s more important to treat the whole patient. He used cholesterol as an example. “I refuse to treat a lab test!” he would exclaim. He had dozens of stories of using wit and ingenuity to solve patient problems, most of which didn’t involve lab tests.
Last November the American College of Cardiology and American Heart Association issued new cholesterol guidelines, a major update since the 2004 ATP III (Adult Treatment Panel) report.. These new guidelines seem to have caught up to old country docs by getting rid of target numbers.
According to the experts, there is no evidence to treat to LDL cholesterol targets of less than 100 or 70 mg/dL. Instead, patient groups are identified with appropriate statin therapy recommendations for reducing cardiovascular disease:
- Individuals with clinical artherosclerotic cardiovascular disease
- Individuals with LDL >= 190 mg/dL e.g. with familial hypercholesteremia
- Individuals 40-75 years with diabetes and LDL 70-189 mg/dL and no evidence of artherosclerotic cardiovascular disease
- Individuals not in the above categories but who have an LDL 70-189 mg/dL and a 10-year risk >= 7.5%
If statin therapy guidelines are followed, physicians don’t have to fuss about reaching a particular number. According to cochair of the guidelines Dr. Donald Lloyd-Jones at Northwestern University Feinberg School of Medicine, evidence to treat to a target isn’t there, although LDL is still important. The test is a means, not an end.
Retired family physician Harriet Hall blogging at Science-Based Medicine sums up, “In essence, they switched from treating lab tests to treating patients.” Good old Dewey (he was fond of signing his notes to clinic staff G.O.D.) would agree.
A staff member told a story about a local country doc she telephoned one day to report that lab equipment was down. He said, “I’ve gotten along for forty years without lab tests, I guess I can manage for a few hours.” I sometimes wonder if these doctors are a vanishing breed. I hope not.
NEXT: All The Other Labs Do It
As the people who best know the variables that affect turnaround time, we exploit them to explain away variation. I hear this almost every day. “That culture took a long time because it was subbed again,” or “I knew the ED didn’t want that result finalized so I worked on other things,” or “We were busy!”
I don’t care about turnaround time if providers get results in time to treat patients. I say this every day I hear excuses. Fact is turnaround time does vary for good reasons. The techs are correct. So.
Is turnaround time important?
In a sense, no. A test takes however long it takes, and if a manager presses speed over accuracy that’s exactly what happens. It’s better to emphasize quality and an open dialogue with providers to make sure their needs are met. Lab techs all tend to see turnaround time as a fixed perception e.g. “We have an hour to do a STAT,” when providers see a treatment choice pending a result. Labs serve patients better by understanding time frames related to making those choices.
But turnaround time is a reliable metric that tells us something about a system. Question is what?
Last week I created a daily summary of turnaround times that prints outliers defined per test, excluding routine outpatient work. A script saves an information system report to a folder, a filter sorts and tallies it, and whatever exceeds predefined limits or arbitrary default values is printed.
Limits are broad. While the program filters lower and upper limits, we decided to ignore unusually short turnaround times by setting all lower limits to zero. Most of the upper limits are set to 120 minutes. The process essentially treats inpatients and ED, STAT and routine, as part of the same workflow. (Aren’t they?)
The idea is that techs will review and investigate unusual variation that clearly indicates a system failure. I don’t expect this happens often, because providers are generally happy. I’m interested in what emphasizing unusual variation to focus on quality over speed does.
NEXT: The Skinny on Fats
When we went paperless in order entry, it meant much more than just dumping paper, binders, index cards, labels, and hand-carried requisitions. Since all staff needed this information, each person had to have the right computer skills to use Access, search folders on the server, copy and paste, cut and paste, drag and drop, use wildcard characters, and print to a PDF.
Most of this was hands on learning, but a lot of it involved writing down the steps. How many says a lot about our profession. As I blogged, missing steps in a laboratory procedure can imply workarounds that can lead to error. This is true with computer software where a missing keystroke or mouse click can crash the whole shebang.
Thus, our computer procedures tend to be a literal listing of each keystroke, mouse click, entry variable, and any variations that can occur. They are written this way out of necessity, but they are a stark contrast to other procedures where most space between the steps is filled by professional judgment and experience.
Recently we had a problem downloading a report into a format correctly. I developed a workaround in which techs could pull up the correctly formatted result on the reference lab web site, copy and paste this into Notepad, and copy and paste the Notepad copy into the result format. The interim step was needed to correctly translate the web page, particularly spaces and tabs.
I showed this to techs. “It’s three or four steps,” I explained with brash sincerity.
Well, “three or four steps” turned out to be at least 29 steps (ten more and we would have a Hitchcock movie) when this procedure was written out, keystroke by mouse click, on two sheets of instructions. Everyone laughed. And while it really does take at least 29 discrete steps, I see only a handful e.g. three or four of steps. The gaps are filled in by experience. In this case, this perceptive dissonance is funny because we don’t all share the same experience.
Something to think about when writing procedures.
NEXT: Is Turnaround Time Important?
Procedures are the core of every laboratory, but are they followed? Watching people work, I wonder. Most techs have workarounds for the trivial and the critical, from organizing an instrument run to blood bank serology to reading culture plates. It isn’t that tasks are difficult to standardize; procedures can be incomplete, lacking details of variation that lead to significant workarounds causing errors. Thus, many techs believe workarounds are a matter of personal preference so long as results are reliable. Ends justify the means, in other words.
Do workarounds eventually cause error? That’s another matter.
Procedures can do more:
- Initial training. Students and new hires use procedures to learn how the work is done.
- Competency assessment. All staff use procedures when assessing competency to make sure the test is done correctly and there are no workarounds.
- Direct observation. When directly observing a peer or employee, the procedure is traced to ensure steps are followed. Deviations are noted and reviewed.
- Quality improvement. Management includes details that lead to variation and include metrics to monitor performance in the procedure. Good procedures consider variation in all phases of testing.
- Incident root cause. When an error occurs, reference the procedure to assess expected vs. actual behavior.
Workarounds are a symptom of who uses procedures. Instead of reading a procedure and reporting that a step is missing, a tech may assume the gap is filled by “professional judgment.” While this can be true -- a procedure can specify such instances -- the cumulative effect of process variation is unpredictable and onerous to analyze.
Developing procedures that reduce sources of variation, include quality metrics, and specify how to validate performance and correct problems aligns with new IQCP (Individualized Quality Control Plan) requirements. Procedures can integrate performance and quality.
Getting techs to use such procedures is tricky. We intuitively understand critical steps in any process and sensibly consider some variation inevitable and trivial. It’s impractical to mirror the complexity of most laboratories, and focusing on details tampers with perceptions. Bench techs should be involved in developing procedures for these reasons.
How about you? Do you follow procedures?
NEXT: Three or Four Steps
With all the talk of resolutions inevitably failing or succeeding, it’s easy to forget how we’ve failed or succeeded. I haven’t made resolutions since 2012, but last year blogged about goals. Here is how 2012 and 2013 shaped up:
Here’s how I did for 2012:
- Use email less. I can’t say I use it less, but I spend less time on it. I respond less often, write shorter responses, and rely on rules to sort emails. In particular, any email mass mailed to all employees goes into a junk folder.
- Use technology more. I really wanted to ditch paper, but the limitations of a slow computer, glitchy network, and one tiny monitor forces me to use more paper than I care to admit.
- Improve performance appraisals. I shortened these to thirty minutes or less, although real “improvement” is elusive. No one is quite sure what these accomplish.
- Give away more. I’ve mentored and delegated with some success. One thing I didn’t count on is how dramatically this changes a workplace dynamic.
- Listen. Uh... what was that? I’ve been told I look like I’m listening to people, and that’s something.
- Online procedures. Not even close, and the techs don’t want it. The problem is PDFs are slow and resemble paper. Paper is fast and IS paper. Why don’t IT people get this simple truth?
- Get rid of filing cabinets. I got rid of a huge filing cabinet in my office, adding room for a chair.
- Get rid of posted paper. See “use technology more” above.
- Drills. Nope.
- Patient rounding. I’ve had some success doing this since September, but the techs aren’t quite sold on the idea.
It is interesting that the few successes are specific and measurable. A filing cabinet, for example, is a specific object that can be eliminated if not used. Posted paper doesn’t mean much or, perhaps, it means too much to too many people.
Most of the 2012 resolutions took more than a year. For example, I didn’t change performance appraisals until last summer. Maybe, that means my 2013 goals won’t be done until 2014.
NEXT: Do You Follow Procedures?
A University of Scranton study lists the top three New Year’s resolutions: losing weight, getting organized, and spending less. Only 8% of the 45% of Americans who make resolutions achieve their goals. An article in The Wall Street Journal cites a British study concluding that 88% of resolutions end in failure, which, at least, is a tad more optimistic. We can always resolve to be less of a failure at keeping our resolutions.
The same article describes a neat experiment in which undergraduates were divided into two groups. One group was asked to remember a two-digit number, the next a seven-digit number. They were asked to walk down the hall and choose between cake and fruit salad. The group asked to remember the longer number were more likely to choose cake. Why? Their minds were two preoccupied with the extra numbers to resist temptation. Our willpower, it seems, is easily worn down.
The problem with resolutions is they are often too vague to succeed on willpower alone. “Lose weight,” for example, isn’t a plan with specifics, mile markers, and an endpoint. Likewise for getting organized, spending less, getting to work on time, being a better coworker, and anything else we think we’re setting our minds to.
If you aren’t planning to celebrate success, you don’t plan to succeed.
One approach that can work is to set SMART goals, created by George Doran in 1981. It’s an acronym that’s easy to remember:
- S - specific
- M - measurable
- A - attainable
- R - realistic
- T - time bound
Doran describes this in terms of management, but the idea works in real life, too. For example, “lose weight” can include a plan of getting up 30 minutes earlier to exercise, using a smartphone app to track calories burned and food intake, and realistic target goals of foods to eat and pounds to lose.
The beauty of a SMART plan is it doesn’t occupy our prefrontal cortex while you’re trying to choose between cake and fruit salad. It’s automatic once set in motion. Lab techs already have too many numbers to remember.
NEXT: Last Year’s Resolutions