The ASCLS web site says this about Medical Laboratory Professionals Week: “As team members of one of the largest industries in the United States, the dedicated efforts of laboratory professionals often go unnoticed by the general public, as well as by the very institutions employing their services.”
Amazing. But true.
I’ll admit that I have a sketchy notion of what imaging, respiratory therapy, physical therapy, dietary, social services, discharge planning, risk management, and departments other than nursing performs day to day. But these professionals are often more visible than the laboratory. We live and work in a box that spits out results. I suspect the above knows far less about us than the reverse.
A few years ago at a meeting there was discussion about using non-clinical departments to “shadow” patient care. One of the nurses said, “We can use the lab!” Apparently, we’re just button pushers and vampires. We often aren’t seen as clinical.
Lab week is a chance to highlight our efforts, educate our colleagues, and hopefully change perceptions of what we do. Especially in small hospital labs where the entire staff are generalists, the number of clinical judgments made day after day, week after week, month after month without serious error is astonishing.
Our business is separating the normal from the abnormal, finding unexpected values, and putting it all in the hands of those making treatment decisions. A physician may suspect what a result is, but the only way to actually know is to run the test. Doctors and nurses have no choice other than to rely on laboratory methods that they know next to nothing about. That’s also astonishing when you think about it.
We should celebrate lab week -- anyone up for a giant sub? -- but also use it as a springboard to change perceptions of our profession. While we have everyone’s attention, talk about what we really do. I think they’ll be impressed, don’t you?
NEXT: Are Mistakes Systemic?
Each morning in our laboratory, we round the wards to review charts and talk to nurses and doctors about care related to lab issues. We’ve been doing this for a couple of years. This year we added patient rounding.
The idea is simple: each morning we choose one or two patients and do a “check in” to say hello, introduce ourselves in the light of day, check the wristband, check any venipuncture sites, etc.
Here are a few obstacles we encountered:
- Nursing. Patient rooms are nursing territory unless we’re collecting a blood sample. I explained the idea to nurse managers, assuring them we would ask if the patient needed anything else and be an extra set of eyes and ears. Staff nurses got the idea right away and supported it.
- Choosing patients. At first we chose patients at random, or chose patients who had received blood, or chose patients who had been stuck. This turned out to be a lot of work. Eventually we decided to run a census report and choose patients who had been admitted in the last 24 hours. This way, the morning following their admission the friendly laboratory pays a visit to check in.
- Techs. Also at first the techs objected to going into rooms without a purpose. These apprehensions disappeared quickly. It’s a happy thing to walk into a patient room without a needle, it turns out.
- Scripting. Most mornings I take a tech with me, and I ask them to follow my lead. We introduce ourselves and explain that we’re checking wristbands. We check any venipuncture sites for bleeding, hematoma, or skin problems, and then finally ask, “Is there anything we can do for you while we’re here? Is there anything you need from your nurse?”
We don’t go into rooms unnecessarily, so we exclude isolation patients and patients receiving treatment from this process. Sometimes the nurse is present. Quality data on wristbands is collected in the meantime. The quality of the smiles exchanged can’t be measured.
Is anyone else doing this? Just curious. So far I don’t see a downside.
NEXT: It’s Lab Week!
It’s inevitable. Sooner or later as healthcare professionals we become patients ourselves or our family members are patients. As insiders we are invaluable observers. We know how things should work. We know what to look for. Yet our input or feedback is less valued and seldom sought, another blog.
Recently in the ED with a family member I had a chance to observe many employees, including doctors, nurses, and technicians. Everyone was professional, friendly, and attentive. Everyone was careful to wash hands. I don't think this was done for my benefit. Most noticeable was less obvious: not everyone introduced themselves.
Saying, “Hi, my name is Scott, and I’m from the lab” to a patient I don’t know is more than scripting. It’s polite, courteous, and lets the patient know I’m accountable for what I do and say. It tells the patient he or she is important. It communicates vulnerability, making a connection with a patient who is already vulnerable. Not doing so communicates the opposite. So it’s very odd that everyone doesn’t do this.
Maybe I was tired -- it was in the middle of the night on little sleep -- but this was a big deal. When a physician walks in and says, “I’m Doctor Jones,” and a nurse walks in and says, “Hi, I’m Helen,” and then another person in a white coat walks in and just starts talking, it hits you on the head. My reaction was, “Who are you? Excuse me?”
More remarkable is our lab’s reaction to this. At our morning time out meeting I asked people if they introduced themselves to patients. Some did, some didn’t. Some resisted the idea, most had an attitude of, “Sure, it can’t hurt.” A few said, “We’re wearing a nametag, why should we?”
I suspect these perspectives are common in healthcare, possibly because we don’t all have a patient perspective. I’ve heard similar stories from other hospitals, and I wonder why we don’t ask patients for this kind of feedback. Introducing yourself is such a simple, small thing and yet so vital for human contact essential to compassion.
NEXT: Patient Rounding
Our laboratory uses many “plop plop fizz fizz” tests for qualitative screening, like most labs. These quick and easy tests have been in labs as long as I can remember with a few enhancements over the years that have made them even easier e.g. internal controls. Some of them, such as our influenza test kit, haven’t changed years.
When should we revisit our kits?
It’s interesting to consider why laboratories choose to change. Much of the time, change is done to us (regulations, administrative policy, budget cuts, etc.), but choosing to change a test menu item is done to ourselves. The physicians won’t notice on a report if a result is still positive or negative. It’s one of those cases in today’s medicine when change can be constructive. It’s also a chance to involve everyone in the decision.
Reasons to change kits include:
- Group Purchasing Organization (GPO) compliance. Your hospital may belong to a GPO such as Premiere or Healthtrust that contracts with vendors for discounted pricing and rebates. Your laboratory may have to order a certain percentage of supplies (varies according to the GPO) to comply. Generally a GPO is a good thing, since price contracts are often aggressive compared to what a company will offer, especially for lower volume testing.
- Cost. Sometimes -- well, always -- it’s about cost. The cost per test is calculated by the total cost of supplies, controls, repeats, confirmations, and other variable expenses divided by the number of billable tests. This can vary quite a bit from what the vendor claims.
- Better sensitivity and/or specificity. Technology improves incrementally, so it’s always a good idea to check literature and vendor references. New kits can offer better sensitivity or specificity or a different technology e.g. an optical reader that can make a test more reliable.
Labor and comfort level are important intangibles. If techs hate a kit because there are too many steps, the timing is too fussy, or the end point is too equivocal, the time and repeat testing can be expensive. That’s when revisiting can help a team the most.
NEXT: Introduce Yourself
The dictionary defines innovation as “something new or different introduced.” If your culture doesn’t encourage innovation but you have a great idea to improve your laboratory, what do you do?
Employees learn to resist change because they are seldom empowered to initiate change themselves. Change is imposed from management as a “do it or else” or “this is good for you” choice. Change is more work: same old, same old. And management isn’t interested in your ideas.
There is nothing special about the ideas of management. They may have a better sense of the strategic plan, but being less connected to work on the bench almost guarantees any new idea to improve work will miss the mark. Everyone in any organization can innovate.
Psychologist John Shafer blogs in Psychology Today about using psychology to craft an effective message. “Communication is more than conveying ideas just as innovation is more than the bottom line,” he writes. Presenting a new idea with a “I have a better idea” declaration also says, “You’re wrong,” something that few of us like to hear. This puts the other person on the defensive, forcing them to defend the status quo even if the new idea is better.
As Shafer points out, we all have egos. The world revolves around us and our ideas, and any intrusion is seen as a threat. “I” and “you” set up the communication as a conflict that will generate winners and losers. Management wins, you lose.
He suggests eliminating our ego when presenting a new idea. Instead of saying “I have a better idea” start with “I’d like your advice on an idea that will improve our lab.” This approach avoids the cognitive dissonance of you being right and your manager being wrong, presenting your idea as an option to improve the team. It doesn’t hurt to stroke the boss’s ego, either. After all, he or she may have more experience or tried many new ideas in the past. The downside, as Shafer points out, is that you may have to share credit.
Can pushing innovation be that simple?
NEXT: Revisit Your Kits
A work schedule reveals how techs work together. Techs may prefer to have weekends and holidays mapped for a year or longer, may prefer certain days off, and may have different rules for swapping and volunteering. The ends justify the means, since all the shifts have to be covered.
As a manager it is very frustrating to work hard to make a schedule fair only to generate suspicion, complaining, and unrest. A schedule can be the bane of any manager’s existence. But there are a few rules of thumb (please add your own in the comments) that can fix a broken schedule:
- Write it down. A written staffing plan is a blueprint for a schedule, because it describes shift times, how many people work, how holidays are covered, how swaps happen, etc. It’s a good idea to write it down, make sure everyone understands it, and follow it. Techs will use it to hold their manager and each other accountable.
- Spend as little time as possible. The more time a manager spends working on the schedule, the more suspicious people get. Unless an elaborate scheme to distribute shifts is explained or justified, techs will wonder (and probably look for) what took so long. Perceived fairness -- the only kind there is -- is inversely proportional to time.
- Use templates. Spreadsheets are great tools to create perpetual schedules based on a rotation for weekends, holidays, or an entire schedule. It’s helpful if techs know what weekends they are working for planning vacation, swapping, etc. It also saves management time.
- Be consistent. The more predictable the process, the better. Deviations from how a schedule is created, posted, or formatted (to an extent) can erode trust and generate suspicion.
I’m not keen on letting staff self-schedule. That might work, but a manager loses a prime chance to build consensus and demonstrate leadership when abdicating such an important task.
Unpopular scheduling decisions stink, but a good team makes it very clear when that has to happen. Fixing a schedule is a perfect chance for any manager to improve participatory leadership skills.
NEXT: Pushing Innovation
In a Roseanne episode where Darlene tries to explain to Dan a bad word in front of young D.J. D.J. says, “The B word?” “Worse,” says Darlene. “The F word?” “No,” says Darlene. “The L word?” “What’s the L word?” asks Darlene. D.J. shrugs, “I dunno. What’s the F word?”
All employees know the S word.
A work schedule affects our quality of life. The hours we work, our days off, and our perception of how fair it is can have a huge impact on time outside of work. It’s difficult enough to leave work behind without worrying about the next weekend, holiday, or evening shift.
Schedules are used as instruments of punishment by management and staff alike. Managers can try to be fair, but it’s often a losing battle if staff opts to call in sick, refuses to swap, or cherry-picks vacation time. Staff can refuse to answer the phone, refuse to work when there’s a call-out, bargain, but likewise be bullied or coerced into working. Favorites may or may not be given the best shifts, but it’s perception that matters. It doesn’t matter what the intent of the manager is. The buzz rules the roost.
It doesn’t seem possible that a single piece of paper should have so much power over a group. Every time the S word is mentioned, it can bring feelings of dread and apprehension. What does she want now? Will this affect me? Everyone has an agenda, which is understandable, because the schedule is everyone’s agenda.
Hospital laboratories need twenty-four hour coverage. This means early shifts, evenings, weekends, nights, and possibly call. Someone has to cover the shifts. Add to this mix labor union rules, real or imagined past practice, and seniority, and the schedule can be remarkably difficult to reengineer into a tool to get work done efficiently. Any change to an established order, from who works what to how the schedule is displayed and posted, is seen as a threat.
Next, I’ll consider a few ways to fix scheduling.
NEXT: Fix That Schedule
More times than I can count I’ve discovered a problem with an instrument because of an unexpected shift or trend in quality control, called tech support, and been told there isn’t a problem. Recently a hematology field service tech told our techs that a shift wasn’t a shift, and (basically) that none of us knew what we were looking at. He refused to do anything to the instrument, the shift persisted across all levels and patient results, and we ended up calling him back.
Quality control can be the first clue something is wrong, something techs who are used to reviewing thousands of points per year can be very sensitive to. It can be a range adjustment, it might be within the “package insert ranges,” and it could be nothing that affects patient results. Or just maybe a bench tech with decades of experience looking at QC knows perfectly well when something doesn’t look quite right.
I hear the same story over and over. “Tech says it’s within the package insert means,” or “They say our controls aren’t out yet,” or “They think it’s a range adjustment.” But they also aren’t standing in our lab running our tests.
Why doesn’t tech support believe techs?
There could be a wide range of understanding and competency in the field. It’s possible that many techs don’t pay a lot of attention to quality control or are enabled by micromanagers who insist on troubleshooting. Or it’s possible that some labs over-manage their quality control with too-narrow ranges that create extra work for everyone. Maybe, tech support just gets called when QC is out.
I doubt any of that happens often enough to justify a culture of disbelief. Just a guess, but maybe they are the ones not trained in the subtlety of quality control or are not familiar with what a significant shift or trend looks like in the real world.
Does tech support believe you? You know what you’re looking at. And if you’re wrong, well, no harm done.
NEXT: The S Word
At a recent lab manager meeting a group of us shared pet peeves. “What bugs me,” I said, “is when someone will pop into my office and say something like, ‘So-and-so went to break with so-and-so!’” They laughed but agreed this kind of complaining is common. “It’s like we’re back in Junior High,” one of them said.
There are two interesting things happening here.
The first is that yes, in a real sense it is like Junior High. The 2004 Tina Fey comedy Mean Girls highlighted relational aggression in schools. Relational aggression is covert and designed to hurt another’s social status. Boys get into fist fights; girls use status to victimize each other. I can’t relate to the latter but appreciate the phenomenon, especially after reading Odd Girl Out.
Women assure me that school is a vicious snake pit of nastiness, one upmanship, and betrayal for girls. They’ll say, “You’re lucky being a guy.” True, at least I knew what I was up against. None of us paid attention to how girls treated each other and would have made fun of it anyway.
It’s easy to characterize “She has more than I do” complaining as relational aggression. Maybe it is, maybe it isn’t. I suspect it’s a learned form of expressing frustration and trying to gain influence. Or it could be aggression. Who knows?
Which brings me to the second point of what’s really happening here, a not-too-subtle attempt to wag the dog. A complainer expects a response, which is reasonable when the complaint is personal or system related. But what does a person want when the complaint is about a coworker’s behavior? “She’s been walking around with her arms folded for the last half hour!” is a way of saying, “Do something about her.” What that is I never know, but speaking to an employee “in the office” has a humiliating effect. Could that be the point?
I am lucky to be a guy. I can pretend not to notice or understand, and not be wagged. Just like Junior High.
NEXT: Does Tech Support Believe You?
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