At a meeting our QI director at that time pulled out a folder and told me, “These are your troponin turnaround times.” It showed hardly any times under 60 minutes, an industry
consensus. Most of the times were over 90 minutes. When I returned to the laboratory to check the numbers from the information system, times were far lower.
In one study, the median diagnostic TAT was 122 minutes. Four points were measured: the time
of ED arrival, the time the test was ordered, the time when the blood samples arrived in the laboratory, and the time of completion and reporting. For many laboratories, only the last
two times are known with any certainty. In the above study, the laboratory time was half the complete diagnostic TAT.
Accurate timing is critical. In our case, the time of arrival was recorded from memory in the patient chart by the attending nurse. This was sometimes earlier or later than the
electronic registration time, depending on who visited patient registration. The electronic ordering time is known, but verbal orders and arrival of samples in the lab are not.
One scenario, for example, is that a patient with chest pain arrives by private vehicle to the ED. The attending RN places the patient in a room while alerting the physician, who gives a
verbal order to start an IV line and draw labs. A family member goes to patient registration. By the time the patient is prepped for the IV a patient registration clerk arrives with a
wristband, and the patient is identified and banded. Labs are drawn and sent to the lab. All before the physician sees the patient.
All this illustrates how subjective turnaround time is. This process is efficient from the ED point of view but does not capture data that reflects troponin TAT from a diagnostic
perspective. And while the consensus target is less than 60 minutes, it is from arrival to completion.
As another study points out, this is possible if ED and lab collaborate. This is a great improvement opportunity. Has anyone collaborated and been successful?
NEXT: On Call Providers
It makes sense for an employer to encourage employees to use their time off. It also makes sense to be as fair as possible. And here’s where it gets interesting.
As a bench tech you may feel that your vacation time is arbitrarily denied or other techs are given preference. The same thing happens to managers. I’ve worked jobs where I could
not have specific days off each month, no matter what, and others where a last minute inspection or crisis cancels time off. Managers get called back from vacation, too.
The word fair means “free from bias, dishonesty, or injustice.” Problem is “fair” is itself subjective.
What I think is fair and what you think is fair are often different. It doesn’t matter what our roles in the organization are. Seniority, desirability of the time off, existing policies, and union
rules all add to perceptions of unfairness.
Is something unfair if it happens to someone else and doesn’t affect you? I’ve seen new hires treated unfairly, and those with seniority in the organization will say, “We’ve paid our
dues.” They don’t have an opinion or believe it’s fair until it happens to them. Uh-hunh.
The solution is to schedule vacations in a transparent, open fashion with ground rules that everyone agrees upon and understands. That way a manager only has to be consistent to
be fair. Here are a few ideas:
- Set a minimum staffing plan that is clear to everyone with an agreed upon rule of thumb e.g. no more than 2 people off the same day.
- Map weekends and holidays as far ahead as possible, and hold people accountable to switch with each other as part of their vacation planning.
- As a manager develop a clear replacement strategy to avoid busting the budget. Don’t just let everyone have vacation and fill all the holes with per diems or overtime.
A great rule to establish immediately is “Everyone’s time is equally valuable.” This might be a tough sell in some labs, but without it unfairness is a given.
How does this work (or not work) in your lab?
NEXT: Faster Troponins
Vacation time - PTO (paid time off) or ETO (earned time off) - is a benefit offered by many organizations. There are no federal regulations regarding what employers should do, but most who offer it do so on a seniority scale. The longer you work at an organization, the more time you earn off, with a peak average of 27 days a year for 15 or more years, according to Salary.com.
Organizations may offer vacation time as a separate benefit from holiday or sick time. Or everything is taken from the same bank. Payroll is a fixed expense - employees are paid unless they are on FMLA or some other leave - and vacation time is an accrued expense that adds up quickly on the books. It’s in the interest of your organization to encourage you to take all your time off. Managers should create a staffing plan around how much time off people can take.
Does your organization encourage you to take time off? Does it have a consistent policy?
I’ve never heard of a place that encourages vacations, unless it’s the end of the year and it’s “use it or lose it” because time won’t roll over. Every organization I’ve worked in expects employees to track their vacation benefit and ask for time off as far in advance as possible, with or without guilt. Some employees plan vacations for a year, others use almost all their time during the summer, and a few ask for a day of vacation as soon as they accrue a day.
Suzanne Lucas writes in CBS Moneywatch that 47 percent of workers call in sick just to get a day off, but 72 percent of their coworkers are onto them. This could mean employees are being treated unfairly e.g. vacations are arbitrarily denied. “Getting a day off (one that you have earned), can be difficult. But, if you say, ‘Gosh, I'm sick,’ there's nothing a boss can do about that. Sick is sick,” Lucas writes.
Too much sick time is a clue. Next, I’ll consider a fair vacation policy.
NEXT: Scheduling Vacations
Summer is hot, even in Maine. We do more outside, stay outside for longer periods of time, and sweat more. Employees may exercise by walking a lunch break or may sit outside during breaks and meals to enjoy the weather. Laboratory environments can be hot and humid, and changes in temperature between the laboratory and patient rooms can seem extreme. All this adds to a need to drink more water.
Lost fluids must be replaced or dehydration results. What’s interesting is that even mild dehydration (1-2% of body water) can have noticeable effects on work performance.
Industrial Safety and Hygiene News reports that numerous studies link dehydration to lower physical and mental performance. Dehydration impairs motor tracking, short-term memory, and reaction time. It may even increase the likelihood of fainting when changing from a sitting to standing position.
WebMD reports that a study published in The Journal of Nutrition concludes mild dehydration can cause dampened moods, increased fatigue, and headaches in young women. A previous study on male subjects showed similar, if subtle, mental difficulties when dehydrated.
As we age we lose body water, increasing our risk of dehydration. This is a concern for the elderly but also for older techs working in hot, stuffy environments where they may not drink water throughout the day. It’s just easier to become dehydrated at 60 than it was at 20. (The more I hear about getting old, the less I like it.) Other factors include diabetes, medications, and stress.
Staying hydrated is easy, but it takes consistent effort. Plan to start your day with a glass of water and then throughout the day using the rule “a little but often.” It’s easy to underestimate the amount of water lost while sweating, in particular. Instead of using the “eight glasses of water a day” rule, go by the color of your urine. For lab techs, that’s easy enough. Pale yellow is just right.
All this might seem obvious until you start minding how much or how little water you drink throughout the day. Rehydration should be a constant effort to replenish water lost.
NEXT: How Many Vacations?
Catalase is an enzyme present in many living cells responsible for breaking down hydrogen peroxide (H2O2) into water (H2O) and oxygen (O2). It prevents peroxide, a byproduct of many reactions, from damaging cells. Catalase is also used in food and wastewater treatment industries.
The catalase test is a simple microbiology biochemical test to speciate Gram positive cocci. Using a loop, a colony from an agar plate is smeared into a drop of hydrogen peroxide on a glass slide. If catalase is present, released oxygen produces bubbles. Staphylococcus is catalase positive (bubbles). Streptococcus is catalase negative (no bubbles).
This reaction is so simple that it’s hard to forget. For many of us, it was one of the first tests learned to identify bacteria. It’s a classic manual test that hasn’t changed in decades (if ever). And for the most part it is foolproof.
Other common bacteria produce catalase, of course, including diphtheroids (Corynebacterium). Enterococcus is catalase negative. Most microbiology labs have flowcharts to detail how a catalase test is applied in identification of Gram positive bacteria in sources. For the most part these, too, are foolproof.
Well, you know how these things go. There are always exceptions that make laboratory medicine fascinating.
A novel strain of Streptococcus didelphis, for example, is catalase positive. Morphologically similar to other streptococci, this strain is unique, showing a strong catalase reaction similar to staphylococci. While its virulence factors are unknown it causes lung, kidney, spleen, and skin lesions as well as septicemia. The good news is that so far the literature only reports this strain in opossums and raccoons.
Two species of staphylococci are known to be catalase negative: Staphylococcus saccharolyticus and Staphylococcus aureus subsp. anaerobius. The latter has been isolated from diabetic foot ulcers, and it’s likely a human pathogen in other settings, although the incidence in unknown. We simply don’t look for catalase negative staphylococci.
While this is the kind of thing that could keep an infection control nurse up at night, it’s more of a typical exception in laboratory medicine. It’s one reason this job remains interesting after so many years.
NEXT: This Summer, Stay Hydrated
Consultant Rebecca Mazin complains on the website All
Business, “I have personally noted many examples of flagrant, highly inappropriate workplace texting.” What about your laboratory? Chances are, it’s happening regardless of policy
enforcement. A 2011 Pew Research Center report found that Americans age 18 to 29 receive five times as many text messages as telephone calls. It’s a safe bet some of this happens at work.
According to Career Builder, employers rank cell
phones and texting as the number one productivity killer (number two is the Internet). Technology has bumped old fashioned gossip around the water cooler and in the break room to
number three. Employers are scheduling break times, monitoring computer use, limiting meetings, and favoring open office designs to limit social time wasters.
Fortunately, most lab techs are parents of children 18 to 29, not so much into texting every thought and posting every feeling, and laboratory productivity is largely a matter of
monitoring automation. And who measures the productivity of paranoia?
All this is, I suppose, a natural adjustment period to what is relatively new technology. Imagine the furor in mid-15th century Germany as employers worried about the distractions
caused by employees reading books once Gutenberg came along. The reality of new technology is that it always brings change, much of it good.
Texting is a good way to communicate in a minimally intrusive, efficient way. I’ve received pages, texts about the arrival of a salesperson, reminders, and other short, useful
messages. Techs find it easier to text simple questions about scheduling. In every case these are simpler, quicker, and quieter than a telephone call.
Secure texting is also a reality, making it possible to text lab values directly to physicians or patient status updates to nurses. One service called TigerText, started in 2010, allows
secure messaging over cell phones, claiming to be in use in over four thousand healthcare facilities. As their site succinctly puts it, “By providing the ability to securely communicate in real-time, administrators, clinicians and staff are able to more rapidly address
patient needs and drive toward better outcomes.” 8^)
NEXT: Catalase Oddities
Layoffs, cutbacks, mergers, downsizing, and outsourcing, common in business, have come to healthcare and laboratories. What used to be a secure job with plenty of opportunity now is filled with unknowns in an uncertain economy. According to Forbes the average worker is interrupted seven times an hour and distracted over two hours during the day. It could be more for the average bench tech. And it’s no secret that healthcare has been struggling with a greater demand for services for less money. Cutting a budget only works so long, and any bad news from administration always seems like a threat. It all adds stress.
Reducing stress is crucial to better patient care and for you to make good decisions about your career. How do you do it?
First, recognize stress. Some of the signs are: feeling anxious or irritable, loss of interest in work, trouble sleeping, fatigue, stomach problems, loss of concentration. Even if you aren’t stressed, those who are around you will affect you in a negative way.
One site offers these tips:
- Take care of yourself. The last thing you need to lose is your health. Regular exercise, healthy food choices, a minimum of alcohol, and plenty of sleep will give your strength and perspective to reduce stress and make good decisions about your future. Think of it as a boot camp for going to war with stress. You can win!
- Act, don’t react. Prioritizing and organizing are two steps that will give you more control and better balance between work and family. Don’t over-commit, try to leave earlier in the morning, and plan to take breaks. All work and no play, etc.
- Improve emotional intelligence. You can learn to use your emotional energy in positive and constructive ways that draw people to you to overcome differences and work together to reduce stress. Recognize when you're stressed, paying attention to your body language and nonverbal cues. Use humor.
The site has other good information worth checking out, and there’s a lot of other excellent help to be found with a few searches. Why not start today?
NEXT: Texting at Work
ABC News reports Medical Professional as right in the middle of the most stressful jobs in America, right behind working parents, deployed military personnel, and police officer. These types of lists vary from survey to survey, but the reason stress is high is the same: when the stakes are high, the pressure is on.
The CDC reports alarming statistics: a quarter of employees view their jobs as their number one stressor; 40% of workers say their job is “very or extremely stressful;” 26% are “often burned out” by stress; most believe there is more stress than a generation ago.
Much of this stress comes from an accelerating pace of change and loss of control. In the laboratory, this includes increased regulation, increased competition, decreased reimbursement, and more demands on skill sets not taught in laboratory programs (think meaningful use). More and more, clinical professionals are being asked to be data analysts and business experts, and somehow more patients have to be treated with fewer resources, fewer people, and lower cost. Not all change is bad, but it all adds stress.
For a bench tech stress can be brought on by: low wages, excessive workloads, few opportunities for job growth, work that is not challenging, lack of support, lack of control, and unclear performance expectations.
Signs and symptoms include: feeling anxious, irritable, or depressed; losing interest in work; problems sleeping; fatigue; trouble concentrating; headaches and stomach problems; social withdrawal; using drugs or alcohol to cope.
None of that sounds good, but it sounds believable for a short staffed, overworked laboratory with an uncertain future as hospitals everywhere look to cut costs, downsize, merge, and outsource just to survive. It’s a recipe for less attention to detail, cutting corners to save time and money, and making more mistakes. That adds more stress, too. Does more stress make techs scared they will make more mistakes? You bet.
But change is here, the industry is not what it was a generation ago, and neither are we. How should we cope with this stress at work? How do you? Please share in the comments.
NEXT: Reducing Stress
A recent study in Population Health Management shows a link between unhealthy eating and lower work productivity. Sleep deprivation and smoking are also linked to hits on productivity. According to the study those between 30 and 39 were most susceptible, while those 60 and over were least.
The CDC points out that a workplace health program has many benefits. Research shows that a healthy diet promotes weight management, reduces the risk of high cholesterol, reduces the risk of developing type 2 diabetes, and reduce the risk of hypertension. Combined with physical activity programs, a healthy nutrition program at work makes good sense for employees.
But every morning I see people arrive with frothy lattes, sodas, breakfast sandwiches, donuts, bagels, and other goodies on the run. At break people eat carbohydrate and sugar laden food (even peanut butter is loaded with sugar). And for lunch the cafeteria may or may not offer healthy choices, ranging from a salad bar with full-fat dressing and cheese to deep fried foods and pizza.
A hospital is a place of healing that should promote health. It seems reasonable that a hospital cafeteria should offer a limited choice of junk food, fried food, and other unhealthy food choices. A cafeteria should offer choices that reflect a mission to promote health and wellness for employees and the community.
But a hospital cafeteria is a retail business within a non profit organization that has to offer choices that also appeal to visitors and family members seeking comfort. There is no productivity factor to consider with the general public. A family visiting a sick loved one may not be interested in healthy choices. Of course, people are free to buy food outside the hospital, but a hospital should also offer compassionate support and be understanding to the needs of family and friends. And food can be a big comfort.
What about your hospital? Does it promote healthy eating choices? If so, how? Simply offering a choice is not enough, and severely limiting unhealthy choices may not work. Incentive programs may work, but then what about those employees who already eat healthy?
NEXT: Stress at Work
While on safety rounds in our pharmacy one day I noticed a switch on their biosafety cabinet for an ultraviolet light. Is this used? I wondered. Neither of us used UV, but we decided to check, since both of our hoods were due for annual maintenance.
According to one of my sources, these lights are used in pharmacies. According to the biotech guy, laboratories use them. Who is correct?
There is an excellent article online that summarizes this issue from Applied Biosafety. There is controversy about this topic, partly because UV light is a health hazard. A pamphlet from the CDC and NIH is quoted:
Ultraviolet (UV) lamps are not required in BSCs. If installed, UV lamps must be cleaned weekly to remove any dust and dirt that may block the germicidal effectiveness of the ultraviolet light. The lamps should be checked periodically with a meter to ensure that the appropriate intensity of UV light is being emitted. UV lamps must be turned off when the room is occupied to protect eyes and skin from UV exposure, which can burn the cornea and cause skin cancer.
UV light is an effective surface germicide and virucide. The above article cites 12.5 minutes as sufficient with a minimal acceptable irradiance to kill spore forming organisms. Does this have a place in hospital laboratories?
What’s the harm in turning it on for 15 minutes or so a day as part of daily maintenance?
It’s an attractive idea, but it could be a solution looking for a problem. Any such method also requires validation of claims, maintenance, and regular testing. Added to these complications are health risks associated with exposure to UV light, minimally defined when turning the light switch on or off.
But the idea is worth a test. We cultured numerous surfaces under our hood, turned on our UV light for 15 minutes, and cultured again. This is not terribly scientific, I’ll admit, but it could be suggestive. Pre-UV light grew only two Gram-positive colonies. Post-UV light cultures were no growth. Not enough to make a difference.
NEXT: Healthy Choices
A full time employee easily spends most of his or her time at work, especially when you include prep time (rearranging personal schedule, laundry and ironing, shopping for uniforms, travelling, homework, and all the worrying behind the scenes. You might think your hourly rate is fair, but if you factor in the actual hours devoted to your job you’d be disappointed.
Why not make sure a job is a good fit?
As one executive at a recruiting and staffing firm correctly points out, “Obviously the company is vetting you to see if you’re worth hiring, but you should also be looking at the company and asking, ‘Is this a place I can see myself spending most of my waking hours?’”
To answer that career expert Deborah Brown-Volkman suggests asking these questions:
- Who’s the boss? If you don’t like the boss during the interview, that won’t once hired, either.
- Do you click or clash with future coworkers? Listen to your inner voice, she advises.
- Who are you trying to convince? Remember, you can easily talk yourself into anything.
- What matters most? Every company is different, and their priorities may not be yours.
- Is it the right job, or just right for now? Beware of accepting a job for 1 or 2 years because of financial need.
- Who are you fooling? Avoid making promises you can’t keep once you have the job.
All these signs point to our tendency to want the job first and think of ourselves second. It’s how people get stuck in jobs that don’t challenge them. This is seldom the fault of the job or the culture. It begins with the interview, your best chance to see what you’re getting yourself into.
Making sure a job is a good fit can decrease stress, make work relationships more pleasant and fulfilling, and boost your career. Instead of going to a job you feel trapped or lost in, you can feel valued and valuable. And what a great feeling to work in a place where people “get” you.
Think about your current job. Is it a good fit?
NEXT: To UV or Not to UV
It’s easy to forget that interviewing is about buying and selling. It’s easy to be so focused on getting a job that you forget the importance of getting the right job. The wrong job (if you haven’t had one yet, just wait) can be miserable and all-consuming. Terrible jobs can cause burnout, cynicism, and make you dump laboratory medicine as a career. They can make you feel trapped, embarrassed, and helpless.
A terrible job is a choice made starting with the interview process, like it or not. Somehow and for whatever reason you choose to ignore warning signs: the curt tone of the manager, the scowls of the techs, the clutter, the condition of the equipment, etc. It’s easy to be too eager to land the job, because your mind is naturally focused on your own welfare in the immediate future.
I spoke with a colleague recently who said he had a great interview candidate who asked to speak to the techs. She wanted to hang out at the bench and see how the work was done, how well people worked together, and (presumably) how she would fit in such a workplace. What a refreshing change! Most applicants ask few if any questions at all.
A manager might invite you as an applicant to spend time on the bench. But I’ve done dozens of interviews and this has never occurred to me. I always bring out an applicant to meet people and chat, but I haven’t invited them to shadow techs. I haven’t been asked, either.
But what a great idea! A candidate could sign a confidentiality agreement and be assigned a preceptor to monitor their activity. Bench techs could be given score cards to rate the applicant. Each side would make an informed decision about fit. Is anyone out there doing this?
In the course of our careers we will each make good and bad choices, but they don’t have to be ignorant choices. It makes good sense to gather all the information possible to make the best decision, including interviewing at the bench.
NEXT: A Good Fit
Customer service has its bromides: follow the Golden Rule (treat customers as you want to be treated); the Platinum Rule (treat customers the way they want to be treated); exceed, don’t meet customer expectations, etc. But all this boils down to one simple assumption: the customer doesn’t work for you.
Since laboratories are point of service businesses for outpatient customers, fast food restaurant experiences illustrate my point. When you go to McDonald's, you stand in one of several queues, are greeted by a friendly server who keys in your order, and if you order drinks you have to get them yourself. This self-service masked in the guise of convenience means you are doing the work instead of a McDonald’s employee. It might be fun for kids, give you something to do while waiting for your food, or even be preferable (because you get to choose your quantity of ice), but you’re still working for them. For free.
Similar points can be made for drive-through service, bagging your own groceries, and those irritating bank mazes. Is all of this good customer service? Perhaps, if it’s more efficient. But ultimately self service makes it cheaper and easier for those delivering the service.
McDonald’s or any other business - your laboratory included - can just as easily do everything for customers. It’s possible to find a way to deliver a customer experience that means no work, no wait, and no hassle. But you’ve got to start with the assumption that the customer doesn’t work for you.
Consider your outpatient experience. Do you force customers to search for parking, navigate a maze, wait in line, bring their own paperwork, and remember complex instructions? Remembering that the customer - in this case a patient or family member - doesn’t work for you means eliminating obstacles to a pleasant, comfortable experience.
If you have adjoining clinics, do you expect patients to carry their lab slips across campus to your laboratory waiting area and draw station? If so, I’ll bet many don’t. Good customer service isn’t self service. Which reminds me, I have to fill the tank.
NEXT: Interviewing at the Bench
Saturday Night Live used to have this recurring skit about a rude computer technician played by Jimmy Fallon. He’d appear and respond to polite questions with snarking geek jokes, yell “MOVE!” and type the solution in a few keystrokes. “Was that so hard?”
There’s more than a grain of truth in this humor. While jargon-laden professions with obscure silo-based rules tend to make fun of outsider mistakes (think specimen collection and rejection, for starters), a lot of the humor comes from how the company employees react. They just want to print a file, stop their computer from locking up, and other everyday tasks so they can get work done. They don’t care about firewalls, IP addresses, print servers, clearing the cache, creating a macro, and most (if not all) of the other stuff IT geeks talk about.
How about your company’s computer guy? Is he (or she) like Nick Burns on Saturday Night Live? Let’s hope not.
It’s frustrating to be asked to use something that doesn’t work, doesn’t save time, or breaks down. Computers and networks are often all three. And with the expansion of their use into all areas of healthcare, the guys in IT are doing double and triple duty to repair, upgrade, and install software and hardware to meet the needs of users who are not trained in the whys and hows. Nor do most care.
I appreciate the Nick Burns character, having worked in IT many years ago. (I’m ashamed to admit I get his jokes, too.) In his defense, some users don’t seem to want to help themselves by learning what appear to be simple rules. To his shame he doesn’t create teachable moments, unless it’s teaching users to hate computers.
Your IT staff may not be a room of Nick Burns, but they probably don’t have the time to figure out how to really help. They deal with all systems, not just the laboratory. How does a laboratory help itself get out of this frustrating rut of depending on the company computer guy? Has your lab done it? Share in the comments below.
NEXT: Customer or Self Service?
Lab techs typically think of “corrective action” as it relates to quality control. A QC point is out, the tech checks reagent levels, finds out the reagent level in the well is low, puts on fresh reagent, and repeats the controls. But was this really the problem? If the QC is in e.g. “corrected,” we all assume yes.
Experience with methods teaches techs the most likely causes of error. It could be temperature, water, reagent levels, mixing probes, carryover, or any number of variables. Typically a tech will learn problematic methods that require TLC, too, and make sure reagents are fresh in advance, controls are fresh, or a different artificial set of circumstances to avoid wasting time and material.
This is particularly obvious in coagulation testing, where methods are sensitive to changes in temperature and pH. I’ve seen techs put fresh reagent on and reconstitute controls that aren’t “fresh,” e.g. made up during the last shift. Despite package guidelines on storage and stability, techs learn through trial and error how to avoid common problems.
For similar reasons techs will run all quality control for the day after performing maintenance and system functions checks. It’s easy, it’s expedient, and it saves time later during the day. It’s better to fix a problem early.
But is this effective quality control? I wonder. Shouldn’t controls be run at random times by different techs throughout the day to control all states?
While there isn’t anything wrong with choosing a most likely culprit for QC being out, too, I wonder if that’s really good corrective action. After all, corrective action itself should be unnecessary. If, for example, a method consistently fails with a low volume of reagent in a reservoir, shouldn’t the corrective action be collected as quality improvement data and a change in practice made? Sample lookbacks are tedious and can be expensive.
Corrective action is important quality information that is often overlooked. We should collect and plot these actions, effective or not, to tweak and improve our quality systems. Does anyone do this? Has any middleware been programmed to do this?
NEXT: Your Company’s Computer Guy