As professional data collectors, lab techs are poor data collectors, at least when it comes to quality assurance. I’m not sure why this is. It could be a flaw in the collection method, distractions that take priority, measurement interference with the process, or a combination of factors.
For example, we tried to collect data on how many hemolyzed samples we received collected by the ED. Easy, right? Create a log, put it by the STAT centrifuge, and tally specimens as they are unloaded.
Except techs recorded inconsistently, to varying degrees, and when it was extremely busy not at all. Some techs didn’t want to collect data on colleagues. Others thought it wasn’t a big deal to have a hemolyzed specimen once in a while. When I compared the number of draws performed to the data collected, it was obvious we weren’t capturing it all. And since there was really no way to randomize the collection process, we abandoned the idea.
In the meantime we continue to receive hemolyzed samples. This means patients are stuck again and results are delayed.
I’ve seen this kind of thing happen often. Collecting data about a process within the process doesn’t work, at least not well. Audits - a logical alternative - are tedious and time-consuming. For example, a tech could tally specimens in racks at the end of the day in the above. Is that the best use of time?
I don’t know. Has anyone found a good answer?
Ideally, a process should be self-documenting. The collection shouldn’t be a layer of work added to a process, but essential to quality of outcomes. This doesn’t work with spot checking, but it can work with ongoing quality monitors.
Like most labs, we document when a specimen that needs to be tested is hemolyzed. If an extra tube is hemolyzed, it isn’t used and no big deal unless an add-on means a redraw. Collecting good data is a first step in deciding the significance of these random events. I’m interested to hear how you’ve done this in your lab. Please share in the comments.
NEXT: Small Favors Improve Teamwork
One of my management resolutions will be easy to keep in 2015, because it’s already happening: fewer meetings. The monthly, boring department meeting is so entrenched in corporate culture it’s difficult to imagine work without it. But once gone people don’t miss it.
The New York Times offers this meeting litmus test: “Will this meeting help you in achieving your goals?” Carson Tate writes:
...a majority of executives spend a significant percentage of their workdays in meetings. And the higher their rank, the worse the situation. Top executives bear the brunt of the burden, but our meeting-intensive culture affects employees at all levels. Just look around your office. Where is everybody?
I’ve worked in places where some people seem to do nothing but go to endless meetings. In today’s economy is there a need for these kinds of jobs? Can any of us afford the cost associated with attending a useless meeting? But it’s built into our culture as the essential way to communicate, brainstorm ideas, and solve problems.
Monthly meetings suffer from Rehash Syndrome. By the time an issue is brought up at a meeting it’s already been fixed, blamed, or shelved. The workplace culture has efficiently processed it, so whatever is done to it at the meeting is a waste of time. New issues that haven’t already been processed aren’t seriously discussed.
Few are engaged, and those who are drive a groupthink mentality that block real solutions from being discovered. All that’s left is to lamely remind people to try harder. Perhaps, your experience is different.
Last year I tried a radical step to reduce the “...and another thing” derailment that was happening. Staff members brought lists of reminders, problems, or went off on tangents that left meetings in overtime and bogged down in frustration. At the end of my agenda I said, “Let’s go around the room and you each get one issue.” Staff almost immediately started passing and borrowing issues to talk more. I should have seen that coming, I guess.
So just like that I stopped having monthly department meetings.
NEXT: Collecting Good Data
A work culture defines how things are done. Susan Heathfield defines this as a workplace personality - a good definition - writing it “is made up of the values, beliefs, underlying assumptions, attitudes, and behaviors shared by a group of people. Culture is the behavior that results when a group arrives at a set of - generally unspoken and unwritten - rules for working together.”
Culture is how management communicates with employees, how schedules are created, how errors are handled, how clean the workplace is, how new the equipment is, etc. It includes stories, legends, symbols, and all the other quirks of our larger societal culture, encompassed within the bubble of the workplace.
I’m beginning to think it’s impossible to change it without changing people.
For one thing, like hires like. Hiring practices are also part of a culture. A workplace culture teaches us how to behave and react in situations. The way things are done is often seen as the only way they can be done, regardless of the frustration of many employees from the top down. I’ve heard managers and staff alike complain that the culture has to change. (The amount of complaining is also part of a culture.)
It isn’t enough to merely talk about cultural change. People have to make different kinds of decisions, talk to each other using different language, display different symbols, and create a different work environment. It’s a personality change.
Can you change your personality? Can anyone, really? I doubt it for the sake of work alone.
It would be as if your manager suddenly started arriving at a different time, speaking using different words and inflections, expressing different values e.g. money first instead of patient care, making completely unexpected demands, changing the test menu, and switching vendors. This kind of cultural change only happens with a new, radically different person.
People already in positions or hired from within are unlikely to change no matter how often lip service is given to changing culture, because they are products of the culture. To change the culture, you have to change people.
NEXT: No More Monthly Meetings
Many years ago when I was taught to run a Monospot, I was instructed in the fine art of rotating the card in a figure 8. The goal was to equally rotate the mixtures in all circles while scanning for agglutination. But in case that was too difficult, vendors marketed a slow-motion rotator that did the same thing. That was progress for the time: walk away serology.
I doubt any of those mixers are still in use, although some may have repurposed for mixing something else. Most of immunology has moved to a rapid EIA cartridge based testing model. Plop plop, fizz fizz has been replaced by plop plop, wait for the lines.
But most laboratories still have plenty of old equipment lying around, much of which still works great. For example, we recently replaced a CO2 incubator that has been working steadily, twenty-four hours a day, since June of 1978. The new incubator is pretty, but the old one was a beaut. I doubt anything made today will last 36 years.
Look around your laboratory. What’s the oldest piece of equipment still in use? Can it be replaced with something better, or does it work as well as it ever did? Choosing equipment now is a matter of cost and contract, but choices aren’t any better. What is old works just as well as what is new.
Here’s some of what we have still in service:
- American Optical microscope in urinalysis. Still works great, although the light bulb contacts are fussy in high humidity.
- Agglutination viewer in blood bank. This has to be one of the original Clay Adams models; it looks ancient but works perfectly.
- Dade Immufuge in blood bank. This looks like the first blood bank centrifuges I worked with when we did major and minor crossmatches and scoped everything.
- Incubator in microbiology. We have a smaller, non-CO2 incubator in microbiology that still works like a champ. My guess is it’s older than our CO2.
Our newest computer, by contrast, is two years old and runs like a dog. Progress just isn’t what it used to be.
NEXT: To Change Culture, Change People
As a profession, we are used to having the answers: glucose values, compatible units of blood, pathogens in a urine culture. As simple as this seems to outsiders who see lab techs as mere button pushers, we know there is a lot of judgment involved. In many cases “the answer” is ambiguous or at least far from simple. We have to answer, “Does it matter what it is?”
For example, a few weeks ago our micro techs were looking at a follow up throat culture on selective strep media to confirm a negative screen and noted a pure growth of a fine lawn of weakly beta hemolytic colonies at 24 hours. It didn’t appear to be Streptococcus pyogenes by Taxo A disc, but what was it? Did it matter?
Excellent questions. Experience teaches that asking the physician is always answered with “Yes, work everything up.” So much for asking the doc.
Arcanobacterium haemolyticum is a Gram positive bacillus that can easily be confused with Streptococcus macroscopically, first described in 1946 in cases of sore throat in US servicemen in the South Pacific. While its morphotype should be evident microscopically, it is catalase negative and often Gram variable at 24 hours. According to Medscape:
A. haemolyticum may be missed on routine throat cultures because of the use of rapid group A streptococcal antigen assays and the use of special culture media for optimal isolation of group A streptococcal species. Most cultures for pharyngitis are evaluated at 24 hours, at which point A haemolyticum colonies are very small and demonstrate minimal hemolysis, and the cultures may be discarded.
A. haemolyticum causes 0.5-2.5% of pharyngitis cases, especially in adolescents. Rare complications include an inability to swallow, peritonsillar abscess, and sepsis. Most strains are easily treated with antibiotics e.g. macrolides such as erythromycin.
I suspect A. haemolyticum was our bug in this case, although we didn’t find out for sure because it was a screen for Group A beta hemolytic strep. It’s one of those cases where the answer to “Does it matter what it is?” is “probably not.”
NEXT: The Old and the New
Merriam Webster defines career as “a job or profession that someone does for a long time,” a traditional definition related to one’s vocation or life’s work. But the website Dictionary.com adds a more general “a person’s progress or general course of action through life or through a phase of life,” e.g. soldier, student, etc. Your social media career counts, too.
Like our jobs, social media define us in terms of values, time, and associates. It’s a less inhibited window into our lives, showing the good of family, friends, and life accomplishments, but also the bad. People post comments without thought or in anger, “like” the wrong things, or take photographs that in retrospect should have stayed on the camera or not at all.
I suspect we can tell a lot about a person through social media, such as how many hours are wasted online. Do you brag incessantly about your kids? Do you post every tiny detail of your life? Do you comment on every post? I suspect even basic facts can be revealed: extroverts have more friends than introverts, perhaps.
If you think a social media career is private and separate from your work career, think again. According to Forbes, “... while you’re busy crafting your personal image, potential employers are busy using it to predict how you might be as an employee.” A CareerBuilder survey reveals that almost half of all employers research social media to look for evidence of poor choices that translate into poor job performance: provocative photos, drug use or drinking, negative comments about a current or former boss, or inappropriate comments.
Truth is if it’s online it might as well be plastered on a billboard on the interstate.
In my workplace, Facebook and other social media are blocked. Managers don’t have access as part of the recruitment process. But of course everyone checks their smartphones and tablets throughout the day. Most of the time I hear the rumor mill beginning with, “I read on Facebook...” or “I posted on Facebook...” Like it or not, your social media career is here to stay.
NEXT: Does It Matter What It Is?
Time lists these commonly forgotten resolutions: lose weight and get fit, quit smoking, learn something new,eat healthier and diet, get out of debt and save money, spend more time with family, travel to new places, be less stressed, volunteer, and drink less. That’s a pretty good wish list for most people.
I almost always forget to make New Year’s Resolutions, but the above list has a few items that give me ideas for lab resolutions:
- Encourage wellness - most workplaces have a token or better focus on “employee wellness,” but does the work environment reflect it? Investing in ergonomic solutions, flexible scheduling, and stress reduction are better than lecturing employees to eat right and exercise more.
- Involve everyone - the above is largely a list of things we feel are out of control, and work environments are no different. Involving people in ways to save money and work more efficiently, for example, can produce results and give employees more control.
- Work with other departments - as an endpoint in patient treatment labs are often helpless in changing outcomes e.g. how the nursing department collects specimens. But it’s a win-win to “travel to new places” and work with nurses and doctors face to face to improve collection and ordering practices.
- Focus on values - workplace values are often under the radar, but they drive every decision made and define a culture. To change a culture, thus, values must be acknowledged and changed. This may happen with a change in leadership, but it can be done deliberately to improve conditions.
This time of year is a natural break to wipe the slate clean and prepare for new challenges. It’s a chance to set realistic goals and change how things are done. And (most importantly) it’s a chance to look back at the previous year to celebrate all that’s been done.
Despite all the negative press healthcare seems to get about medical errors, skyrocketing costs, and fears about the Affordable Care Act, I’m optimistic about the new year. If only I could remember to make resolutions.
NEXT: Your Social Media Career
I’ve worked many Christmases, like most lab techs. Someone has to, right? It isn’t all bad, either. Some techs prefer to work Christmas because they might celebrate the holiday on a different day. In other labs the noobs get stuck with Christmas, which really isn’t fair. In our lab all the holidays are rotated, and the techs are free to swap.
Here are some random memories of Christmas past:
When I was in the Air Force working at Malcolm Grow Medical Center near Washington, I worked Christmas day. Far from home and knowing few people on the base, I was happy to be busy during the holiday. Manning a STAT lab next to the processing department, every time I answered the telephone I said, “Merry Christmas!” Everyone said it back, too. I smiled a lot that day. Great Christmas.
A lot of Christmases were slow, because there were no outpatients, offices were closed, and patients who could be discharged were sent home to be with family. I remember many holidays where the hospital seemed deserted: the parking lot, hallways, cafeteria, and waiting rooms had a surreal look with decorations and few people during the middle of the day. It felt even weirder that people were in a great mood despite working the holiday. A free meal in the cafeteria was always a plus.
When my boys were little every Christmas Eve I put Santa hats on them and took them to the hospital to hand out candy canes to staff, visitors, and patients. I remember vividly holding their little hands as they carried their gift bags stuffed with candy, their faces shiny with glee, shyly squeaking “Merry Christmas!” and their grins at all those smiles of delight. At the very least it kept their minds off whatever Santa might bring. It gave Mom a break, too.
Christmas isn’t what it used to be in many workplaces. It’s become the Day That Must Not Be Named, its trappings, parties, and gift exchanges for a generic “holiday.” Bizarre as that seems to me, it doesn’t change some wonderful memories of Christmas past.
NEXT: A New Year
One of our more common complaints is that we didn’t do the correct test. We missed a test because it was not seen, illegible, or written on the back of a two-sided form; we assumed an abbreviation meant something unintended by the physician; we entered an order incorrectly into our information system. In very few cases do we forget to perform a test or perform it incorrectly. It’s always GIGO: garbage in, garbage out.
Reading and transcribing orders incorrectly is a common source of error. It is the largest identifiable source of medication errors, for example. CPOE (Computerized Physician Order Entry) is designed to reduce the errors associated with reading and entering handwritten orders into an information system. But even CPOE doesn’t eliminate written requisitions.
Not only are these errors difficult to spot - they largely rely on the negative feedback mechanism of an error or complaint to detect - they are notoriously difficult to design away. The likelihood of order entry errors is increased by the variety of orders laboratories receive: scripts, requisitions, charts, electronic orders, verbal orders.
Checking requisitions against what’s been entered in an information system is often fruitful. I’m not sure this is possible for large laboratories and even small labs that see many outpatients. We manage to do this every day, but it’s a challenge to see everything in an environment with distractions. It just gets fit in between everything else.
And when we find an order entry error, what then? We can correct the report, but these kinds of process errors invite a “Oh, that’s human error and we need to work harder” lame solution. Given the complexity of the order entry and phlebotomy process, I can’t imagine people working “harder” at it.
I have ideas: check a requisition with the outpatient, perform a “time-out” with another tech before collecting samples, check the requisition before performing the test. All are rejected by techs as time-consuming and futile against the “human error” excuse. The alternative - accepting errors as part of the service - is worse.
How does your lab prevent order entry errors?
NEXT: Christmas Past
Hematuria, or blood in the urine, is distinct from microhematuria. The latter isn’t visible to the naked eye and is detected under the microscope. (The prefix micro is from the Greek mikros, meaning “small.”)
It isn’t unusual in urinalysis to see a clear urine with microscopic red cells. Microhematuria may be detected on the dipstick either as hemoglobin (diffuse color on the pad) or individual cells (spotted color on the pad). Hematuria may be painful as when associated with kidney stones. But it can also be painless e.g. cancer and other diseases.
When reporting microhematuria, most labs will have a procedure to semi-quantify small amounts e.g. Rare, Few, 0-1, 2-5, etc. The elephant is known to bench techs: intra- and interlaboratory variation. One tech will see and count differently than another, and another lab may have a completely different procedure. In broad strokes everyone is right. But it’s important not to be more precise than the total error of the method.
All this is fine inside a laboratory bubble, but we’re in the business of giving physicians data they can use to make good clinical decisions. A few weeks ago I got a call from a urologist who complained that our lower limit for reporting red blood cells in urine was too low. “I need to know if there are less than five,” he told me. “It’s the difference between making a diagnosis or performing thousands of dollars of further testing.”
The American Urological Association defines asymptomatic microhematuria as 3 or more red blood cells per high powered field in the absence of a benign cause. This suggests a lower cutoff of less than three. (Ours had been 2.) Three, five: tomato, tomahto.
Our reports should have value. For that to happen, we need to talk to the docs and understand what they need and how they use our results. Practice guidelines are a good start. Without that we’re working blind or just for ourselves, which may or may not hit the mark.
How does your lab report its lower range for urine red blood cells, and why?
NEXT: Order Entry Errors
It’s becoming harder and harder to see what I used to take for granted. I’ve always been nearsighted and worn glasses since age ten. I’ve never thought twice about it until a few years ago. Myopia (nearsightedness) is caused by an image focusing in front of the retina because the eyeball is too long, the cornea or lens are too curved, or a combination of these factors.
According to one site, myopia is the most common refractive error in the eye and becoming more common, from 25% of people in the US to nearly 42% recently. Fortunately for lab techs, most of our work requires near vision. We can always take off our glasses.
But presbyopia, or age-related loss of eyesight, is different. It typically starts in the mid-forties when we start holding reading material farther away, experience blurred vision at normal reading distances, or get headaches after close work. I noticed this in not being able to switch focus between, say a magazine and television. Typically these vision changes are caused by a hardening of the lens. It’s unavoidable, annoying, and part of aging.
US Census Bureau data reports 135 million Americans age 40 or older in 2008 with a median age of 36.8, and none of us are getting younger. This creates a growing demand for eyewear and surgery to correct failing vision.
But have we changed our workplace? Are they still designed for twenty-somethings?
Maybe it’s just me, but the font size in package inserts and on reagent containers is getting smaller and smaller. Most of the time, I have to remove my glasses to read it. I have a hard time seeing certain details within analyzers, reading serial numbers, finding teensy screws, and generally seeing in dim light.
This is can cause errors in areas of the laboratory where visual acuity is required, such as blood bank or microbiology. It’s easy to misread a lot number or expiration date. At the very least, we need to give our aging eyes time to properly focus in these cases to make sure we don’t miss anything significant.
Asking for help can be difficult. We think of it as a sign of weakness, an act of capitulation, or a loss of political capital. But as Lorie Corcuera, co-founder and CEO of leadership firm SPARK Creations, writes in Inc., “The truth is, we never do anything on our own. And as leaders, we shouldn’t want to.”
We revere self-reliance. Life coach M. Nora Klaver says it can be difficult for women to ask for help, since our culture expects them to be caregivers. “Asking for care ourselves feels like a personal failure,” she says. Why? Primarily to avoid seeming weak or incompetent, factors magnified in a competitive business environment.
But asking for help is easy. Here are tips from The New York Times:
- Be straightforward. Ask specifically without micromanaging. This works no matter what the request e.g. “Would you result that STAT while I go to break?” or “Would you supervise collection of 40 patient samples for our normal range study?”
- Rely less on obvious people. Managers who avoid confrontation may seek “go to people” for help in filling schedule holes, completing projects, or championing new ideas. Often a less obvious person is just as capable and eager.
- Make your request face to face and in private. This depends on the nature of the help. Asking in public can shame a person, create emotional blackmail, or cause he or she to agree for selfish reasons, all to be avoided.
- Listen for cues. Is that “yes” enthusiastic? Is the person’s body language turned away from you or toward the door? Asking for help invites collaboration, not coercion, and communication cues can help you see the difference.
- Say thanks - always. A sincere thank you makes all the difference.
Research suggests that we tend to greatly overestimate the number of people we’ll have to ask. “People are more willing to help than you think,” states Frank Flynn, an associate professor at Stanford. In part this is because we fail to appreciate the social pressure on others to act benevolently. We think it’s easy to refuse, but it often isn’t.
NEXT: Our Aging Eyes
What we do is often complicated. For example, asking for help from coworkers sounds easy but isn’t. Clinical psychologist Ellen Hendrickson cites several reasons we don’t including fear of being a burden, fear of losing control, fear of owing a favor, fear of appearing weak, and fear of rejection. “Asking for help can turn the most self-assured, square-shouldered among us into a nail-biting mess,” she writes. Yep.
As Hendrickson points out, we are afraid to ask for help. We would rather be overworked, overstressed, overwhelmed, and jeopardize patient and our own safety than ask a coworker for help. Then we complain, feel resentment, and retaliate with passive aggressive behavior. Worse, we confront our clueless coworker who for all we know would have gladly pitched in. At best we pick favorites who “always” help and write off others who “never” help.
It’s even tougher for managers. Asking for help is a tacit admission of incompetence beyond that brief honeymoon period for all new managers. Not only does traditional hierarchy make asking for help difficult -- decisions are often autocratic and not open to question -- we are all aware of our place in the pecking order. It’s one thing to ask for help when a few pairs of eyes are on you; it’s quite another to ask when a dozen are watching every move you make. Naturally this magnifies fears and insecurities and can turn the nicest manager into an autocratic boor.
All because we are afraid of looking weak, losing status, or being told no. We would rather be miserable and trapped in a cycle of resentment and payback, waiting for others to ask for our help (why should we offer if they don’t?). We would rather choose by judging who is weak and who should be able to do the work on their own. And we would rather martyr ourselves for the sake of imagined status than think of safety first. It’s what we do.
But it is easy to ask, isn’t a sign of weakness, and better patient care to ask for help. Next, I’ll consider how.
NEXT: Asking For Help
As the holidays approach I’m reminded how families get along (or don’t). Our work families are no different. Coworkers with different styles and priorities forced to work together can test patience and professionalism. So long as the work gets out accurately and timely, the ends may justify the means, but we’ve all worked with a tech (or are one!) whose work habits grate nerves.
Here are a few morphotypes:
- The Slob - this person has junk everywhere: tubes, caps, labels, scraps of paper, etc. Worksheets are scribbled on, written on sideways, and filled out haphazardly. Yet when you ask what is going on, he or she knows the status of everything.
- The Neatnik - the exact opposite of the Slob, meticulously aligning everything, making sure all junk is cleared away, and dotting all i’s and crossing all t’s to an OCD degree. Likely to arrive at any bench and start immediately rearranging it. Also likely to arrive at the Slob bench and just straight arm the whole lot into a bin.
- The Hoarder - closely related to the Slob, the Hoarder never chucks anything. (The Slob cleans house once in a while.) Every nook and cranny is packed with something: pens, magazines, caps, samples, clips, cheat sheets, phone lists, package inserts, tools, extra tubing, “extra” stuff just in case, etc. Their free bench space is a tiny little square, yet they manage to get everyone done on time.
- The Paper Freak - has to write everything down and leaves note everywhere. Instruments are plastered with paper, computer monitors have a halo of notes, and cheat sheets are taped to procedures and kits. This isn’t a bad thing in itself, just impossible to know what to read first.
- The Talker - while there are people who gab and gossip, this person talks incessantly while working, muttering to themselves to the point of distraction. You just hope they don’t do it around patients.
Dull would our workplace be if we were all the same. And surely each of us annoys someone. How do you work?
NEXT: It’s What We Do
Every meeting takes at least an hour, not including prep, finish, and homework time. Many meetings run over. They are, as Charlie Kim describes in the Huffington Post, red wine discussions (might as well drink, because nothing will be accomplished) or lectures (why attend at all?).
I’ve been working hard to break that, at least in the lab. Instead of monthly staff meetings, we do this:
- Daily Time Out - following rounding, we have a standing meeting to discuss issues on the floor and ED and anything else going on in the lab e.g. instrument repairs, product recalls, procedure changes, etc.
- Monthly Action Meeting - once a month we have an hour-long meeting with an agenda that is our action plan from the previous meeting. The goal is to improve efficiency or service. Each meeting we look at HCAHPS scores; other than that we focus on how to make real improvements.
These action meetings result in decisions that directly affect how work is performed on the bench. Recently, for example, we decided to change the time of day that certain reports are run to reduce afternoon bottlenecks. Not only does this involve everyone in decisions, the next month the action is reviewed to see if it’s working. If it isn’t, another decision is made.
I don’t know if this would work on a broader scale, but I don’t see why not. Traditional staff meetings consisting of reviewing minutes, old business, to-do lists, attendee reports, etc. are boring to run and torture to sit through. But changing this culture is tough. Most people who go to meetings hate them but assume they are what they are.
I can’t imagine anything would get done on the bench if before each decision was made techs had to review the minutes of the last decision, old business, to-do lists, etc. Instead, of course, the daily work is done while dozen of decisions are made on the fly. And if those don’t work, different decisions are made. It’s time we pushed action meetings up the ladder. Isn’t it?
NEXT: How Do You Work?