Peer review is essential to science to critique and validate published claims. As the site How Stuff Works succinctly puts it, “Think of peer review as a quality-control system.” Peer review is part of the open nature of scientific research.
This also happens in all labs to some degree: a microbiology tech may ask a coworker for an opinion on a culture plate; a hematology tech may ask for consensus on a bizarre looking “skipocyte;” a bench supervisor may review critical results daily to ensure policies are followed correctly. Each of these actions improves quality.
There is resistance to some peer review. Some techs, for instance, don’t like to be observed performing a test. Others don’t like a peer checking work, which can have some bias if the tech reviews his or her own work. And no one likes specific “errors” targeted, since the nature of error is random and their generation often complex. Catching and stopping errors is a game of Whac-A-Mole, something all experienced techs understand.
Yet (to coin a phrase) peers are without peer. Only those doing the work really know what happens on the bench, and those techs are crucial quality improvement. Peer review can remove blinders and reveal a process for what it is.
Two things can make that easy.
- Managers need to let techs make changes. If techs are paralyzed at the bench to make any changes or forced to modify procedures themselves, quality improvement stagnates. Techs need to freely make suggestions, collect data, and interact with coworkers in a critical atmosphere focused on outcomes.
- Techs need a standard reference. Peer review isn’t much if it’s just an opinion e.g. “I do it this way because I like it.” Techs should be able to review procedures, package inserts, and metrics to compare what happens on the bench to what should happen on the bench. This is also something management needs to facilitate.
An open atmosphere where peer review is not only accepted but expected will improve quality, almost without the effort of management. It’s how lab stuff works.
NEXT: Using FORD With Patients
Sometimes, I wonder if life is work between breaks or breaks between work. Conventional wisdom states if we love our jobs it isn’t really work, but that’s bargaining with reality. We all need a break. Taking time off is important.
Despite the health benefits of time off, including a reduced risk of heart disease and improved reaction times, we may not take enough. A 2010 survey by the online travel agency Expedia showed that Americans earn 18 vacation days each year but take 14, according to US News and World Report. Taking less and less time off makes it harder to relax, because the neural connections that make us calm eventually weaken.
In the meantime, the phone rings. The night tech called in sick, a physician is complaining because he can’t find a lab result, and the chemistry analyzer is down. An ambulance just appeared with a trauma that could be a bleeder. How much O Negative is on the shelf?
The above findings are echoed by a study of 1,399 participants at the Mind Body Center at the University of Pittsburgh showing that leisure time resulted in less depression, lower blood pressure, and smaller waistlines as reported by NPR. Another study by the Marshfield Clinic reports that women especially benefit, suffering more depression and stress if they don’t take a vacation every two years.
But work piles up, bills pile up, teenagers need braces, driver education, car insurance, and that new roof isn’t going to be put on by Santa’s elves. Your HR department entices you with an ETO cash in policy to reduce their bottom line, and extra cash is nice. Besides, the more you work the more you get caught up. Right? Everyone hates returning to piles of mail, email, telephone messages, complaints, problems, and change.
Holiday time off is a mixed bag: shopping, travel, and family obligations add their own stresses. Maintain a balance between time on and time off, don’t worry about work or inches around your waist adding up -- that’s what New Year’s Resolutions are for -- and enjoy it all.
NEXT: Peer Review Improves Quality
James Westgard writes on his web site, “Multirule QC uses a combination of decision criteria, or control rules, to decide whether an analytical run is in-control or out-of-control. The well-known Westgard multirule QC procedure uses 5 different control rules to judge the acceptability of an analytical run.” One of these is the 41s rule.
A 41s rule violation happens when four consecutive data points exceed one standard deviation on either side of the mean. It’s a useful rule, because it can give a tech dealing with a list of numbers a mental picture of what might be happening on the chart. A 41s indicates a recent shift or trend.
I’ve been puzzled over the years at resistance to this rule. Perhaps, it’s because the 12s and 22s require hard and fast action, while the 41s requires some investigation. Perhaps, it’s because it means more work when the control is technically Ok.
Some of the same conceptual barriers exist with other numbers, such as the SDI or z-index, which shows how far away from a target or group a number is. All of these techs will instantly interpret L-J charts, which leads me to wonder if this is a left-brain right-brain issue.
According to this theory, each side of the brain thinks differently. The left brain is more logical and analytical, while the right is more intuitive and subjective. Studies have shown that both sides work together equally, but they are better suited to different tasks. The right brain recognizes faces, music, emotions, images, and so on. The left brain is better at language, logic, numbers, and reasoning.
Here’s a fun online test. I scored slightly higher on the left.
Does resistance to interpreting a 41s indicate that lab techs are right-brained thinkers or that QC interpretation is better suited to the right side of the brain? Studies aside, I tend to think the latter. A 41s error is designed to be suggestive, but an image of a plot contains information an experienced mind intuitively recognizes.
To 41s or Not 41s? That’s the question. In the meantime, check the chart.
NEXT: Time On, Time Off
Merriam-Webster defines consensus as “a general agreement about something: an idea or opinion that is shared by all the people in a group.” That’s a pretty good definition. Examples in the laboratory:
- There is a lack of consensus about the holiday schedule.
- The decision to order additional O units was made by consensus.
If this seems trivial, consider that consensus is a tool often overlooked in the management toolbox. More often than necessary, a hammer is used to make a blunt decision. This may seem expedient and even desirable. But consensus is usually better. In other words, if a manager says, “This it the holiday schedule for the next three years!” it gets the job done, but a general agreement that everyone can live with before deciding is met with less resistance and resentment.
Managers are hired to make decisions, but they are also hired to enforce the rules and reach the goals of the organization. Outcomes can be fuzzily complex to predict. A balance has to be maintained between decisions and consensus. In my experience, I have needed to make very few hard and fast decisions. With a little time, a consensus gets the job done. It’s better for the team, who will let me know when they need me to make a decision. Hint: that’s not terribly often.
Wikipedia outlines the basic steps in the consensus process:
- Discussion - the subject is discussed in a group to get information, opinions, and ideas of what should be done. As a manager, a “round robin” technique works well, encouraging everyone to speak.
- Brainstorming and other open-minded exercises can generate creative solutions.
- Forming a proposal - a proposal (tentative decision) is made to the group.
- Call for consensus - this can be a vote, for example. Each member of the group agrees or disagrees with the proposal.
- Addressing concerns - if consensus is not reached, each dissenter presents concerns.
- Modification of proposal - the proposal is reworded, amended, rephrased, or otherwise tweaked until the group agrees.
That sounds a lot like Plan-Do-Study-Act in the QI world, doesn’t it?
NEXT: To 41s or Not 41s?
Our quality improvement projects have often involved collecting data for a period of time and then deciding what to do with it. This proactive approach that relies on performance measurement should be more relaxing than responding to negative feedback, which is often the case with improvement projects. It’s difficult to strip down and redesign a process under pressure, and fires are often tampered out.
But it’s also hard to collect reliable, real-time data. Junk data means junk decisions. This can be even worse than tampering.
For example, suppose your techs complain that the specimens drawn by the ED staff are often hemolyzed. This involves recollection and a delay in treatment. To track this, you decide on a paper form at the centrifuge where techs can log which specimens are hemolyzed and which aren’t. Exceptions are extra tubes that aren’t needed. Simple, right?
Except, of course, for those times when techs are too busy with patient care stuff. This happens with random regularity: STATs, instrument failures, centrifuge problems, too many ED tubes, too many send out tests, one tech helping another in a pinch, etc. Standardizing mere data collection can be difficult.
Another example: you want to know how much coagulation reagent is being wasted at the bench. Is the too much discarded in the bottle, does the bottle outdate, or is the aliquot on the analyzer have too much reagent in it? To track this, you design a paper form sitting next to the analyzer for techs to note when reagents are reconstituted. Simple, right?
All the same problems exist as above: techs are busy at the random times that reagents may be reconstituted. The complexity of adding quality controls -- which includes instrument troubleshooting -- and the inevitable distractions of telephones, beepers, timers, buzzers, and all the other pandemonium in a typical laboratory that makes mundane data collection difficult.
Is there a better way to collect data about a hands-on process without a hands-on process? It’s one more thing to do, one easy thing to not do, and data that probably isn’t worth a lot. Junk begets junk.
NEXT: How To Reach Consensus
There are two types of people in a hospital. Clinical professionals care for the patients, perform diagnostic testing, and make decisions that directly affect the quality of care. Everyone else should be in a crucial supportive role to that primary mission of healing our patients: housekeeping, plant maintenance, dietary, bookkeeping, payroll, administration, etc.
It’s easy for a place to be out of balance, however, with clinical folks tossed under the bus or the needs of the patient superseded by bean counter policies. This “clinical gap” makes it harder for those caring for patients to do their jobs. It can turn the tables where those in supportive roles are instead obstacles.
For example, suppose a hospital redesigned its outpatient registration area with a phlebotomy draw station adjacent to registration. The phlebotomists, however, have no way to see a queue and are forced to periodically walk into the waiting room to ask who is next. The lab manager asks for a physical or virtual pass-through between lab and registration. He meets vigorous resistance: plant maintenance says it would involve new construction, IT says it would involve too much wiring, medical records says it would be a HIPAA violation, HR says it’s discriminatory, and the CFO says it isn’t in the budget.
Maybe it isn’t discriminatory, but you get my point.
The patient in the waiting room doesn’t give a hoot. He or she chooses a hospital with an expectation of up to date equipment, compliant policies, and trained personnel. Most people will tolerate some inefficiency if human beings are working at a business, but they won’t understand why they can’t have access to the best services, especially while worried about their health or the care of a loved one.
And that is what is hard to explain to nonclinical people. Many times, they dismiss us with a wave of a policy, interpretation of the law, budget figure, credentials, or a claim that we don’t see “the big picture.” For me and most clinical people, that picture is not much bigger than a patient needing the best care.
NEXT: Junk Data Means Junk Decisions
When an error happens, it often seems like choices are limited. The effects of the error are corrected, the incident is documented, and the tech involved counselled. I’ve worked in many labs where the “be aware and work harder” ethic is never questioned as the way to avoid errors. Good techs own their mistakes; great techs change what they do.
What happens with this philosophy? Given time, each tech develops personal workarounds for each procedure based on experience. In blood bank, for example, one tech may shake down tubes one at a time; another tech may shake them down in groups that check for quality e.g. anti-A and anti-B together. We tend to lump this kind of behavior into “personal preference,” but they are really workarounds to avoid errors.
In such a system, techs can workaround comprehensive procedures and still make errors, because the workarounds themselves are ad hoc and uncontrolled. Their cumulative effect is random -- a ripe environment for errors.
This isn’t to suggest that techs can’t space out at the bench, goof off, or make stupid mistakes. But I suspect those things happen very rarely and need not be a significant fear for an experienced staff.
An alternative approach when an error happens is to ditch the “work harder” bromide, assume people already work hard, and change how that work is done. Changing everything retools and realigns workarounds. Ideally it makes them obsolete.
Changing everything instead of blaming the individual -- in a positive spin, letting someone know that they made an error -- can be a hard sell. The other day at a meeting we were discussing how a different department handles errors. Do the other staff work under pressure in a punitive environment? It’s impossible to know in a silo environment.
One of the techs said, “When WE make an error... you change EVERYTHING!” I was happy she didn’t say, “... you chew us out!” But fact is trying harder to avoid one error naturally increase our chances of making a different error.
What happens with errors in your lab? Change or chew?
NEXT: The Clinical Gap
If only everyone would do what the lab tells them, life would be easier. If offices filled out requisitions properly, if patients would follow prep instructions, if registration would check with the lab before sending a patient without paperwork, if nurses would ask how before collecting specimens, if doctors would call first before collecting a fluid in a syringe and sending it to the lab with a needle attached, and if everyone would label specimens immediately after collection in front of the patient, life would be grand.
If we didn’t work in the real world, all that could be true. Sigh.
We call the offices for more information, send patients home with better instructions, and ask registration, nursing, and doctors to please comply with this or that requirement. And we reject a lot of specimens that are leaking, mislabeled, improperly stored, or clotted. You’d think people would learn.
Good customer service is all about accommodations, but one customer’s convenience is one tech’s workaround. Techs naturally want consistency for the sake of efficiency, and doing one thing for one person and another for everyone else can be annoying. In our lab the techs call this “babysitting” out of sheer frustration.
“Why can’t you just make them do it?” they’ll ask.
“They don’t work for me,” I’ll reply. “If this helps the patient, we should do it.”
For example, our post delivery order sheets have a pre-checked item for “Fetal screen (lavender top) on Rh Neg moms.” The understanding is that the laboratory will cancel the test if the cord blood is Rh Neg. But the ward secretary does not order this test until approved by the RN caring for the patient, who is obviously busy with the delivery. Given our low volume of deliveries and risk of missing RhIG administration, why not always order a fetal screen, and the lab cancels the test if not indicated?
“Babysitting!” cry the techs.
I see their point: why should the lab assume responsibility for something that should be a process in another department? But I also see the patient. The patient is too busy admiring her new baby to care.
NEXT: Changing Everything
There are 11 million meetings every day, and most professionals attend 62 meetings every month. My total is somewhat less at around 30, adding up standing committees, ad hocs, department meetings, mandatory meetings, and last-minute teams to hose the fires. Many of these are dreadful, mind-numbing exercises that decide -- if anything -- when to meet again. Ostensibly these are how problems are solved by the most informed minds brainstorming creative solutions.
I can’t think of a surer way to kill creativity. But I’m an introvert who prefers to work alone or in small teams to fix problems. Inspiration requires thoughtful marination and immersion in a problem, exactly the opposite of what a meeting does. If there are any extraverts out there, weigh in. Maybe, you feel differently about meetings.
But here’s a trick I’ve discovered that has made meetings bearable: fake it.
Instead of affecting a bored attitude, arguing stupidly, working on something else, writing mindless doodles, playing with your smartphone, thinking about your trip to the store after work, or anything other than paying attention, pretend. Fake it. Sit raptly at attention, hands clasped, elbows on the table, back straight, and attention fully focused on the speaker or presentation. Really act interested. If the topic is really boring or doesn’t apply, then spend your energy thinking of ways to look even more interested. Shift from clasping hands to one hand under the chin. And above all remember to nod, which is a form of active listening.
For all I know, this is what everyone who looks interested does. Cynicism aside a “fake it til you make it” strategy done well is invisible to the other participants at the meeting and engages them. Good meetings are all about listening, and an appearance of active listening is as good as the real thing. Interested people are more interesting, too. I’m not ashamed to admit that I now fake it in meetings and despite my mind wandering to creative ways to look like I’m paying attention, I really pay more attention.
Ain’t that something.
NEXT: Babysitting Other Departments
I have lately enjoyed some one-on-one time with my son, who has a driver’s permit and is a captive audience. The other day when he was complaining about a decision one of his teachers made, I said, “Well... these kinds of things can be drilled into by asking, ‘Who benefits?’ If we know who benefits from a decision, we can find the motivation for it. And we resist a decision when it doesn’t benefit us personally.”
At work, for example, a laboratory rejection policy arbitrarily enforced on nursing can seem to benefit only lab techs. In the absence of knowledge, the nurses may assume we blindly follow rules. The nurse may ask, “How does this benefit the patient?”
Given time to explain and a desire to listen, a decision to reject a specimen that was difficult to obtain because of what appears to be a technicality can make a lot of sense to everyone. But this isn’t always possible. We don’t all have that luxury to understand how the patient benefits. We can be frustrated by angry responses.
In these cases, good relationships build success.
A good working relationship with a colleague has trust that there is a benefit to concerned parties when a decision is made that seems out of place. If, for example, lab techs work closely with nurses, a decision to reject a specimen is met with disappointment and not suspicion. A nurse is less likely to believe a tech doesn’t care about what benefits the patient if there is trust. And the only way to build that trust is through an ongoing, open, and honest relationship.
Working once removed from direct caregivers makes it harder for us to build good relationships, but it can be done. Face to face communication with a lot of listening on our part is a must. Helping when we can and breaking rules when safety isn’t the issue aren’t bad ideas. Success for us is also success for the patient.
If you’re curious, my son and I don’t always wax philosophical in the car. It’s usually about video games.
NEXT: In Meetings, Just Fake It
How do you keep a physician in suspense? Ask him or her to order a culture. In small labs where most routine cultures are urine, sputum, blood, and
surface wounds, there can be a daily battle between getting microbiology results in the hands of the docs when they need to treat the patients and getting the
rest of the lab work done. Techs in microbiology often don’t know when physicians need information about cultures.
For example, if a urine culture is ordered on a symptomatic patient but the physician prescribes antibiotics, he or she might wait to see what happens. If the
patient responds to treatment, the culture results are confirmatory. If not, there is a greater sense of urgency.
Blood cultures can generate more anxiety, particularly with septic patients, and a laboratory can receive multiple telephone calls asking about their status.
In some cases, cultures following treatment are important to know if an infection cleared. As with many cultures, there is no “one size fits all.”
Laboratories can use a number of strategies to deal with these issues, including giving physicians online access to unverified results, creating preliminary
reports, and telephoning prelims.
But no growth cultures, it seems to me, can be expedited most quickly. Urine cultures negative at 24 hours and blood cultures negative at 48 can be
finalized and quickly available with a comment that these cultures are held, reviewed for any growth, and amended reports issued as appropriate.
Consistently reporting these negative cultures at 24 and 48 hours builds an expectation in the rest of the team that can reduce anxiety and improve care.
Question is how?
Waiting for the morning review of cultures works for the laboratory, but of course all cultures aren’t plated or incubated in the morning. Since they arrive at
all times, some kind of alert system to read and result the negatives makes the most sense. Most lab information systems, for example, can generate
outstanding reports that can highlight overdue results.
How do you keep a lab tech in suspense? Ask him or her to report a culture.
NEXT: Good Relationships Build Success
Maine Law LD597
Concerns grow over tick-borne illnesses in Maine.
This summer (where did that go, by the way?) the 126th Maine State Legislature passed LD 597 that requires patients to receive a copy of their lab report, effective October 9th. “Health care provider” as defined by the bill includes physician, hospital, or a person licensed to provide services in Maine.
Local press presented the bill as a victory for Lyme disease advocates over the medical mainstream, which relies on guidelines of the Infectious Disease Society of America, although the bill was amended to drop a requirement that the Maine CDC link to an organization recommending different treatment. An article dated June 14th states:
Many Lyme patients and some doctors believe the disease is far more prevalent than most physicians recognize and that it can linger in the body after treatment with antibiotics. Doctors’ rigid view of the disease prevents many Lyme suffers from proper diagnosis and causes avoidable suffering, they say.
Most Lyme disease experts, on the other hand, argue that the disease has become a convenient diagnosis for a wide range of health complaints. Some call long-term antibiotic therapy harmful and unwarranted.
I don’t remember a lot of panic about ticks when I was a kid, although I saw dog and wood ticks. These days, especially in rural Maine, there is growing concern over tick-borne illnesses. Clearly this bill reflects that concern and is seen as a patient victory for some, an intrusion into medical practice by others.
As the public becomes more informed about their healthcare, including its cost and long-term effects, we may see more of this kind of legislative intervention. What the local press reports is at least as interesting as what it leaves out. Health care concerns have moved into the political forefront while laboratories work in the background. I don’t disagree that patients need to be informed of their results, but Lyme disease test results can be hard to interpret. I can’t think of a worse choice offhand, which leaves me scratching my head wondering what these politicians are really thinking.
Question is who gives the patient the results?
NEXT: No Growth Cultures
Laboratory report formats can be cluttered with interpretive comments. While useful for the sake of providing complete and accurate information specific to the test, they can easily become a distraction.
At a recent lab manager meeting the group discussed how to attach interpretive ranges for pediatric patients to a lipid panel report. We examined reports from several labs. Is this new information on the report in addition to the adult interpretive comments or does the information system add the correct information based on patient age? The former creates a report too long to be useful; the latter is possible but potentially cumbersome. Any modification to an information system needs maintenance, too. The more complicated a format, the more difficult the upkeep and the more likely the reason for it will be forgotten in six months. What should the comment be?
I raised my hand and joked, “Maybe, ‘You Should Know This.’”
Physicians are trained to interpret our test results. So as long as they understand what is normal in a given population, the only other information they need would be something uniquely related to the test, such as a gray zone related to analytical sensitivity, therapeutic ranges that overlap a critical limit, etc. Lipid panel and other testing guidelines (e.g. glycated hemoglobin) are well established so to be universally understood.
I asked physicians during rounds one morning about an interpretive comment recommending a repeat test depending on a value. One said candidly, “I don’t like those comments that tell us to do this or that! I don’t want to be held accountable when the chart is audited and the question is asked, ‘Why wasn’t that repeat test done?’ when it may not be needed. That’s my decision.” He’s right, of course.
In other words, doctors are doctors and lab techs are lab techs. We need to have a firm understanding of what they need from us to treat their patients and how to give it to them with the least interference. We don’t like requisitions that specify the tube, instrument methodology, incubation temperature, and so on. Just saying.
NEXT: Maine Law LD 597
Does what we wear make us smarter? Researchers at Northwestern University have coined the term enclothed cognition after conducting an experiment and concluding that our clothing can influence our psychological processes. What’s interesting is how this could affect the laboratory in a hospital setting.
The researchers, Hajo Adam and Adam Galinsky, conducted three studies measuring cognitive attention and agility. In the first study one group wore white lab coats and the second street clothes. The group wearing the white lab coat made half as many errors. In the second study the groups were asked to wear either a doctor’s white coat or a painter’s smock that were identical coats; the first group performed better. And finally, two groups were asked to simply look at coats identified as a doctor’s or painter’s and write an essay about what they thought about them, again with similar findings.
Adam and Galinsky concluded: “the current research suggests a basic principle of enclothed cognition—it depends on both the symbolic meaning and the physical experience of wearing the clothes.” Wearing a lab coat makes us smarter, in other words.
Doctors are thought of as intelligent, agile thinkers able to rationally sort out problems under pressure as depicted in television shows like ER and Grey’s Anatomy. They are trained to be precise, data-driven professionals. By contrast, painters are unconventional thinkers who don’t rely on data and precision to make decisions. Apparently, what we believe about these roles and our association with what they wear influences our own performance.
This idea of “enclothed cognition” can be used to our advantage. We can dress the role for an interview, management position, presentation before the board of directors, or an encounter with a patient. If the above study is correct, then wearing a lab coat at the bench could improve attentiveness and cognitive performance in daily lab work.
I wonder. Do lab techs who wear white lab coats make fewer errors? I can imagine this is possible with new techs, but I’d hesitate to make any conclusions about experienced professionals. I’d have to put on my coat and examine more data.
NEXT: Interpretive Comments
The great things about a small hospital are exactly why it is important to keep micro: a close connection over time with individuals in the community, a good working relationship with a small group of doctors, and a limited number of nurses to educate in the importance of collection and labeling issues. Even so, keeping micro can be difficult.
Once bean counters start scrutinizing hard dollars, it can seem simple to weigh “make here” vs. “buy elsewhere” arguments for tests not performed STAT. That includes much of clinical microbiology.
Advantages to keeping micro include: high recovery rate of microorganisms, reduced turnaround time, better communication between the lab and physician, making a local antibiogram, and better infection control, as pointed out in one journal. The impact of rapid and direct communication between the tech reading the Gram stain or looking at the plates and the physician making treatment decisions is invaluable. Unfortunately for laboratories, this value is measured in soft dollars: reduced length of stay, better wound care, and other team-related success.
Thus, a two-step approach can help keep micro in house:
Training. The more techs that perform microbiology testing, the better. More techs means better flexibility on weekends, schedule redundancy, more active discussion on quality issues in a group setting, and better recovery after someone leaves.
Communication. Talk face to face, early, and often with caregivers about microbiology issues. This includes nurses, pharmacists, infection control practitioners, and physicians. It means reviewing chart history, antibiotics, and orders. The more your techs know about how and why cultures are being collected and acted on, the better.
The laboratory has to initiate these changes. We won’t be asked.
At our hospital we make daily rounds of inpatient and ED areas, looking at charts to focus on microbiology, including blood and other cultures. If a culture needs recollection, we speak directly to the nurse. We let physicians know face to face what early results show. The harder we can make those soft dollars by being a visible, indispensable part of the process the better. It’s better patient care, too.
NEXT: Dress Smart