Are we seeing the last gasps of community hospital laboratories? Sometimes I wonder. A 2007 article in Clinical Chemistry states, “Many laboratories already outsource esoteric tests to other (reference) laboratories, but outsourcing should also be considered for non-esoteric tests (6). The motivation to outsource should be that a specific test can be done better, more often, and at a lower cost in an external organization. In other words, the external organization has a higher level of expertise, is more efficient, and can take advantage of greater economies of scale.”
The “O” word isn’t new. I’ve heard “economies of scale” so many times since 2007 the phrase has almost lost its meaning. Bigger is better, cheaper, and smarter. It is, in the words of bean counters that are the new agents of change in our industry, “the new normal.”
It’s true that bigger organizations have greater clout with vendors, have more resources, and can do more with less. The greater the ratio of billables to non-billables (quality control, calibration, etc.) the cheaper the cost per test and the higher the productivity of the laboratory. This industrial approach to laboratory medicine makes perfect sense for routine screenings, esoteric testing, and even urgent work if the service can be affiliated with Big Brother or outsourced in a way that doesn’t sacrifice quality.
The laboratory has always been driven by bigger and better technology, but it comes at a price that is increasingly scrutinized. As a pathologist told me recently, “There is nothing unique in what we do.”
Bench techs have a different story. The value of the generalist in a small laboratory is in the details of care: faster turnaround times, multitasking across departments, and a personal relationship with team members that spans disciplines. I’ve worked in medical centers where I have arrived at work in the dark, worked a double, left in the dark, and never seen a soul outside the laboratory. That almost never happens in a small hospital. Local, personalized care has a unique quality impossible with “economies of scale.”
Next, I’ll consider how to make “what we do” unique.
NEXT: Get Out of the Basement
All the labs I’ve been in have a radio on. A surveyer once commented on this in a lab, saying in her experience they were usually by a sink. In our lab there is a radio directly outside my office, which is the only place we get reception. All day, every day it plays country western music. Not all the techs - myself included - prefer this genre, and most don’t complain. But does it help? Can music at work improve productivity?
The New York Times reports that melodious sounds help release dopamine in the reward area of the brain. One study showed that workers listening to music completed their tasks sooner and came up with better ideas, because music improved their sense of focus and their mood.
CBS Money Watch reports the same, adding that music makes you feel calmer at work. Listening to music lowers your perception of tension, which is even true for energetic music. Music can also have positive effects on people who suffer from adult ADD, again by increasing the dopamine levels in the brain.
Dopamine is a neurotransmitter with a number of functions, including mediating pleasure in the brain. It is released during pleasurable activities and stimulates one to seek pleasure. But it’s also associated with attention and cognition. Science Daily reports that dopamine also helps with difficult cognitive tasks: “Our key cognitive center, the prefrontal cortex, which we use for abstract thought, rule-based decisions and logical conclusions, is intensively supplied with dopamine.”
Bench work is filled with rules-based decisions and simple math, such as verifying results, troubleshooting quality control, and unit conversions. The above suggests that music not only improves our mood but our ability to do lab work, as well.
Sometime last year I started listening to music while writing, and to my amazement I wrote faster, more clearly, and with more focus. Usually, this involves headphones, Grooveshark, and power pop tunes. Beats me why upbeat, energetic music improves writing, but it does. I can easily imagine it helping at work, too. And who knows? It might keep people awake at meetings.
NEXT: Economies of Scale
The American Academy of Microbiology website states, “The human microbiome, the collection of trillions of microbes living in and on the human body, is not random, and scientists believe that it plays a role in many basic life processes.” Our gut flora is increasingly being seen as communities of microbes that work with us to influence our health. This is a startling change from the pathogen/species focus of clinical microbiology.
This suggests that our gut flora is not just essential but has to be cared for in terms of lifestyle, habits, diet, etc. And indiscriminate use of antibiotics that can destroy entire populations in the gut may have unknown or negative consequences. The most obvious example of the latter is hospital acquired C. difficile infection, an opportunistic colitis.
These populations don’t just keep us from being overrun with pathogens - a focus of laboratories - but help us digest food. A 2013 study in Nature indicates that changes in the microbiome occur rapidly in response to changes in diet. Ten participants switched to either a plant- or animal-based diet. In the latter group there was an increase in Bilophila wadsworthia, a bacteria linked to inflammatory bowel disease in mice.
The changes occur rapidly, too. Rather than days or weeks, the microbiome seems to respond within hours. This suggests an evolutionary advantage for early hunter-gatherers whose food supply could change from day to day, helping these humans achieve maximum absorption of nutrients.
The Nature article states, “Microbial activity mirrored differences between herbivorous and carnivorous mammals, reflecting trade-offs between carbohydrate and protein fermentation.” I suppose, it also shows difference between vegetarian, typical Western, and other diets. It’s something I have never thought about when choosing what to eat. I’m not sure I’d know where to start. But the study suggests that bile-tolerant species such as Alistipes, Bilophila, and Bacteroides that contribute to colitis are linked to animal-based products.
As laboratories will we eventually being reporting percentages of populations from stool cultures to give a snapshot of this activity? I wonder. It would be a change to look at populations and not pathogens.
NEXT: Music Improves Your Work
There’s been a lot of paranoia about influenza, much of it justified. The 1918 pandemic killed as many as 30-50 million people worldwide, and 675,000 in the US. We don’t know for sure. But in an average non-pandemic year influenza kills between 3-49 thousand in the US. The figure I keep in mind is 35,000 a year, about the population of Bangor, our nearest city. So if that fear makes you get a flu shot, good.
Respiratory syncytial virus (RSV) season runs from approximately November through late February in this region and typically overlaps influenza. I was surprised recently to learn that RSV is deadly in adults, for many of the same reasons as influenza. According to the CDC, while infants and children are the most frequent concern, each year there are 177,000 hospitalizations and 14,000 deaths among adults older than 65.
Nearly half as many as flu? I find that surprising, but it seems plausible for a virus that targets the lower respiratory tract. Why isn’t this on the radar for these patients? Why don’t we routinely test older patients for RSV?
I talked to one of our hospitalists about this, and at first he was skeptical. “I don’t believe those numbers,” he said. “First of all, we don’t test for RSV. How does the CDC know?”
That’s a good point. The CDC admits on their website that it is difficult to estimate, since influenza and other viral agents are not often listed as a cause of death on death certificates. Laboratories don’t routinely test for RSV for a number of reasons. Most (if not all) of the rapid kits are insensitive to adult populations and have only been approved for pediatric patients. And there is no RSV vaccine, which may be another reason we don’t test. Treatment options for RSV are limited compared to influenza.
A local microbiologist working in a lab that routinely tests RSV as part of a respiratory panel shared numbers that suggest RSV is prevalent in older patients, along with influenza. In his opinion, the CDC figures are believable.
NEXT: Populations and Pathogens
Your laboratory is probably a mix of old and new technology. You may have refrigerators decades old, small centrifuges that were purchased used and still run strong, a coagulation analyzer at the end of its five year contract, and a chemistry analyzer you just installed a month ago. Ideally, each new piece of hardware represents a new service, cheaper cost, or faster and better testing ability. When should you upgrade?
It’s not an easy question to answer. Some factors to consider:
- Is there a demand for new technology? Immunochemical fecal occult blood (iFOB), for example, is better in many ways than a guaiac test, but will it be supported by your medical staff? Can you sell it?
- Is it really an upgrade? Any new technology should be a big enough leap to market as a true improvement. A more sensitive troponin, a 6-part CBC differential, and a rapid culture identification are good examples that can improve your service and sell extra expense to administration.
- When will the status quo fail? In general major instrumentation lasts five to seven years. If you start looking for an upgrade a year or two early it gives you plenty of time to decide, strategize, and find support for new technology.
- Does it save money? It’s rare that new technology reduces cost, but it happens. Look for new contracts, year-end deals, zero percent interest rates, and rebate incentives that sweeten the pot. Competition is always fierce by definition. And bean counters are convinced by numbers.
- Is it the only option? Your organization may have a policy to get several quotes on purchases, but it’s a good idea anyway. You can always pit one vendor against another. Simply saying, “I’m considering other vendors” is often enough, since everyone knows who the players are. And who knows? You might be pleasantly surprised.
Finally, you should consider the state of the competition. If all the labs around you have hematology analyzers that report a 6-part differential, it may be time to seriously consider an upgrade, for example. Your lab needs to stay current to be competitive.
NEXT: RSV Season
When I was a teenager a local businessman ran a company called ABC Rubbish, I suppose so it would be listed first in the telephone book. We always called it “Already Been Chewed.” To this day that’s the main reason I remember that company. Mnemonics (from the Greek word for “memory”) are definitely handy.
A common “ABC” that you may not think about is one you see every day. It’s in your workplace, grocery store, department store, corner market, and probably your home. It’s what describes a type of fire extinguisher.
Not all fire extinguishers are the same. Different types fight different types of fire. OSHA has a handy “etool” that explains this. The most common types are:
- A (water, usually a large metal canister with a hose) - used for paper, wood, linens, and other ordinary combustibles; anything that leaves an “A”sh.
- BC (CO2, the kind with a horn nozzle) - used for flammable liquids, greases, and paints (anything that “B”oils or “B”ubbles) and for electrical fires (anything carrying a live electrical “C”urrent).
- ABC (dry chemical, usually a small or medium red canister with a hose attached) - suitable for all fires (A, B, or C).
The most common type of extinguisher you’ll see is ABC. Usually a label on the extinguisher says “ABC” but may also contain universal symbols denoting the type of fire: a burning trash can for A, gasoline can for B, and electric plug for C. Since the dry chemical is released under pressure, these extinguishers have a gauge with a needle that should be in the green. There should also be a tag attached denoting monthly checks.
It’s common in laboratories, IT departments, and other places with a lot of electronics to have a BC type extinguisher. But an ABC is also needed for any general type of fire. The dry chemical, which is intended to smother the fuel source, can be used on an electrical fire, but it effectively ruins the equipment. It’s something to think about when selecting a fire extinguisher, and a good reason to know your ABCs.
NEXT: When Should You Upgrade?
Healthcare is hazardous to your health. A 2010 Bureau of Labor Statistics report lists the highest number of workplace injuries in healthcare (176,380), followed by manufacturing (127,410) and construction (74,950). Nearly half of lost workdays caused by injury happen in the healthcare sector, four times the national average. Back injuries alone cost over $7 billion per year. And as dangerous as our work environments are, OSHA carries out few inspections.
It seems hard to believe, at first. After all, we work in enclosed, climate-controlled environments. We aren’t monitoring enormous machines in plants or moving steel girders hundreds of feet in the air. We don’t have to wear hard hats, respirators, hazmat suits, or face shields every day.
But in 2011 nurses ranked highest among occupations for numbers of musculoskeletal disorders resulting in lost work days. The wear and tear of patient handling is a major contributing factor. The workforce is getting older and the patients heavier. The reality of modern nursing accounts for many injuries.
Lab techs may not lift patients, although many items are heavy, such as large cubes of saline. Laboratory equipment, instruments, and tasks routinely involve exposure to high speed rotors, moving parts, heating elements, needles, and other sharps around fingers and hands. The degree of fine motor control required can cause repetitive motion injuries. We deal with harsh chemicals such as corrosive acids. And blood and body fluid exposures are a constant occupational risk.
Often, it’s ambient factors that go unnoticed. These include temperature and humidity, ventilation, cleanliness, clutter, and ergonomics. A laboratory that is too cold, too hot, too stuffy, or too dirty can be a difficult, hazardous, and stressful environment to work in. Clutter and poor arrangement of workstations can sap productivity. (There’s no such thing as being “organized under the surface.”) Poorly designed chairs, counter surfaces, and floor mats also cause musculoskeletal wear and tear. And labs are incredibly noisy, too, with all the bells, buzzers, high speed motors, and telephones. It all adds up.
So the next time you arrive at work, look around. How safe is your lab?
NEXT: Know Your ABCs
Interviewing for a job is stressful, especially if you don’t have a job and need one. It’s easy to forget that you’re not just buying what an employer is selling - working conditions, pay rate, benefits, culture, etc. - but shopping. What should you be shopping for?
Like most shopping, we want value.
The Guardian reports that, at least in the UK, work-life balance is number one. Location and job stability rank second and third. The interview is your best chance to ask about work factors important to your “real” life: shift times, rotations, holiday schedules, staffing levels, etc. It’s also a chance to ask about the financial health of the organization and its strategic plan.
There are other factors included in “value” that will vary from person to person. Here are two that have made a difference to me:
- Commute time - it amazes me that people will choose to drive an hour or more to a job. An hour commute is two hours (depending on seasonal traffic) out of your day. If you consider this as time worked (it’s not play, that’s for sure) it dilutes your take home pay, along with gasoline expense. I’ve worked most jobs with a two to five mile drive, which is great. Most days I can go home for lunch, too.
- Please and Thank You - a lot of fuss is made about “corporate culture,” but it all boils down to “Is it a nice place to work?” Unless you have experience at a workplace as a customer, the best way to tell is by walking around and observing employees. If they smile, say please and thank you, and get along that’s a good sign. The only thing worse than working at a place where people dislike each other is being one of their customers.
I rarely interview candidates who ask me about the above, and no one has ever asked me about the future plans of the hospital. But this kind of value is important in a place where you hope to spend a lot of your time and creative energy.
NEXT: How Safe Is Your Lab?
Hospital acquired anemia can be an issue if multiple tubes are collected several times a day. Over time, small amounts of blood (5 mL is a teaspoon) add up. I’ve developed a “short draw” protocol to use low volume tubes and chart the amount drawn for patients if a physician has a concern.
However, it’s common to draw a rainbow - one of every color - when time is a factor. This has been common practice in the ED and with EMS personnel. Before the doc sees the patient and while the nurse is starting an IV, a rainbow is drawn just in case on some patients.
Pros: when the ED doc orders a test, blood is in the lab and in many cases spun, reducing delays. We can anticipate an order in some cases e.g. chest pain and have a test running.
Cons: Extra tubes sitting around without laboratory barcodes are a problem that needs to be constantly checked. If information in an account is corrected, tubes are labeled incorrectly, or a test is ordered that needs a special tube e.g. lactate, delays happen. Tracking tubes without orders is a distracting process variation.
Indeed, I’ve toyed with the notion of not accepting any specimens without an order. But specimens sitting in the ED could cause bigger problems.
What if the ED stopped drawing a rainbow? What if they drew only the tubes needed for the tests ordered?
Pros: tubes are more likely to be received with orders already in the system. Less blood is collected from the patient. Cost is reduced.
Cons: it’s harder for ED and EMS to fit a draw time in at the doc’s discretion, so the lab is more likely to be called to draw the patient, causing delays. There is a predictable delay in processing samples if the draw waits for an order. Untrained or hurrying personnel can forget which tube goes with which test, resulting in redraws and further delays.
It’s lab meets nursing meets cost containment and efficiency.
What about your lab? Do you draw rainbows? Why or why not?
NEXT: When Choosing a Job, Shop for Value
Working for a micromanager is demoralizing, and what’s even worse is when you can’t leave. Maybe you’re a new graduate and it’s your first job, you really like your coworkers, you
need the money because you have kids that just started college, or there just are no other jobs in the area. Feeling stuck can be a nightmare that never ends.
The Harvard Business Review points out that micromanagers are not all cut from the
same cloth. While generally they want to control situations, some simply have extremely high standards and feel the world doesn’t measure up. These are bosses you can learn from in
the long run. But there are also those who micromanage to prove they are in control of every tiny detail. Experts agree that there is no use fighting back.
Author Simon North writes in Forbes, “As
annoying as micromanagers are, they’re incredibly predictable... Knowing their pressure points can help you ease them.” North advises anticipating a micromanager’s needs and being
reliable. Not giving him or her a chance to feel out of control is a good strategy to reduce stress for everyone. It helps to give coworkers a heads up, too.
Concrete steps you can take include documenting your work and giving feedback to the manager. Instead of waiting for a daily request for what’s being done, anticipate this need
and be proactive. Provide a daily report, for example. If your micromanager insists on controlling details, make sure he or she knows them. It doesn’t matter if it makes sense, wastes
time, or is annoying. What matters is your sanity in your job.
There’s a chance a micromanager is simply a good boss interested in helping you succeed, too. Good managers should be involved with setting employee goals, mentoring, and
tracking outcomes. Good managers are also willing to step in and help when needed, check in, or meet with employees working on projects. This can seem like micromanagement at
times, but it may simply be extra scrutiny. So it’s important to always ask, “Am I doing anything to deserve this extra attention?” Maybe, you are.
NEXT: Thinking About Rainbows
Merriam Webster defines micromanage as “to try to control or manage all the small parts of (something, such as an activity) in a way that is usually not wanted or that causes problems.” While managers are sometimes labeled as such, micromanagement is really a style of management. It can be taught, mentored, and embedded in a culture. Sometimes a person who micromanages can’t help it because of personality.
Wikipedia offers these symptoms:
- The micromanager monitors and assesses every step of a process and avoids delegating decisions
- The micromanager demands frequent and detailed reports and focuses on procedural trivia rather than overall performance
- The micromanager who delegates will still micromanage, taking credit for positive achievement and shifting blame for mistakes
Micromanagement is a form of workplace bullying. Certainly, it borders on harassment and at times humiliation. It’s easy to dismiss these irritants as “control freaks,” but it’s more than that. Micromanagers seem to need to feel indispensable above others to an organization. Their opinions, their decisions, their telephone calls, everything is more important than whatever others are working on. And in the process their behavior belittles and devalues those around them.
This can be a safety issue in the lab, too. There are enough distractions at the bench without being interrupted to be asked why something isn’t done, where a report is, or asked to do something else. Instead of managing workflow and quality, micromanagers think they need to manage competent subordinates already performing the work.
What’s surprising to me is how many of these people I’ve known or worked for over the years. I’ve had bosses who have redone my work, stormed into my office and thrown stuff at me, or emailed me a dozen times in one morning demanding why I wasn’t finished with a project I was in the middle of working on. Most demanded constant reports and updates, just as predicted in the above. It creates frustrating stress that makes it difficult to get anything done. It’s exhausting, too.
Next, I’ll consider a few strategies to deal with a micromanaging boss.
How about you? Are you micromanaged?
NEXT: Surviving Micromanagement
When I blogged about looking at inpatient charts in 2012, we had implemented CPOE (Computerized Physician Order Entry) to a limited degree. Now that it’s commonplace and there are few written physician orders, it’s still useful to look at charts.
Each morning we take 15-30 minutes to round at the nursing stations to check a few charts, among other tasks. The selection process varies: sometimes random, new admissions, a patient getting blood, a patient with a positive culture. The question we hope to answer is, “How can we help improve what we do?”
Generally, I look at laboratory reports already filed for completion, legibility, or duplication. It’s interesting to see these on a chart with values circled or notations made by the physician. The docs look online, sure, but it’s amazing how much paper still exists. Some of it comes from other facilities, too.
This has provided clues to improve our lab reports, from accidental duplicate comments to spelling errors to interpretive comments that are verbose or confusing. As a result I’ve changed a number of formats for the better. I’ve found misfiled reports, too.
I’ll also review the history and physical to see what a complaint is if the patient has a pending or positive culture, a transfusion request, or an unusual order or finding. But sometimes this can be useful with a random selection. The other morning I reviewed a chart listing a diagnosis of pyelonephritis, but we didn’t have a urine culture pending. (It had not yet been collected.)
I’ve found this to be a useful practice that gives us valuable insight on inpatient workflow. When reviewing a chart with a pending sputum culture that needs recollection because of a Q score I’ll talk to the nurse directly. Usually I bring a microbiology tech along, and she can give the nurse or hospitalist a heads up on cultures. We can clarify orders face to face, a real plus.
It is overall useful post analytical QI and time well spent. But I’ve no idea how common this practice is. What about your lab? Do you look at charts?
NEXT: Are You Micromanaged?
There’s a misconception in management circles that people need to know each other socially to get along. If I hang out with you in a non-stress environment where we can avoid talking about work I’ll find out that you’re really a great person and not just a boss, charge nurse, or other demanding coworker.
I’ve always found these events painful, to say the least. Nothing seems more forced to me than the boss trying to act cool and yuck it up with employees. Fortunately, there’s a simpler way to like others and to get them to like you. It’s called the Ben Franklin (yes, that one) Effect.
Common sense dictates that we do favors for people we like and don’t for people we dislike. The Ben Franklin Effect describes the exact opposite. Instead of deciding we like a person before doing him or her a favor, we grow to like the person as a result of a favor. Franklin himself used this with a political rival by asking him to loan him a rare book and then thanking him. Franklin wrote afterward:
When we next met in the House, he spoke to me (which he had never done before), and with great civility; and he ever after manifested a readiness to serve me on all occasions, so that we became great friends, and our friendship continued to his death.
The reverse is also true: if we hurt someone we are more likely to dislike them. It’s one reason for wartime atrocities.
The Ben Franklin Effect should improve teamwork in your lab, since it will make coworkers genuinely like each other more. Instead of expecting a coworker to help you and getting angry when he or she doesn’t, ask for a small favor e.g. “Would you mind doing me a favor and putting on this STAT for me?” The Ben Franklin Effect predicts that the coworker will justify doing the favor by assuming he or she must like you. And it works. It certainly won’t hurt to try and is less painful than a company outing on your day off.
NEXT: Do You Look At Charts?
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