Do older techs hate change? It’s a cliche that an old dog can’t be taught new tricks. When someone is “resistant to change,” ageism inevitably follows. “She’s old and close to retirement,” I’ll hear. Conversely, young people are assumed to be champions of change, malleable, and willing.
All of which may be true to an extent, but adopting such a view dismisses experience as a variable. The reason “older” techs hate change is because they’ve been there, done that, and have a closet full of tee shirts. It’s true that in time we all become tired of change for the sake of change, but it’s worse to be ignored or dismissed. Decades of experience working the bench includes decades of change, large and small. That counts for something, surely.
And younger techs naturally embrace change because it levels the playing field. A lack of experience prevents you from seeing unintended consequences of change. And all change has unintended consequences, hopefully more good than bad.
As a manager, I’ve always taken the approach that resistance is information. “Why would we do that?” and “That is a waste of time,” to mention two classics, should open a dialogue. And here is where it gets interesting.
Why would we do that? Decisions are based on values, whether we appreciate it or not. We value the patient experience, the support of employees, quality, the bottom line, etc. All managers approach their position with a set of values that overlap with those of the organization. Unpopular change involves unpopular or unknown values. Good managers are consistent in expressing their values through decisions. But when a decision doesn’t make sense or is out of synch, it’s natural for people to ask the question.
That is a waste of time. This is a clear clash of values and vision. As a manager you might see a change as important, and when challenged in this way there are several alternatives. You might, for example, attempt to explain why. You could invite the group to brainstorm alternatives to the change and possibly be surprised. Or you could just pull rank and tell everyone to suck it up. What you choose will be a reflection of your values.
The mantra in management training is that “resistance” is inevitable. I disagree. Like a trick, the acceptance is in the presentation. The last thing that any tech who works a hard 40 hours a week is that he or she will be asked to do more. Or less! Efficiency can be threatening to those worried about losing hours.
Do older techs hate change? I don’t think so, at least not in any meaningful sense. Experience hones instincts and brings wisdom, two qualities any manager needs to succeed. Ask why people hate a change, and they are likely to tell you. Opening this kind of dialogue is a first step to success.
NEXT: Who Can You Follow?
In my last blog, I described how to create a table in a database that stores blood bank index card file information. At a minimum, this should contain the patient name, date of birth, and a checkbox to indicate if the patient has antibodies. That’s the easy part, and it can be done in a few minutes.
The other features of OpenOffice (and Access) are creating Queries (search filters), Reports (to print or view data), and Forms (to enter and view data). At a minimum you’ll want a to create a form to make data entry easy. The good news is that creating a form is even easier that creating a table.
- Click Forms
- Click Use Wizard to Create Form...
- The form wizard will list all the fields in your database table. Add all fields but the ID field (a unique record identifier) by highlighting and clicking the right arrow. You should see the field names move to the box on the right.
- Click Next
- Leave Add Subform unchecked. Click Next.
- Click a control arrangement for your form e.g. Columnar - Labels on Top.
- Click Next 3 times to select defaults.
- Enter a name for the form e.g. Edit Cards. Click Finish.
Once you open the form, it looks something like this:
It’s nothing pretty, but it is functional and gets the job done. You can enter data, using Tab or Enter to go to the next field. At the bottom of the window are tools to search and page through your records.
For those of you who are database savvy or know someone in the building who is, it’s possible to optimize this form by creating a date mask in the DOB field (so all you have to do is enter six digits) and skipping the Antibodies checkbox when routinely entering data. This will allow you to enter data as quickly as possible. If you are entering the data sequentially from the card file, you can also use Windows cut (Ctrl-C) and paste (Ctrl-V) shortcuts for last names.
Once all the cards are entered, then what? Here are ideas:
- Use the mirror to see if a card is in the file. This can be done before or after. If you choose to add blood type to your table, it can be helpful for the blood banker.
- Plan to scan. Although this can be involved, it’s easy to add links to scanned images associated with the patient, such as handwritten cards, transfusion reaction workups, antibody panels, etc.
- Create another table for the data on the card itself and link it to the main table using your ID key. This is slightly more complicated than creating the simple form above, but OpenOffice makes it very easy.
Entering demographic information is the hard part. Once data is entered you may, for example, decide to migrate card information as needed to the database, gradually eliminating your paper card system. You can begin by migrating those patients with antibodies or other unique needs that make misplacing their cards such a high risk.
NEXT: Do Older Techs Hate Change?
In building a blood bank cardfile mirror, the main element is the database table. A table is a collection of records that stores data in fields. In the case of OpenOffice Base, when you open the program (called Database in the OpenOffice main menu) a dialogue asks if you want to create or open a database. Then the screen looks something like this:
Create Table in Design View…
Use Wizard to Create Table…
Your blood bank cardfile table is created in the [highlighted] tables tab, and all tables appear below. To create a new table, click Create Table in Design View and enter your field names and type of data. Free text the Field Name and choose Field Type from a drop down.
The ID field indexes your table. It also allows you to link records to other tables. Right click the box to the left of the ID Field Name and select Primary Key. Then make sure AutoValue in the Field Properties tab on the bottom of the screen says Yes. Save and you’re done.
It’s easy enough to add fields to this table. For example, you may find it useful to add a blood type field. This would also be a Text [VARCHAR] type. Note that all this works very similar in Microsoft Access.
The hard part is always data entry. Blood bank history files are deceptively large. It’s easy for a small hospital laboratory to collect thousands of cards over the years, but all the information has to be entered. It’s something to think about when designing your table. You’ll want to enter a minimal amount of data as quickly as possible. You can always add more later.
If you double click on your table, you can start entering data in what looks similar to a spreadsheet. But is there a better, easier way? Next, I’ll describe how you can create a data entry form in minutes.
NEXT: Form and Function
The concept of a database is simple: data is stored in tables and linked together. Once the data is stored in a table of fields you design, you can do anything with it. You can sort, print, or filter it.
The problem of a blood bank card file mirror may sound trivial, but the impact can be significant. If, for instance, 5% of 5000 cards are misfiled, that means 250 cards are not exactly where they should be. Depending on your population, your lab will have a variable population of patients with clinically significant alloantibodies. But let’s assume for the sake of argument that 1 out of every 250 antibody screens is positive. All it takes is one.
A table is a list of fields. Conceptually, it’s very similar to a spreadsheet where each column is a field and each new record is a new row. In this case, the fields are Last Name, First Name, Date of Birth. The simpler you make it, the easier it is to enter data. For now, all we want to know is if there is a card in the database.
Not all cards are equal. The possibility of the patient with a titer of anti-Kell too low to be detected is significant, for example. Fields can store a variety of data: text, date, integer (a whole number), and Boolean, a $64 word that means “true” or “false.”
In my database, I added a field called “Antibodies,” a Boolean type that flags a patient with ANY reason to order special blood types (usually antigen-negative). These are the cards you never want misfiled.
You can see where I’m going with this. A patient arrives in the ED, and you check the database to see if a card exists. Even if you don’t find the card, it helps if “Antibodies” is unchecked. But without a mirror database, you have no idea how many cards are misfiled.
If you Google “openoffice base video tutorial,” you can get started. It’s easy. Next, I’ll describe what the finished table looks like.
NEXT: Cards on the Table
There are many kinds of software licenses, some more restrictive than others. If your hospital uses Microsoft Office, for example, a certain number of licenses has been purchased to match the number of workstations the software can be installed on. Typically, the cost of these volume licensing agreements are customized to the type of organization, number of users, and infrastructure, and it isn’t cheap. These days, it’s a cost of doing business.
I have used Access, a database application packaged with Office, in previous positions to create a simple mirror of a blood bank cardfile, for example. Manually filing paper cards always risks misfiling, and there is a small but significant chance that a lost card containing information about a patient alloantibody could enable a transfusion reaction. The concept of a database mirror is simple: if a patient is in the database, there is a card in the cardfile. If the card can’t be found, it must be misfiled.
Access is easy to use and wizard driven. No programming is required.
But not all flavors of Office come with Access. If your hospital has purchased Office without Access or has a limited number of Access licenses, is there an alternative that is easy to use?
You could, for instance, maintain a list of names in the cardfile in a spreadsheet such as Microsoft Excel. The problem with Excel is that it can’t easily do what a database does: search on complex terms and link tables together. It’s also too easy to alter information in the file. But sure, Excel could do the job.
Fortunately, there are free alternatives to Access. OpenOffice Base, part of the OpenOffice suite, is an open source product that is completely free. “Open source” means the source code is freely distributed, allowing programmers to modify and improve the program. This kind of collaborative coding improves code for its own sake instead of profit. The power of open source software is that it is always being improved.
Can OpenOffice Base create a blood bank cardfile mirror? Sure. It can do much more. Next, I’ll explain how.
NEXT: Building a Cardfile Mirror
Each new year brings change after a season of excess. At home it’s time to hit the gym, dust off the exercise bike, and put the juicer back on the kitchen counter. At work it’s time to bundle up 2015, discard old records, and think about planning vacations for the year. Perhaps, you have resolved to mend relationships, forge new ones, or rekindle old ones. A new year is a fresh start.
List makers (and you know who you are) already started a week ago. But for the rest of us, the year is a clean slate. Here’s what I’m looking forward to in 2016:
- Online blood bank cards. Many blood banks have a paper card system to look up recipient history. But what happens when a card is misfiled? In 2016 I’ll begin migrating cards to an online database that is fast, simple, and easy to make.
- Autoverification. I’ve tried autoverification with other systems without much success. It could be an idea best left to middleware. Our current system has this capability, and I’d like to try it. The amount of time a tech spends reading and verifying normal values is too large to be ignored.
- Simpler competency assessment. Competency assessment is something all labs struggle with, but it should be treated like any other aspect of method validation. Time spent on competency assessment adds up, too. And all tech time costs money.
Labor shortage woes are well known. I don’t have a sense that movers and shakers are motivated to help our industry. As more techs retire or move on because of pay or advancement issues, doctors rely more on accurate, timely testing. That’s one big iceberg ahead.
I often think a layperson would be surprised at how much our industry still relies on paper. The electronic medical record is coming, but it has been bedeviled by the complexity of delivering care, interface woes, and Federal sticks and carrots. 2016 could be the year of the computer in healthcare.
In this blog, I’ll begin describing how to build a simple card database. Did I mention it’s free?
NEXT: The Power of Open Source
No one like confrontation. I get it. We come to work, we do our work, we have pleasant conversation with co-workers, and we go home. But of course it isn’t that easy. Even Gilligan’s Island wasn't that easy.
Confrontation is necessary because unspoken rules are often broken: a coworker takes a too-long lunch; a coworker leaves work for others to complete; a coworker doesn’t play by the rules and appears to get away with it.
These are not easy interactions by any means. In my experience people will avoid such painful exchanges at all costs. Only bullies look forward to confrontation, which by definition is aggressive.
Yet differences must be resolved. Here are tips:
- Mentally prepare - the real issue in any confrontation is, “What’s in it for me?” In my experience, if you expect people to agree with what you want, you’ll lose almost every time.
- Set the stage - the last thing an antagonist - the person at the other end of a confrontation - wants to hear is that you don’t care or aren’t interested in what they want. Be hard on issues and soft on people. It’s difficult (but necessary) to put yourself in the place of the other person.
- Remember, it takes two - if all interactions were pleasant we’d be living in a paradise. Last I looked, this hasn’t happened anywhere yet. Remember that the other point of view is always valid.
All this sounds great, but it remains extraordinarily difficult to deal with the employee who has slacked off, decided not to pull his weight, or otherwise dropped out of the team. That’s where a manager / coach has to step in for the sake of the team’s survival and morale.
Which brings up the point that it is a manager’s responsibility to confront employees on their behavior. I’ve been in both kinds of labs, where managers address everything and where they address nothing. I’m always cautious of attempts to manipulate my influence, blow off extenuating circumstances, or just efforts to target an individual. We all know how to work the system, bullies most of all.
NEXT: Looking Ahead
“Our dilemma,” said the American journalist Sydney Harris, “is that we hate change and love it at the same time; what we really want is for things to remain the same but get better.” Ain’t that the truth.
The holiday season is a time for loved ones to gather, and it’s a time to reflect on the year. Was it easy or hard? Static or full of change? Did it get better?
Healthcare is changing, with a push toward centralization, consolidation, and cost control on a scale never before seen. Small hospitals, in particular, have suffered to keep up and at the same time deliver top-quality services.
But circles of change ever decrease to our own lives. Here’s what I’ve seen in 2015:
- My oldest graduate High School and start college. If there’s anything that makes one reflect on life, it’s that.
- Starting a new job. For the first time in many years I’ve had to learn a new job, a new culture, and form new business relationships. If there’s anything that makes one realize how complacent life can be, it’s that.
Through all this, the good news is that my experience has taught me each time to weather change for the better. I bring to this new job all that worked well in my previous positions and (hopefully) left behind what didn’t.
What we are seldom prepared for is the emotional devastation of change in life, that wrenching feeling of being uprooted and tossed to the wind. It’s even harder in this economy. I’ve seen this happen to many as the paper industry in Maine has struggled.
But we are stronger than we believe and should continue to be inspired by others. I’m touched and heartened by the kindness and sincerity of strangers. It isn’t that people are kinder or more sincere, but it has become more natural to see these qualities over time. In this sense the world has remained the same and gotten better.
Hopefully no matter what kind of change you’ve seen - marriage, grandchildren, career change, retirement, etc. - your life is better this season. Have a happy.
NEXT: Confrontation Rules
We are living in weird times. Our schools label any form of visible aggression as “bullying,” forcing natural behavior to go underground where lessons cannot be taught by elders. Workplaces are filled with buzzwords such as empowerment, team building, and consensus, but without rules of engagement there is no room for healthy disagreement. Without disagreement, there is no understanding and no growth. Are we simply afraid of confrontation?
I’ve been told at times, “Don’t be afraid of confrontation.” Should I be? The dictionary defines it as “a situation in which people, groups, etc., fight, oppose, or challenge each other in an angry way.”
That certainly sounds like something to be avoided! It’s only a job, after all. But the manager mantra is still to have “crucial conversations” and confront employees about their behavior. I know it can be a matter of semantics, but only a bully enjoys confrontation. Setting up a workplace to avoid disagreement and dissent while encouraging bullying only creates a vicious cycle in which no real understanding or growth happens.
The funny thing about all this, at least from my perspective, is that those in charge are often well intentioned. After all, who wants bullies? Who wants disagreement? But all cultures assume that what seems to work does so because of obvious reasons. Since like hires like, the cycle just continues unless someone less obvious comes along.
Think about your laboratory: are you allowed to disagree with management, ask why, and arrive at a mutual understanding based on respect and shared goals? Or are you expected to comply with decisions, not be “resistant to change,” and be ready to confront people? Not only are these unspoken rules cultural, they are top-down driven. From my perspective, for example, I’ve learned to consider “resistant to change” as an invitation to engage people and find a common ground. Insubordination is uncommon, to say the least.
Next week I’ll consider rules of confrontation, because as a worst case scenario it is inevitable with coworkers, bosses, and employees. It’s also not as bad as it seems.
NEXT: Looking Back at 2015
Charge masters are unruly beasts that must be tamed to ensure we get paid. How labs do this varies with each information system and who has access to what. These days, a laboratory manager has to either understand databases and Excel or have someone on staff who does. It’s one of those problems that IT can’t solve.
Most hospitals have their charge masters periodically reviewed by an outside firm, which is one approach. It’s also possible to go through a master item by item, comparing it to either invoices or test catalogues. These approaches are time consuming, exhausting, and only ensure the charges are accurate until they are changed.
For me, the toughest leg of this beast to wrangle is referral lab testing. It isn’t uncommon to have several similar items with a half dozen associated charges each that change or reflex depending on the results and where the referral lab sends the test.
But charge accurately we must. If we don’t charge for a test, we not only don’t get the revenue for that test, we can’t offset its cost that we have to absorb. That can quickly translate into needed equipment, supplies, or people.
I’ve developed a few approaches that work:
- Learn how to extract data from a system. This varies, but generally if you can pull charges, CPT codes, prices, and how they are linked into Excel or other software, you can more easily get a handle on outliers.
- Dynamically update the charge master. Rather than an exhaustive overhaul, I compare a database dump of charges to an electronic version (ideally) of a statement. It’s easy in Excel to create identical keys in both and link them using a VLOOKUP statement. Whatever doesn’t match is a problem. A large statement can be culled in minutes, allowing you to update your charge master.
Managing such large databases is overwhelming and difficult in these days of labor shortages and cost-cutting. It also requires more advanced computer skills than many of my generation possess, although the learning curve for using SQL (and others) isn’t as steep as you might think.
NEXT: Who Enjoys Confrontation?
The conundrum of Rh confounds many a blood banker. Since its discovery nearly 80 years ago, our understanding and treatment of Rh types have evolved. Here are a few common problems that I encounter:
- Weak D. A weak D recipient is considered Rh Neg. A recipient who has a weak (or partial) expression of the D antigen can theoretically be sensitized to D. But as a donor this person is considered an Rh Pos for the same reason. Thus, an individual can be considered both. Fortunately, I’m A Neg.
- Unfortunately, Rh Negative units are commonly conserved for emergency release candidates and women of childbearing age. Everyone else is a candidate to “convert” if actively bleeding, meaning that an Rh negative patient is given Rh positive blood as standard laboratory protocol.
The latter is one of those acceptance issues that varies from place to place. It’s unusual for the laboratory to present a situation where the physician is forced to accept more risk for his or her patient, but switching blood types is one of them. I see their point: Just order more! But as we all know it isn’t that easy. Depending on the region of the country, supplier, and local usage, O Negs can be in critical supply.
Typically, O Negatives are reserved for emergency release (the blood type is unknown) and women of childbearing age (sensitization to D proves deadly for future pregnancies). I’ve been told by several pathologists that under stress a patient’s conversion rate dramatically decreases, but how does an attending physician deal with this issue?
As a manager, I always think, “That’s why pathologists get the big bucks.” Let there be a solemn conversation that is peer-to-peer to sort the risks and issues out, and then let the tech on the bench do whatever is needed. In small hospitals docs typically prefer to stabilize patients, send them out, and be more conservative about conversion. A tech working the bench should certainly never be engaged in a discussion of risks with the attending. All they will hear is “No.”
But that’s me. What about your lab?
NEXT: That Pesky Charge Master
A year ago CMS issued a memorandum about “off-label” use of waived blood glucose monitoring systems, typically used by nurses and other non-laboratory workers in a variety of hospital settings.
“Using a test outside of its Food and Drug Administration (FDA)-approved/-cleared intended use, limitations or precautions, as indicated in the manufacturer’s instructions, is considered ‘off-label use.’”
In these cases, the waived test defaults to high complexity under CLIA. The FDA does not prohibit off-label use, but those performing the testing have to meet high complexity requirements, the method needs additional validation, etc.
Generally, waived tests are those designated by the FDA as having an “insignificant risk of an erroneous result,” although these are broad strokes. A urine pregnancy test can be waived, but using serum on the same test kit is not, for example. More importantly, off-label use means an office or other waived lab could lose its waived status. Labs have to follow all manufacturer instructions, including intended use.
In March of this year CMS withdrew the November 2014 memorandum and reissued it as a draft for comment, stating “Waived BGMC are being used in a variety of settings and applications, which may indicate diverse clinical utility.”
That’s true, especially in hospitals. If you check package inserts for Abbott and Cobas meters, they specifically state the intended use is to monitor diabetic patients and performance has not been evaluated in critically ill patients. The latter becomes an issue in the ED, OR, and on ambulances. Other instructions are related to hematocrit ranges and circulatory issues.
A rapid fingerstick glucose provides useful information that may or may not change treatment with off-label use. While the risk of error may be greater, an error may not be significant to the attending clinician.
This isn’t only an issue with glucose meters. It applies to all waived tests, including strep screens, occult blood, and other point-of-care testing. Any off-label use requires a lab to establish performance standards, at least. And of course the test is no longer waived.
Has your lab or medical staff addressed this issue? If so, how?
NEXT: The Rh Conundrum
An “us versus them” attitude is common in all workplaces. Lab techs don’t understand nurses or nurses don’t understand lab techs. I’ve heard techs whine many times over the years, “If only the nurses could come down here and watch what we do for a day.” Never once have I seen a tech volunteer to do what a nurse does.
But the same attitude can exist in the lab between techs and phlebotomists. “It’s too complicated for the phlebotomists” or “they have to check with me first” are comments I’ve heard. Perhaps, this is true in your workplace.
One of my first jobs was as a phlebotomist in a 450-bed hospital in Maryland. That is honestly one of the hardest jobs I’ve ever had. I ran all day, every day with very little downtime. There was always paperwork, baskets to be restocked, and cleaning when there wasn’t patients. In one day I could collect blood on all ages, all wards, trauma cases, isolation rooms, and psych wards. It was an eye-opening experience.
I recall one young man who was admitted to ICU. He was apparently sick but looked very healthy. I drew his blood, chatted, and left. It may have been two months later when I drew his blood again in an inpatient isolation room. He was emaciated and dying. That was a tremendous shock to me, and I’ve never forgotten him. Later I learned he had died of stomach cancer. It’s this kind of thing phlebotomists see more than many techs.
Techs and phlebotomists have different skill sets and different responsibilities, but we’re all in this together. Because phlebotomists are on the front lines, interact with our patients, and collect many if not most of our specimens, they need to be included in the what and why of workflow changes.
For example, if there is a problem with ED specimens not matching orders (either by showing up out of sync or not at all), your phlebotomists are an excellent creative source. They should be empowered to suggest ideas, work through problems, and present possible solutions to the group.
NEXT: Off-Label Use
A STAT list is a relic of a time when it was common for labs to have call, labor intensive
tests, and batch testing. If your lab has any of these, you may also have a STAT list. It’s a
list of tests that your lab performs STAT, and anything not on the list usually isn’t. If, for
example, a B12 and Folate is not on the STAT list, a provider (in theory) can’t order these STAT
in the middle of the night. If your lab batches a test to be run two or three times a week, same
I worked at a lab many years ago in which if a provider did want a test not on the STAT list
STAT e.g. a uric acid, we called a pathologist to get approval. And guess what? Every single
time the pathologist said, “Run the test.”
What does a STAT list mean? Is it informational or restrictive? Refusing to run a test is
risky. The tech working on the bench is not the person assuming the responsibility for patient
care. Neither is the pathologist. It’s one thing if the test really can’t be done STAT e.g. AFB
culture, but quite another if your lab does the test in house. If you can do it, why not?
For ED patients, a STAT list may violate EMTALA (the Federal Emergency Medical Treatment and
Active Labor Act). EMTALA provides that patients must be provided with “appropriate medical screening” before a hospital decides to treat or transfer. If your laboratory batch tests
microalbumin, for example, and an ED provider orders one, not performing the test could violate
EMTALA. Lab techs can’t decide what’s appropriate.
A STAT list may be symptomatic of a lab that lacks efficiency and clear lines of
communication. Laboratories adopting continuous flow work models strive to reduce variation,
eliminate batch testing, and produce a consistent output. My guess is these labs don’t have a
need for a STAT list. They may even have less STAT abuse, if successful.
How about your lab? Do you still use a STAT list?
NEXT: We’re All in This Together
How many old methods are being performed in your laboratory? Old technology gives way to new at varying rates. Examples of “old” technology include Westergren sedimentation rate, Miller disc
reticulocyte estimates, and bleeding times.
These and others have generally been surpassed by newer, better, and more reliable technology. It is the laboratory’s responsibility to make physicians aware of these changes as they occur. Most will
accept a change if it means better numbers or greater sensitivity and specificity.
I remember performing Miller disc reticulocyte counts, for example. This labor intensive test has poor precision (around 30-50% on latest surveys). Automated counts are faster, more reproducible, and
probably cheaper. I suspect the manual method tends to underestimate reticulocytes as well. Does this matter to a clinician? Perhaps. Our agenda is to give the most reliable answer possible.
We all know those physicians who want what they want. There’s always a doc who wants a manual differential count, for example, even though an automated count is far superior in terms of precision and
accuracy. The proliferation of 6-part differential technology may change this, it may not. A 100-cell differential banged out with a counter under a scope is pretty old technology, for the most part. Most labs still
reflex to a manual differential if certain parameters are abnormal. Should they report this instead of absolute numbers that are available?
Laboratories also want what they want. In many cases we continue to do something because it’s the way it’s always been done. Your laboratory may still report bands, recheck urine dipstick values with
manual tests, or perform any number of tests “just because.” If it doesn’t improve the result or add value to the report it’s wasted effort, money, and time.
An annual survey of methods is one approach to keeping technology up to date. Is a method the best, the cheapest, the fastest? Is it better to keep in house or send out? Is it time to consider a completely
different method? Keeping on top of these issues brands your laboratory as technologically progressive, building trust with your docs.
NEXT: Do You Still Use a STAT List?