management/administration – Page 19

Steady the Ship

The relationships you have as a supervisor with the people you lead (notice I did not say “manage”) are important when it comes to day to day operations. They become especially important is when you have to guide them through change or conflict. I won’t even comment on the appropriateness of intimate relationships except to say if you engage in one then you are taking your career into your own hands and don’t plan on it lasting long. Beyond that, the lines are blurred and you may be engaging in an inappropriate relationship that won’t get you in trouble with management but will with the people you lead.

I am 31 years old and the majority of the people I lead are double my age so I have a unique (but becoming a bit more common) relationship with them. With many reaching retirement age in the near future the younger generation is taking the responsibility of leading and it creates unique issues. Do I sometimes feel awkward discussing a behavioral incident with someone who could be my grandmother? Absolutely, but my approach is what makes it a successful or unsuccessful discussion. I have learned that a “by the book” or “letter of the law” approach is not always successful. This is where emotional intelligence comes into play. As a leader you need to identify the needs of the people you lead, both as a group and individuals. It is very important to distinguish between the two because the needs of the group may be vastly different than as individuals. Once you do this it is easier to lead them because you know what they need to be successful and what you need to avoid, staving off failures. If you can successfully identify the needs of the group and individuals you can have relationships that grow and the people you lead will have confidence in you to lead them.

One issue that gets supervisor/managers into trouble is favoritism. It doesn’t even have to be true; perception in any workplace is often seen as fact. If one employee thinks that you favor another employee over them you will instantly lose their respect (not to mention a certain amount of work ethic). This can be especially difficult if you have worked with a group for an amount of time as coworkers and then you are promoted to supervisor. You will already have developed relationships and more than likely friendships with them so some of the perceptions may start with the start of your new role. If this is the case it may be a good idea to have a discussion with the group once the new role is assumed.

I have had the experience of taking over for someone that had their responsibilities taken away so I had some hard feelings to deal with when I took over. It was very difficult but I learned that if I took it day by day and worked with each individual they eventually came around and understood I was only there to help. There are all different kinds of situations that pop up as we lead our teams. We fight fires and make sure we don’t take on too much water that we cannot float. If you do not address these issues when they present themselves you may wait too long and not be able to steady the ship.

–Matthew Herasuta, MBA, MLS(ASCP)CM is a medical laboratory scientist who works as a generalist and serves as the Blood Bank and General Supervisor for the regional Euclid Hospital in Cleveland, OH.

Perfection

When I was in school I learned a lot about science and the laboratory science body of knowledge. The one thing that was emphasized over and over was accuracy and precision. It wasn’t until I secured my first position and started training did I realize just how important those two words were. Not only are we counted on for our accuracy, we are counted on for the repeated accuracy of everything we report to physicians. I have heard some statistics reported that up to 80% of physician decisions on courses of treatment are based on lab results. I really do not get caught up in that number because if you think about it every single value we report is going into a patient’s clinical picture and can affect a decision on a treatment one way or another. So the question always comes up, how do we deal with errors? This question is multifaceted and as a supervisor/administrator we are responsible for much more than just the correction of the error.

I wrote this in my 5 year progress report article but I think it deserves repeating. Everyone makes mistakes, but, it is how you recover and learn from your mistake that is most important. Everyone has had that sinking feeling in their stomach when they learned they have either reported out an incorrect result or have mislabeled a specimen. As a laboratory professional it is our biggest fear and each and every day we sit down at the bench and are expected to be absolutely perfect. Zero errors are a standard that not even the most efficient manufacturers know is possible yet we are expected to perform on this level each and every day. Errors happen to everyone, and when they do it is what happens afterwards that is key to inhibiting that error to occur again. Especially with newer technologists it is important to teach them so that they are able to recover and not make the mistakes again.

The first thing I do when an error is discovered is address it with the technologist. Ask them, “do you remember this sample or this patient? Do you remember what you were doing at the time this error happened?” One thing to watch is how much the technologist can remember. If they cannot remember too many details, were they trying to do too much at once? If they mislabeled did they have a pile of tube and labels while also trying to result specimens? With mislabels I found it helpful for myself to read the name in my head as I was labeling the tube. That way if what I was reading in my head did not match the label underneath I would stop to look. If it is a procedural error why did the technologist deviate from the actual process? Did they learn a shortcut but that shortcut actually increases the chances of error? Going over this with the technologist also will help them with their problem solving skills. Especially with new technologists building problem solving skills is vital to the success or failure of a young technologist. We know humans are not perfect, but when you work in an industry that accepts nothing less, each error made is amplified but also that much more important.

Enterovirus D68

Over the past few weeks, hospitals around the country have seen a sharp uptick in cases of respiratory distress in children. The majority of patients test positive for Enterovirus D68, and most seem to have a history of asthma.

Only select laboratories test for this strain of enterovirus. If a suspected case comes to your facility, contact the CDC or your local health department for information about specimen collection and shipping.

What’s Your Number?

When I ask “what is your number,” I mean “what is the percentage of time you spend on the bench versus time in the office doing administrative work.” In my laboratory we currently have a chemistry supervisor on extended leave so myself and the hematology supervisor are 90/10 bench/office. I know what you’re thinking, how do you do the administrative portion while working the bench that much? The answer is simply, we can’t. Unless I work 60 hour work weeks there is no humanly possible way to be able to work on the bench and get done what I need to in the office. Prioritizing the administrative duties and taking advantage of slow days on the bench is the number one reason why I am somewhat successful at getting things done.

The biggest challenge I face is competency. One of CLIA’s six competency guidelines is physically watching each technologist/technician perform each test that is on our test menu. So let me break this down. I have 15 employees that need to complete competencies. We perform gel testing in blood bank as well as LISS, PEG, and Pre-warm screens in tube if necessary. Let’s round all of those tests to 45 minutes. 15 employees times 4 different methods is 60, times the 45 minutes is 2700 minutes, or 45 hours. Now don’t forget that I am in the hospital setting which is 24/7 so I have to be available for second and third shift if I want to make sure those employees are competent. So for simplicity sake I’m going to round those hours up to 48 which makes six 8 hour days of competency. If I get two office days a month, competency will take me four months to accomplish and that isn’t counting my other duties. This is also assumes uninterrupted time which we all know happens once a millennia. These are just four tests as well; we perform many others such as antigen testing, long crossmatching, etc. When looking at this it can be overwhelming but there are ways to accomplish the impossible without killing yourself.

One way to help yourself out is to look at the CLIA definitions of who can be a technical supervisor for competency testing. Chances are you have more than one employee who qualifies and as long as you sign them off as competent they can sign off other employees. This can drastically cut down the amount of time you need to spend individually with each employee. Another way is to have the employee’s videotape themselves performing the tests while explaining out loud what they are doing. This not only confirms their competency but you can watch back the tape at your leisure as well as show inspectors if they ask how you satisfy the observation portion of the competency. I now ask you in the comment section below write down your numbers and let me know what your biggest challenges are and some possible solutions. We can help each other out, and share in the continuous struggle. So, what’s your number?

Laboratory Testing in A High-Containment Facility

The team at Emory that cared for the patients infected with the Ebola Virus have published a paper on Lab Medicine about laboratory testing within a high-containment facility. You can read the entire paper on the Lab Medicine website.

Biobanking and Sample Stability

A common question often asked of laboratory professionals is the length of time an analyte is stable in a sample. This question may arise simply because a sample has been delayed reaching the lab, but can also be asked in the case of adding on a test to an existing sample a day later, or a week later. Most laboratory professionals can tell you the stability of an analyte in a patient sample, at both ambient temperature and refrigerated, because assay manufacturers perform those short term stability studies when they create their tests. And many of them also include the stability of the analyte in a frozen sample. Beyond this information, it’s harder to find stability information for analytes.

Some stability information can be found at large reference labs, as they have often done their own stability studies and may know how stable an analyte is when frozen for a month, or for 6 months. The really difficult information to come by is how stable an analyte is for really long term storage. This is a question that needs to be answered as biobanking becomes increasingly popular.

Biobanking is the use of repositories to store biological samples, usually for use in later research. Biological material can be stored frozen in many forms, including tissue, cell culture, serum and plasma and dried blood spots. Determining how stable an analyte is under long term storage conditions is important in order to be able to use those samples for research in the future. And yet sometimes determining the long term stability is itself difficult. For example, if a person wished to see if albumin was stable frozen at -80 degrees for 25 years, the difficulty would be in having the same assay available 25 years apart to perform both sets of measurements. (Not to mention the personnel). Measurement technologies change over time, some very rapidly, making longitudinal studies difficult.

The design of studies utilizing biobanked samples will be important. Even when not performing longitudinal studies, if a sample has been stored for 10 years frozen in a biorepository and I remove it and measure the calcium, how do I know the calcium present is the amount of calcium that was present when the sample was stored? If I have knowledge of the patient the sample came from, I could use this data to say that in stored samples, patients with X disease have higher calcium than patients without disease, but I could not necessarily make the jump to what is true in vivo, without knowing how stable calcium is upon long term storage.

Often stored samples are used for measuring analytes that weren’t able to be measured when the samples were originally stored. In those cases, you may be able to infer stability if the amount of analyte measured in the stored samples is comparable to the amount measured in fresh samples.

Biobanking is a growing enterprise, and stability studies will need to grow along with it.

-Patti Jones PhD, DABCC, FACB, is the Clinical Director of the Chemistry and Metabolic Disease Laboratories at Children’s Medical Center in Dallas, TX and a Professor of Pathology at University of Texas Southwestern Medical Center in Dallas.

Ebola Information for Laboratory Professionals

While it’s unlikely you will ever encounter a case of Ebola, it’s best to be prepared. The CDC has a health advisory page full of information, including specimen requirements for Ebola testing. The laboratory’s first step is to contact their state health department.

Is Your Lab Ready to Give Results to Patients?

In February I wrote about the Department of Health and Human Services regulation that amends the Clinical Laboratory Improvement Amendments of 1988 and the Health Insurance Portability and Accountability Act of 1996 in regards to reporting of patient results. The deadline for implementation is fast approaching–9/27/2014–and so I’m curious as to how prepared laboratories are for this change.

Is your lab ready? What sort of changes have you made, if any? And do you see this as a way for pathologists and laboratory professionals to become a bigger part of the healthcare team? Or is it simply going to make everyone’s life harder?

–Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.

Test Utilization: A Deeper Look

The test utilization seminar I attended at the AACC annual meeting (I talked about it here) presented fascinating information that I’m going to try and sum up for you.

Test utilization isn’t just about ordering the right test, making sure the order entry system is efficient, or even about the accuracy of the test. Sure, all those factors are important, but patients aren’t treated by laboratory data. They’re treated by doctors, and those doctors are human. Humans are irrational and make mistakes for all sorts of reasons like fear, cognitive limitations, and social complications. Medical decisions are incredibly complex and driven my mounds of data. This complexity contributes to medical errors.

I found this notion counter intuitive—one would think that more data would mean better decisions. However, a study conducted by the CIA on horse race prediction found that when analysts were given more data, the accuracy of their predictions didn’t improve. However, the analysts had more confidence in their predictions. What does this mean? Just because your doctor runs fifty tests doesn’t mean he’ll diagnose you accurately. It probably means, though, the doctor will be confident they are right.

Another tidbit from the seminar: diagnostic error is usually the convergence of several different factors that are organizational, cognitive, and technical in nature. Any laboratory professional who has dealt with major errors has seen this in action—an event investigation will usually reveal that anything that could go wrong did, and that’s why the event occurred. The authors of this particular study did note that technical/equipment problems contributed to only a small fraction of diagnostic errors. This speaks to the integrity, critical thinking, dedication to quality that laboratory professionals possess.

If you want to read more, here are a few of the studies mentioned during the talk:

Diagnostic Error in Internal Medicine http://archinte.jamanetwork.com/article.aspx?articleid=486642

CIA: Do You Really Need More Information? https://www.cia.gov/library/center-for-the-study-of-intelligence/csi-publications/books-and-monographs/psychology-of-intelligence-analysis/art8.html

–Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.

Right Test, Right Time, Right Patient: The Age of Lab Stewardship

Last week, I attended the American Association of Clinical Chemistry (AACC) conference in Chicago. I attended molecular diagnostics talks but also talks about quality improvement, the use of “big data,” and lab stewardship. I have an interest in QI as my AACC poster presentation last year was on lab interventions to reduce lab error frequency and I am also a resident on my hospital’s performance improvement committee.

So, what exactly is “big data?” It’s a word that we are hearing more often in the media these days. It’s also a term that is increasingly being used in our healthcare systems. In 2001, analyst Doug Laney defined “big data” as the “3 V’s: volume, velocity, and variety” so that’s as good a point as any to start deconstructing its meaning.

Volume refers to the enormous amounts of data that we can now generate and record due to the blazing advancement of technology. It also implies that traditional processing matters will not suffice and that innovative methods are necessary both to store and analyze this data. Velocity refers to the ability to stream data at speeds that most likely exceed our ability to analyze it completely in real-time without developing more technically advanced processors. And finally, variety refers to the multiple formats, both structured (eg – databases) and unstructured (eg – video), in which we can obtain this data.

I’m always amazed at the ability of the human mind to envision and create something new out of the void of presumed nothingness. Technology has always outstripped our ability to harness its complete potential. And the healthcare sector has usually been slower to adopt technology than other fields such as the business sector. I remember when EMR’s were first suggested and there was a lot of resistance (in med school, not that long ago, I still used paper patient charts). But now, healthcare players feel both pressure from external policy reforms and internal culture to capture and analyze “big data” in order to make patient care more cost-effective, safe, and evidence-based. And an increasing focus and scrutiny (and even compensation) on lab stewardship is a component of this movement.

I often find myself in the role of a “lab steward” during my CP calls. The majority of my calls involve discussing with, and sometimes, educating, referring physicians about the appropriateness of tests or blood products that they ordered…and not uncommonly, being perceived as the test/blood product “police” when I need to deny an order. But lab stewardship goes both ways. And these days, the amount of learning we need to keep up with to know how to be a good lab steward is prodigious, daunting, and sometimes, seemingly impossible.

So do you believe in this age of lab stewardship that it’s the job of the pathologist to collect and analyze “big [lab] data” and to employ the results to help ordering physicians to choose the right test at the right time for the right patient? Or is it a collaborative effort with ordering physicians? With patients? How do you foresee that the future practice of medicine needs to change from standards of practice currently?

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.