management/administration – Page 20

Dispensaries

I know a lot of you have heard already, but for those of you who haven’t, last week CMS ruled to amend CLIA regulations that will now allow laboratories to release test results directly to patients. Once you pick your jaw back up off the floor your mind will start processing a mile a minute what this means for individual laboratories. If you are a supervisor/manager such as me your mind is going exponentially faster thinking of all the ways that this now makes your life more difficult.

Right off the bat as a supervisor/manager you should be thinking about producing an SOP (standard operating procedure) that details how you will handle requests and what you are and are not responsible for when it comes to providing information to patients. You are going to need detailed information on how you will properly identify the patient, patient’s personal representative; or my personal favorite, a person designated by the patient. I can hear the phone ringing now.

“Laboratory this is Matt, How can I help you?”

“Yes, Hello, My name is Lenny Lipase and my neighbor Pete Potassium wanted me to call in to your laboratory and get some of his lab results.”

There is most definitely going to be some individual interpretation of this new amendment and each laboratory is going to have to determine how it wants to address requests. No matter which direction you go a solid policy/procedure for handling these new requests will be your best friend. When you receive complaints, and you know they will come, you will have something to fall back on that states a definite policy/procedure and that meets the new standard that has been set forth by CMS.

So let us address the 800lb. gorilla in the room. You have started taking requests for results and a patient comes to your lab, picks up the results, opens them, and then says, “Why is my glucose so high? Does eating a candy bar for breakfast affect this?” Your worst nightmare, right? A patient wanting counsel on results will be the biggest challenge for any laboratory and may have been a possible oversight by CMS on this ruling. One way to nip this right off the bat is to send hard copies of results in the mail. This assures that patients will not be wandering around your lab asking for counsel on their results. If you decide to be brave and let patients physically pick their results, I would either have a disclaimer page with every result handed/mailed out or written very clearly in your policy/procedure stating that patients only discuss their results with their physician. You must protect yourself from liability when it comes to discussing results with patients. I felt as though the previous ruling was a laboratory professional’s layer of protection against this. We could not directly give patients results so it forced them to speak with their physicians.

I have read that some laboratory professionals are happy with this saying that patients should take more of the responsibility of their own healthcare. I agree with this but I also have spoken to physicians who are not happy with this ruling because they want to go over results with their patients to properly explain what they mean. More than likely a physician will still have to release the results first before a patient can view them but if not you may have a panicked patient calling physician offices or even worse 911. This may seem extreme but you don’t know how patients will react seeing results they do not know anything about. We will now be another controller of patient information that has been deregulated a bit. It is for medical use only of course but how comfortable will you feel being a result dispensary?

–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.

Bueller?…Bueller?

Attendance in the workplace can be a tedious process that most supervisor/managers loathe because it forces us into an almost parental role that can be downright annoying. However you penalize call-offs or late clock-ins/outs, keeping track of attendance can be compared to balancing a checkbook. Even though it may be tedious it is a necessary evil to make sure all employees are being treated equally and not one individual is taking advantage of arriving early or in some cases clocking out late to rack up small amounts of overtime. All of these examples can affect your productivity numbers and also the workflow of the laboratory.

So the question becomes how do you avoid the attendance issue without having to balance the checkbook every other day? First, address each and every attendance issue swiftly and equally with each employee. This will get the attention of all the employees so they know that you take attendance seriously and expect punctuality. If you want to be lenient and let the first one or two instances slide make sure you record this and treat each employee equally. The first hint of favoritism may cause your employees to lose respect which may lead to a much bigger problem other than attendance. Second, if you have monthly employee meetings (which I recommend), be sure to remind everyone your attendance policy and have each employee sign the meeting minutes so you have documentation that each employee understands the policy. Lastly, the best time to properly introduce an employee to the attendance policy is when they’re going through the hiring process. For some of our young hires, this may be their first job after college and clocking in for a full-time position may be a large change from walking in the door half-asleep for an 8am class.

The last attendance issue that should be discussed is call-offs (unexcused absences) that seem to follow a pattern. Employees may feel they shouldn’t work a Friday before they work the weekend. The generally accepted definition of a pattern is three or more examples of the call-off. So if the previous employee example called-off three Fridays before they had to work that following weekend we would contact HR and see if we could address the situation. Some may feel this is obvious but when employees work every third weekend this pattern may take a couple months to present itself. These are especially difficult as a supervisor/manager because you most likely do not have any direct evidence that the employee is calling-off without actually being under the weather. This becomes especially difficult when an employee has an approved medial leave issue and appears to be using it to their advantage.

In each of the examples above the most important item for you as a supervisor/manager is documentation. You must have a detailed record so when the time comes to use corrective action or even address it with HR you have everything you need to address it with the employee. You don’t want to be walking into your laboratory, see an empty bench, and say, “Bueller?”

Customer Service—The Buck Stops Everywhere!

Laboratories are notoriously hidden in basements, outbuildings, storefronts, and historically have been hard to find, difficult to get to, and in many cases, an afterthought in facility planning. It couldn’t be farther from the truth that “labs should be seen and not heard.” Those of us who live in the lab don’t give it much thought…until we have to get OUR blood drawn, that is!

We all know the scene where someone has a “lab complaint.” It typically centers on having their blood drawn, getting stuck multiple times, having a result not ready, or heaven forbid, having to suffer a “re-draw.” If you think about it, the service we provide that has the customer-facing moment is the specimen collection phase. Our pre-analytical capabilities are where our patients/customers/clients judge the quality and strength of our laboratories. I have often described it to students in this way; if you want to buy a house and its gate is broken, the paint is peeling, the door hinges rusted, and the yard is full of weeds, you automatically assume the house is also “broken down” on the inside. It may have upgraded electricity, brand new appliances and plumbing, and the structure is solid and weather proofed. But you decline to delve further based on the appearance. The second house you see has fresh paint, new hinges on the doors, a little grass and flowers in front, and a nice walkway to the front door with a shiny new mailbox. You are charmed…and, sadly, it has a leak in the main drain, the paint inside is lead-based, the electrical system must be rewired and the structural walls are rotting and soon the stairwell will cave in. Nothing you can really see from the outside, but not something you can judge from the street.

I find that the elements of customer service and the way we present and appeal to our patients/customers is the “face of the laboratory.” Professional presentation and treating each patient and each specimen as if it were your mother’s or your child’s specimen gives our clients the confidence and trust they need to feel good about their test results. Communicating, making eye contact, soothing and reassuring those with “difficult veins” makes any situation go more smoothly. And, since most people are unable to judge the quality of our laboratory work—they have no training or understanding of what goes on in that “black box”—remember the house example. We all tend to judge by our first impressions.

Customer Service is a universal concept, and one that is a challenge in every laboratory, everywhere. One of the most popular international training programs ASCP Global Outreach provides is for pre-analytical phase quality improvement, and it always includes a heavy dose of customer service. Not only with patient engagement, but also with other departments, physicians, hospital staff, and even in community outreach. It is universal all around the world, that customer service makes the difference in how people evaluate the laboratory profession. You may be the best clinical scientist or clinician on the planet and your lab may have won awards for superior performance; but no one will know or care about that if they have a bad pre-analytical experience! The buck really does stop EVERYWHERE!

Next time YOU have to have your blood drawn, take a close look around and notice what your patients and customers see. I guarantee you will always be surprised by something, and will leave the drawing room with at least one idea of how your lab can do it better. Next time, we’ll talk about some ideas I’ve learned about customer service in other countries. And, if you have a great example of stellar customer service practices, let me know at bsumwalt@pacbell.net I’m always in the market for new ideas to share.

–Beverly Sumwalt, MA, DLM, CLS, MT(ASCP) is an ASCP Global Outreach Volunteer Consultant.

New Rule Gives Patients More Access

Yesterday the Obama Administration and the Department of Health and Human Services implemented a 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. Basically, the new regulations state that patients (or their personal representatives) can receive lab results directly from the laboratory. In most cases the laboratory has 30 days to comply with the request. This regulation goes into effect 3/31/14 and laboratories must comply by 9/27/14.

So what does this mean for laboratory professionals? The language of the final rule gives laboratories a lot of flexibility in terms of dealing with a request for information. In a nutshell:

Individual laboratories can set up systems to receive, process, and respond to requests for results however they choose to do so.
If a state law is different than the federal regulation, laboratories must comply with the “more stringent” law, with “more stringent” meaning “greater rights of access.” For example, the federal regulation requires results to be given within 30 days of the request; if state law requires those results be given with 15 days, then the laboratory should follow the state law.
Laboratories need to have “verification of identity” policies in place. There is no mandate that requires specific forms of identification.
Laboratories that currently have patient portals in place may continue to use them.
Laboratories CANNOT require patients to make requests only through their providers; mechanisms must be in place for a patient to make requests directly to the laboratory. However, laboratories CAN require patients to make these requests directly to the laboratory.
Laboratories can recoup the costs of providing results to patients, but the fees must be cost-based and reflect labor, supplies, postage, and preparation of an explanation of PHI. Laboratories CANNOT charge fees that reflect the cost of searching and retrieving information, nor can they charge fees for costs associated with verification, documentation, liability insurance, maintaining systems, etc. It should be noted that laboratories cannot withhold future lab results if a patient chooses not to pay the fee.
Laboratories must provide results in the form (electronic or paper) requested by the individual if readily producible. This could be a MS Word or Excel document or PDF as well as access to an electronic portal.
Laboratories are required to reasonably safeguard information (electronic or paper).
Laboratories are not required to include test interpretations but may do so if desired.
Providers are encouraged, but not required, to tell patients they have access to their laboratory results directly from the laboratory.

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

Chutes and Ladders

Mobility in any career can lead you in multiple directions and usually it is up to you which way you go. The laboratory field has become very specialized in the last twenty years and staying a true generalist or a general supervisor is becoming more difficult. I always tell students to stay generalists as long as possible so that your options are open once you get a sound technical foundation of knowledge. This allows them to become supervisors in a number of different areas when the time comes. Much discussion has been made about the proverbial “career ladder” and whether or not the ladder exists as it used to. As an early careerist I am well versed in navigating the ladder and figuring where I fit, and how I plan to climb the rungs as I enter my second decade of my career. I finished my MBA at the beginning of 2013 and put myself into application mode to see what new positions awaited me.

I learned a few things in my quest to climb as many rungs as I could on the ladder. First, if an application states you need a certain amount of experience but you are one or two years short, apply anyway. Employers will at least speak with you if you are a little short. If you wow them with your experience so far in your career and let them know that you don’t just work but you actively observe you can make up that deficit. Second, do not be afraid of lateral moves. If your goal is to be a laboratory director or higher, moving to supervise a different area of the lab can make you a better-rounded candidate once it comes time to go for that higher position. This is especially important if you have become burned out or in need of a change from your current department. Nothing says you have to stay a Hematology supervisor for eight years before you have the supervisory experience to become a laboratory manager/director. One aspect of the lab I find is a good move is to the point-of-care side of the lab. You get out of the lab more and into the hospital as a whole. Usually this role takes on the Quality side of things as well. This role can be a great transition from a technical supervisor to a more general department supervisor where you can learn and grow.

Finally, never be afraid of putting in an application. I find a lot of people talk themselves out of a position before they even apply. Do not be afraid of rejection. In speaking with laboratory professionals, I have heard of a hospital not hiring a candidate for a position but going back and contacting them at a later date for a different position. It never hurts to interview and get your name and face out there. Go on interviews even if you don’t feel the position is a good fit. Practice is the name of the game. When your time comes climb the ladders and avoid those chutes!

Bird Watching

Every inspection cycle we receive our checklists from the regulatory organizations and that is usually when the latent lawyer in me breaks out like the Hulk and I start interpreting the meaning of every word contained within the document. CAP has said on multiple occasions that some of the checklist items are open to interpretation and that there can be several ways to satisfy them. CLIA has their 6 elements of competency and when I first read them my eyes started to turn green and my clothes started to get a little snug. The element that I think is open to the most discussion is the first: “Direct observations of routine patient test performance, including patient preparation, if applicable, specimen handling, processing, and testing.” Some of my colleagues have interpreted this as once a year directly observing a technologist/technician perform each test and then signing them off. When I read this element I can’t help but think that once a year is not enough to verify that an employee is correctly performing each test. The question I always ask is how do we know that an employee does it correctly when we are watching but then does it a different way when we aren’t?

I am a very hands off leader. The reason I can do this is because when I train a new employee it is rigorous and I make sure that they can handle pretty much anything that comes their way. When I read that first CLIA element I feel as if they want us to babysit our employees. I understand the importance of direct observation but where is the line drawn that says so much observation is enough? If you ask me once a year is not enough; however, the more we observe the less time we have to do our countless other tasks as supervisors/managers.

When I thought about it, I came up with a couple methods or ways to “directly observe” my employees. The first obviously is to stand behind them and watch them perform a test. Then the question of how do we observe the off shifts without actually being there? We all have smart phones with cameras so could employees could set up their phones to record a procedure and then we could watch it back later. In blood bank I can have each employee save their gel cards so that I can read them at a later time and make sure the volumes in each well look ok. That would qualify as direct observation of their results and process since if the volumes are incorrect I would be able to tell. As supervisors we are also called to consult with other technologist/technicians frequently. Troubleshooting with your employees usually involves something test related and that to me would count as direct observation as well. Finally, we have students almost year round and our employees usually take on the role of teacher when they are in that spot for the day. When I observe them teaching the students how to perform tests this is a great way to confirm that the employee is competent.

My favorite way to observe is when my employees don’t know I’m watching. I have an office that is not directly in the blood bank so I have to wander in and out fairly often. Sometimes I will sit down or file papers all the while observing my employees and their technique and processes. There are many ways to “directly observe” and using all of them ensures that you are meeting the guidelines enforced by CMS. When inspection time comes you can show the signature that says you directly observed but also have a list of answers when they ask how you did it. When I need some practice I grab my binoculars and do a little bird watching.

Classified

“I retweeted an Instagram picture someone posted on their Facebook page that shows how to place blood tubes in a centrifuge. There is also a vine of it on their LinkedIn profile.” Confused yet? I’m a millennial, more commonly known as generation Y, and if there is a social network out there people my age are either on it or bored with it already. The question that keeps coming up is where do the social networks fit in to professional life? Perhaps the bigger question is can you be yourself while maintaining a professional persona? Most large organizations have social media policies that prohibit their employees from speaking badly about them on social media sites. Some policies also allow a company to terminate someone if the person lists them as their employer and does or posts something that the employer feels isn’t up to their standards.

The reality is if you are on these sites and you list your employer you must be careful. If people ask my advice on social media I usually tell them to stay as ghosts, and don’t list your employer. In my personal situation I don’t even have my real last name on my Facebook account plus it is private and even if you knew what my name was you couldn’t search it. Now, I really have nothing to hide seeing as I have over 1000 friends on my Facebook account but I not only want to control what goes out but more importantly who sees it. My feelings are, keep your personal life personal and your professional life exactly that.

Some may find it surprising that a young person isn’t posting every aspect of their life but I just feel that my organization doesn’t need to know what I have for dinner after I leave for the day. It is really each individual’s choice on what they want to follow or add but it just seems to me that it is a little to easy to become emotional about something and next thing you know it’s out there for all to see. It is pretty much a daily occurrence that some celebrity has to apologize for something that is taken out of context and the same goes for everyone else. When you tweet out that you can’t stand your boss, smiley face; you may not be around to explain the sarcastic nature of the post.

As a supervisor, I would never recommend being friends with people you lead unless you understand and realize that everything you post will be fair game in the workplace. I think a lot of people either forget that or simply don’t understand the significance of social media until it’s too late. Just because something happens outside of the organization, if one of your coworkers sees it you can bet that it will find its way back to the workplace. This is the personal aspect of social media and if your organization requires you to have a public account as a leader to be available for comment and questions nothing says you can’t have two accounts. Have a public profile and a personal one that you can set to private. When people ask me at work if I have any social media accounts I just tell them that information is classified.

Harmonization

What does “harmony” mean to you? And how does it apply to lab testing?

One of the biggest problems that arise where lab testing is concerned is that tests run in two different labs will give you two different results unless the labs happen to be using the same equipment (and sometimes even then the results won’t match!) This is a huge problem for doctors of patients who use different laboratories for their testing or patients who move across the country and need to continue following lab test results. A prime example of this dilemma is the current state of T4 testing. The same CAP sample when analyzed using different assay methods for thyroid stimulating hormone (TSH) can yield results which range anywhere from 2.66 to 8.84 mIU/L. Although CAP samples are not always commutable with patient samples, thyroid testing on patients shows this same lack of harmony.

This example underscores the need for harmonization. In our increasingly small world, where nearly everyone will soon be using the electronic medical record, and all lab results on a patient will be in one place whether they were all performed at the same place or not, it will be paramount that the lab results for any given test can be compared. Efforts to date have successfully harmonized several important analytes, including creatinine (IDMS-creatinine), cholesterol and hemoglobin A1c. Efforts are on-going to harmonize vitamin D assays against the NIST standards. These harmonization efforts took a massive amount of coordination and work between the in vitro diagnostic industry, regulatory agencies and laboratory and clinical societies.

Laboratory professionals have long recognized this problem, and sought to inform non-laboratorians of the realities at every opportunity. Lack of comparable test results can lead to patient safety issues, including misdiagnoses and/or inappropriate treatment. Recently an international consortium has recognized the need for harmonization of all lab results and begun to work on the problem. Although this effort is just beginning and the road ahead is long until general test harmonization can occur, it is a road worth traveling.

-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.

Resolutions

Have you thought about your New Year’s resolution yet? Hopefully you haven’t thought about when you’re going to break it. In addition to personal goals, we should all think about resolutions that we can make professionally. Whether it is stick to productivity numbers or finally finish that last credit to get another certification, this is the time of year to think about how you can grow in 2014. Our personal lives can affect our professional life and it is the balance between these two that keeps us sane and able to go back to work day after day. When one takes a little too much of your time you must step back and figure out where that fulcrum needs to be placed.

Growth in any career can be small steps or can be a leap such as another degree or promotion. Every person’s career is on a different trajectory and it really is up to the individual on how far they want to go. It is the decisions we make that shape our careers. Some people will tell you to be aggressive and take what you think you deserve, and others will say be patient, put in the work, and good things will come your way. (I wrestled in high school so you can take a guess at which philosophy I follow!) Whichever one you follow the big decisions and hard work you put in will only take you as far as you want it to. I have met many people my age that are happy working on the bench and have no aspirations of being a supervisor. Whatever you choose to do you should be happy and feel engaged that the work you’re doing is helping people. We are in healthcare and even though a lot of us don’t directly see patients the work we do helps nurses and physicians help the patient.

With only a couple weeks left in 2013 this is a great time to reflect on personal and professional accomplishments while also getting ready to start a new year that is full of new challenges and also new opportunities. As I usually say, no challenge is too large to take on and no opportunity is too small to overlook. For example I wrote an article for Lab Medicine and gave a 5 year progress report on my career and it turned into an opportunity to blog for one of the most important organizations for the laboratory profession. I always wanted to take the ideas I had in my own lab and throw them out there and see what other people thought of them and how they do certain things. When we write these blogs we love to hear comments and discussions of how you the reader interact and “live” in your own laboratory. Reflecting on 2013 I’m thankful for Lab Medicine for this great opportunity and my resolution for 2014; I’m going to be moving up that ladder, one rung at a time.

Red Tape

I like debates so I’m going to start one and I hope people will comment below and get a dialogue going. How many pieces of paper do you have framed on your wall in the lab from regulatory bodies? If you are a reference lab that serves nationwide customers you may be putting up regulatory wallpaper! I have heard of more and more inspections in regards to laboratories.. My laboratory is inspected by CLIA, CAP, and AABB. With budgetary constraints the importance of the AABB certification has been discussed numerous times. I even feel myself that AABB is becoming more of a consulting company that publishes medically relevant treatment recommendations than an inspection body. I would like to see consolidation between CAP and AABB where the somewhat higher standards of AABB are adopted by CAP and laboratories would not have to pay separate fees for each.

Let’s take it a step further. If CLIA inspections are increasing are there rising tensions between them and CAP? What is making CLIA step up? Do they not trust the job that CAP is doing performing inspections of the laboratories? If CLIA inspections are becoming that difficult what do you as a manager/supervisor put your efforts toward to ensure you will be compliant no matter who inspects you? How does a laboratory go through 3 or more inspections a year and still stay on top of everything else? All these questions must be answered and quickly if you expect to have time to do what is required of you as a manager/supervisor. I don’t think too many laboratorians would care who inspects them, but I do think we would care about having one universal checklist that we can abide by and really dig in to what is important to keep the lab accurate and safe.

How are we expected to grow our business and serve our patients when we are constantly guessing on what checklist to abide by or who is coming to inspect us? We are consolidating in every other sector of healthcare to improve efficiency except in regulatory bodies. Is this just another consequence of big government or do we actually need them all? We should start the discussion and make our voices heard on what we feel we need from regulatory bodies to ensure we are doing our jobs as laboratorians. Are you as frustrated as I am? Or have I inadvertently started my career as a lobbyist for the laboratory field? Comment below.

-Matthew Herasuta