oCtoBeR 2010 - American Association for Clinical Chemistry

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12 CliniCal laboratory news oCtoBeR 2010 PATIENT SAFETY FOCUS TAkING AIM AT REDUCING LAB ERRORS Organizing Specimen Processing for High Quality and Efficiency An Interview with Linda Nesberg Patient Safety Focus first interviewed linda nesberg, operations manager at mayo medical laboratories, in July 2009. in that interview, she described a system for reducing errors related to handling manual requisitions. the system follows lean principles that ms. nesberg used in the computer manufacturing industry before she switched to the healthcare field. a version of the mayo processing system has been successfully implemented in a variety of labs in the u.s., including the lab of the physicians who conducted the current interview. in this follow-up interview, ms. nesberg speaks more generally about proper receipt and processing of specimens and their associated test orders. erin grimm, md, and michael astion, md, phd conducted this interview. When you arrived at Mayo, how was specimen receipt and processing organized? The Mayo Reference Laboratory was growing rapidly when I arrived. At the time, there were three job categories: laboratory assistants, lead technologists, and supervisors. The laboratory assistants processed specimens, and when they encountered a problem, they either attempted to resolve the issue or they referred it to a lead tech or a representative within our client services section. Common problems at the time were those confronting any lab, such as missing data on the requisition, specimen mislabeling, and improper specimen containers. The lab did not have a standardized process for dealing with specimens that required extra work before processing. Why was a change in workflow necessary and what benefits did you hope to realize? The reference laboratory was experiencing double-digit growth per year. Further defining duties and separating tasks were necessary to efficiently deal with the increasing workload. My goal was to separate the problem cases from the general work flow so that the routine work moved through more efficiently and with fewer errors (Figure 1). When looking at workflow issues, do you use any particular approach to problem solving? Yes, we incorporate Lean principles. One of the general principles of Lean is to remove bottlenecks in order to reduce delays, which is one of the main forms of waste in processes. Therefore, we wanted to create a system in which problem cases did not block the flow of routine cases. What organizational changes did you institute to help workflow? I defined additional job categories to separate the duties of the employees responsible for keeping the pace of specimen processing moving from those who were specifically selected to deal with problem cases. The current organization of specimen processing is that a supervisor is in charge of 35-40 people. Also under a supervisor are three or four lead techs. The lead techs are divided into two categories, slow-lane lead techs, who handle exceptions, and fast-lane lead techs, who are in charge of facilitating the work flow of the laboratory assistants and keeping the pace of routine processing on target. There are also other job classifications. One is the lab specialty assistant, who while supporting the lead techs, also aliquots all specimens. Another is the operation scheduler, who monitors daily volumes and determines appropriate staffing schedules to handle those volumes. In this system, the laboratory assistants are on the front-line, and they can process cases without dealing with delays caused by problem cases. The supervisor’s job is to ensure employee well-being. Supervisors help administer training for new employees, provide employee counseling, and triage personnel issues, such as time away from work. They also organize and administer process improvements and quality initiatives. How did you accomplish the reorganization? Was it hard for the lab staff to accept this organizational change? Change is always difficult for some people, but there were also benefits to graduated positions in the system. Previously, a career track for job advancement was not welldefined. Now, there are job classes with increasing levels of responsibility and in- creased pay. In addition, the more specific job descriptions allow personnel to gravitate towards the type of work they most enjoy. In terms of managing the more difficult changes, the largest initial change was that laboratory assistants no longer handled problem cases. Some were delighted, but others saw the problem solving as an integral part of their responsibility and missed that aspect of the job. We made a concerted effort to help everyone understand how the new system improved patient care, and we emphasized that above all high-quality patient care is our goal. Patients benefit from efficient, high-quality laboratory results. While specimen processing is not the area of the lab actively reporting test results, our contribution to patient care is efficient, error-free processing. How do you provide feedback to staff on how the lab is doing? We have large display monitors that show employees our success at reaching our processing timeline goals. The monitors provide real-time feedback to our laboratory assistants, showing them their contribution to our goal of providing rapid, highquality results. You mentioned that you created a special job category called operations schedulers. What is their role in the laboratory? When I first arrived, I noticed that predicting daily processing volumes was not a priority. When I investigated and created some reports, I found that workload followed predictable patterns. For example, we first estimated work volume on a Tuesday by looking back at the data for the last four to six Tuesdays and found that these numbers were a reasonably accurate predictor of volume. Since then, we have also predicted volumes based on orders, many of which are interfaced into our laboratory information system. We pull this data shortly after midnight and create a report that indicates our incoming volume for the day. A hospital with computerized physician order entry could have access to similar data since morning blood draws can be pre-ordered. Why do you have a special job category for aliquoting? There are two reasons why I separated this task into its own job category. First, I wanted to ensure quality care. Manual aliquot- figure 1 sorting routine specimens into a fast lane lets value flow
ing is prone to error. In a Lean workspace with a 5S process, this type of task receives greater emphasis so as to eliminate any unnecessary materials and/or objects from the work flow. Second, I wanted a record of the number of aliquots performed, and there was no way to quantify this metric until the job category was separated out from the other processing duties. How do you handle error reporting? An important characteristic of our error reporting system is that we separate external errors, such as incomplete client orders or client errors, from errors that are true processing errors. Both types of errors are recorded using a similar software tool, but the systems are separate. We do this because knowing the rates of pre-analytic errors or exceptions helps us accurately predict our overall processing times. Both error reporting systems rely on a software application that assigns an individual is- What Can Laboratory Directors Learn from Baseball? By JaMes s. HeRnanDez, MD, Ms Major league baseball pitchers are masters at controlling the location of their pitches, and sometimes they throw balls with the intent of intimidating batters. The slang term, “chin music,” refers to a pitch that comes perilously close to the batter’s head, often causing the batter to move away from home plate and even to fall down. When the baseball actually hits the batter, it is called a “bean ball.” Pitchers are often so accurate that they can literally throw at the batter’s chin, causing the batter to jerk back or even fall down before he gets hit. Sometimes the pitcher’s manager or coach even orders the pitcher to throw a bean ball. This can result in both the manager and pitcher being ejected from the game. Like it or not, chin music and bean balls are part of the game of baseball. They entertain the crowd and boost the pitcher’s ego, especially if the umpire goes easy and lets him off without a warning or ejection. Successful Lab Leaders So how does baseball’s chin music tie into lab leadership? You might ask yourself which type of batters—weak or strong— are the pitcher’s target for this menacing pitch. In my opinion, lab managers who are not at the receiving end of a few bean balls or a little chin music are like weak batters and probably are not really leading the lab. As management guru John Kotter stated, “Management is about coping with complexity…leadership, by contrast, is about coping with change” (1). True leaders take the laboratory to new heights and guide the lab team through the lowest lows. Getting knocked down a few times in the process or taking it on the chin for an unpopular decision is part of leading. sue number to each problem case. That issue number references a file containing the error report and a log of all information related to that case. We record the issue number from our issue tracker with the specimen identification number in the LIS. This way, the LIS can reference a more detailed report. This is particularly helpful when you need to determine the reason behind quality issues. How do you assure that information about problem cases is not lost at the shift change? The error-reporting software is an issuetracker system that allows us to transmit information between shifts. It works as follows: problem cases are removed from the fast lane and handed, with preliminary information, to the slow-lane lead tech. This tech then submits the problem to client services by opening a new issue report in the system. Specimens with unresolved issues laboratory leaders face many challenges. but few situations are as trying as receiving unjust criticism for making an unpopular decision, even when that decision meets the needs of patients and staff. as a baseball fan, i think laboratorians can learn some valuable lessons about leadership from the sport. Patient safety is a non-negotiable matter that demands strong leadership in the lab, especially today. The six Institute of Medicine aims for improving the medical system call for all aspects of healthcare to be safe, effective, patient-centered, timely, efficient, and equitable (2). Even the suspicion of a patient safety issue should cause lab leaders to jump out of their chairs and respond with urgency and concern. Unfortunately, some laboratorians still seem to be opposed to the concepts of patient safety. As lab leaders, we need to understand why. In my experience, some laboratorians simply don’t understand why they are being asked to change how they process blood samples. Maybe their leaders haven’t effectively communicated or shared the vision of how protecting patients’ safety is at the heart of lab operations. In other instances, laboratorians might not be properly equipped or trained to respond to the Institute of Medicine’s goals. Maybe there are conflicting goals in the organization or patient safety is not a high priority in the institution. Some may resist because they simply aren’t willing to follow the new direction. They may be comfortable with the status quo, or there may be too much inertia or a lack of trust in the leaders. Lab leaders need to respond to each of these scenarios differently, just as batters respond in various ways to balls thrown by the pitcher. Charging the Mound Similar to the crowd at a major league baseball game, lab staff watch how the lab’s leaders respond to bean balls and chin music. While some batters lose control and “charge the mound” after being on the receiving end of an intimidating pitch, we, as at the end of the shift are moved physically to specific hold areas inside the lab. Client services continuously monitors the documented issues until they are resolved, and they only close an issue in the software after it is resolved. As long as the issue is open, client services will work on it, no matter the shift. Lead techs who are concerned about a case in the hold area can check the most recent status of each issue by looking up the specimen ID or issue number in the errorreporting software. At the shift change, the lead tech only needs to communicate nonspecimen specific issues. This communication is done via a short checklist designed in-house to ensure that nothing of importance is missed. Does the approach to specimen processing that you describe here apply mostly to large-volume labs, or could it be applied in any size lab? Lean as the umbrella approach to problem- lab leaders and professionals, want to avoid coming unglued and attacking when the pressure is on. If we lose control, the results in the laboratory, as in baseball, are often not pleasant and may live on to taint our career. On the other hand, it is natural to want to be liked and to respond to chin music by backing off— in essence, staying on the ground. True leaders cross the bridge from wanting to be liked to earning the respect of the laboratory staff (3). Patient safety issues require strong and swift action from the lab’s leadership, even if the measures are unpopular. Loving the Game In my opinion, William Howard “Willie” Mays, Jr. was one of the best baseball players ever. Famous for his ebullient love of the game, he was known as the “The Say Hey Kid.” Mays got a lot of chin music in his career, particularly in his early days as one of the first African-Americans to play solving is applicable to any size lab. In addition, the specific principles discussed above—separating problem cases from the routine work flow, tracking problem cases without loss of information, predicting workload and matching staffing to that workload, organizing staff into logical groupings, and isolating and standardizing error-prone work—will help any lab improve efficiency, decrease turnaround times, and reduce errors. REFERENCES Smoothing workflow and reducing errors in specimen processing. Clinical Laboratory News. 2009. 35(7) x. Engineers in the clinical laboratory. Clinical Laboratory News. 2009: 35 (1) x. Erin Grimm, MD, is a resident in the Department of Laboratory Medicine and Anatomic Pathology at the University of Washington, Seattle. lab leaders might do well to think of themselves as batters facing a tough pitcher when it comes to patient safety. after the major leagues were integrated. He frequently would dust himself off after getting some intimidating chin music, smile, and hit the next pitch. How we respond as lab leaders to chin music is a matter of what happens in the five-and-a-half inches between our ears. We can lose control and charge the mound, or we can do what Mays did. The choice is ours. REFERENCES 1. Kotter, John P. What Leaders Really Do. In: Harvard Business Review on Leadership. Boston: Harvard Business School Publishing, 1998: 37. 2. Institute of Medicine, Crossing the Quality Chasm. Available at http://iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A- New-Health-System-for-the-21st-Century. aspx, accessed July 21, 2010. 3. Hernandez JS. Crossing the leadership bridge. Physician Exec 2009 Sep–Oct; 35 (5):92–4. CliniCal laboratory news oCtoBeR 2010 13
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