Distraction

Distraction

In a previous post (http://www.medicallaboratoryquality.com/2014/02/validation-verification-and-vindication.html) I mentioned an observation reported in the Harvard Business Review about 47 percent of people regularly having a wandering mind.  The point was made that distraction is a very common cause of work related error. 

This raises in my mind a variety of interesting avenues, such as, if half of people working in your laboratory are intermittently or regularly distracted, how do we ever get anything done on time and right the first time.  Crosby’s DIRFT must be an impossible dream.  

Well in some respects I think there is some truth here, but we are protected from most disasters because of our own systemic ingenuity and maybe a lot of luck.  James Reason of “Error Fame” points to what some call the Swiss cheese barriers that block most bad events from manifesting.  

We pick up on clues that tell us that what is about to happen is nonsense or wrong.  The name or check mark is not present, the color or shape is wrong, the whistle is blowing.  Something alerts us that something needs fixing.  His point is that for most inadvertent errors to occur you have to experience the uncommon (not uncommon enough!) combination of bad timing, wrong circumstance, bad luck, and absolute obliviousness.  Most causes get stopped; very few work their way through to an outcome or effect.  

But I turned to a book by Edward Hallowell, who writes on attention deficit disorder to see if he had any suggestions that might help the 95 percent of us that do not have ADD, but nonetheless have episodes of distraction that could mess things us. 

So in the spirit of Culture of Quality improvement and Distraction Abatement and Error Avoidance in the medical laboratory and with thanks to Edward Hallowell and John Ratey, I offer the following:

• ·       Both excess quiet and excess noise make a laboratory a not nice place to work.  Often you hear people say they don’t hear all those cabinet fans and motors anymore, but they are wrong.  They do hear them and they drive your staff crazy.  Background music can be a problem because of the wide variety of personal choice.  Some folks actually can work better with a personal headset and an iPod.  Don’t be afraid to give it a try.

• ·       We are all visual beings.  Bright colour is a good thing.  There is no reason that all laboratories have to be monochromatic white or cream or grey.

 

• ·       If your technologists need to regularly work through computer screens, get rid of those old green/white or black/white eye sore monitors and make sure the software screens have enough pizazz to capture your staff’s interest and attention.

• ·       Provide for lunch and learn open-talk sessions on strategies that help reduce distraction and error.

• ·       Encourage staff to take a regular break, even for a few moments when they have been sitting at their bench for more than 30 minutes.  They should stop doing what you are doing, stand-up, stretch and breathe.  Then start again. 

• ·       To the extent possible, require people to take their mid-morning and mid-afternoon and lunch breaks and use it for want they were intended. In my son’s work-site people have access to ping pong, to exercise equipment, to music, or to just sitting or taking a walk.  I haven’t seen than in many laboratories (although lots of places have group exercise) but that would be wonderful.  Note to laboratory managers, spend a little money and make sure that your staff has some comfortable chairs and sofas in their break room. 

• ·       Enough with those conference chairs!!

One size does not fit all.

When I am doing project and lecture preparation, I tend to go back to basics; more times than not that means Deming and Crosby, two men with a common goal, but different approaches.  One place where they differ 180 degrees is in the area of error reduction and prevention.  Crosby promoted the principle that setting a goal of zero tolerance for error was the most effective way to prevent costs and consequence.  Do it RIGHT the first time (DIRFT).    Deming thought this was not only nonsense, but indeed dangerous and destructive nonsense, that would be used as a stick to punish and blame workers when things went wrong. 
 Forty years after the two were busy establishing the fundamentals of business Quality, the truth still lies somewhere in between.  

But as I was preparing for a presentation, I came across an now interesting 2007 article entitled ``Trying to Do It Right the First Time Isn't Always Best``.  Hooray for Google (see http://www.chacocanyon.com/pointlookout/070314.shtml) .  The author, a Quality consultant Rick Brenner, is rather dismissive of the concept of DIRFT (``These slogans might make some sense in the operational context, where tasks are very repeatable.``) , and then makes the points that an important aspect of project management and learning in general is to have the opportunity to do it wrong the first time and that risk taking is about giving permission to allow doing things wrong at first, if the consequence is that you might by accident or intent find a  better solution.

Well I can see where he is coming from.  In the research and development setting, we are looking for new insights, new knowledge, and novel approaches.  That is why we call it ``search and re-search``.  But as much as the medical laboratory is about new information, it is about correct information.  The right information from the right patient sent to the right clinician at the right time.  Everytime.  While  Brenner describes this as being merely operational, but it is pretty narrow-minded when describing this as repeatable as a simple repeatable task. 
 Clearly while being a consultant in one very narrow field, he has little interest or experience or expertise in the broader laboratory world.  
And can we agree that might not be the strategy of choice when building nuclear reactors!

From my perspective, in the medical laboratory, establishing DIRFT is not so much an imperative, but more a target and  attainable  goal, and the only way that we can move towards error reduction and reduced clinical consequence.

I recognize that in the busy laboratory there are many distractions that contribute to slips, but if information is delayed or faulty, the clinician and patient are not  interested in our problems.  They want what they want and they want it when they want it.   Period.

In 1986 Briggs Phillips published in an article entitled "Human Factors in Microbiological Laboratory Accidents" in Laboratory Safety: Practices and Principles.  Laboratory accidents, injuries and infections do not occur randomly;  most happen around a small group of people with repeat problems.  By case-control comparison to accident-free peers, accident involved people were less aware of work environment risks, Less aware of work behaviour risks, and were more prone to working quickly, especially before lunch and breaks and days end.  Accident involved people were more likely to take risks.

There is reason to suspect that similar issues are at play when it comes to Quality slips.  Most slips and errors occur in the laboratory in a similar fashion, a small group of workers represent the largest group of repeaters slippers.  I am not aware of any study that has looked at behaviors of this group, but it would not surprise me if we found a pattern similar to one described above.   Wouldn’t it be great if that type of information was available!

When we don’t don’t have an policy or a mechanism to deal with the repeaters, then we are only apt to find ourselves in the same place over and over again.  That doesn’t mean trashing the person.  Maybe  some investigation into causation and responses to distractions is in order, or some  re-training assistance may be  required.  

Regardless, at some point management needs to have a solution, and it seems to me that having accepted a DIRFT policy and principle to aim towareds is not a bad place to start.  

Human Factors and Safety and Quality (?)

In 1986 Briggs Phillips published a small, probably near forgotten, but important study in laboratory safety (see in Laboratory Safety: Principles and Practices.  ASM Press 1986).  The author was able to identify two groups of people: one group of 33 who had experienced at least one laboratory accident in the last 2 years, and another group of 33 who had been accident free during the same 2 years.   The two groups were matched by job classification.    

The two groups were interviewed and surveyed for additional information.   

While not matched for the following characteristics, all including age, years of education, years on the job, weight, height and gender and marriage status were identical.  In addition, wearing glasses, medication use, showed no differences.  Also of interest, accidents outside the laboratory, and driving records were also equal.  

The factors that had significant differences were (A) smoking  (B) the number of accidents and injuries and infections acquired in the 2 years prior to the current 2 years (C) personal attitude towards safety (D) opinions of the safety awareness of their supervisors and co-workers, and (E) importance of training and communication versus personal experience.  In all these, the accident involved were more likely smokers (remember this was 25 years ago), had a long history of accidents,  believed that technique was more important than attitude, but thought that personal experience was more important than training.   

The accident free group were significantly more critical of the supervisors and significantly more critical of their co-workers safety consciousness, and believed that safety attitude and awareness were more important than having techniques and equipment.  

[If you are safety aware you will avoid getting into the high risk behaviour of rushing or allowing distraction.  If you are not safety aware, you are more likely to assume that equipment will allow you to go faster and increase risk.]

The message of the study points to importance of attitude and awareness in the avoidance of having a laboratory accident or injury.  

So why am I bringing up 25 year old studies?  Two reasons.

First, a recent study in ASQ’s Quality Management Journal V18, N:1, 2011 on factors associated with continuous  improvement in patient safety  by E. Naveh et al came to a similar finding of the relative importance of opinions on attitude and priority.

Secondly, and more importantly, what made the first study possible was that records were maintained on who had been involved in a laboratory accident or injury.  In many laboratories today, we have virtually no records of Quality accidents, and where we do have records,  the names of the people are commonly deleted.  So in many (most?) laboratories if we wanted to study the human characteristics associated with increased error, it would be impossible because we have no place to even begin.

Deming wisely called to “Drive out Fear” and I agree with that.  He also said that most error was systemic, and I agree with that too.  But Quality in the medical laboratory is a new field, and it is important that we study why errors occur.  Confidentiality is important, and so if avoidance of a sense of retribution.  But let’s not “throw the baby out with the bathwater”.  Continuous improvement requires having data to study.

That’s why they call it PDSA.

Resolutions 2011

I used to think that New Year’s resolutions were pretty much a waste of time. Most people that I know still do. I vow to be good; I resolve to quit eating; I resolve to quit smoking:   I resolve to get more exercise.  I resolve to stop being sarcastic. Yeah, yeah, and ...yeah.

But over the 5 or 6 years, the concept of resolutions started to make a little more sense. New Year's Resolutions are just a variation on the theme of setting Objectives and Goal.
I mentioned before that CMPT`s quality system has been certified to ISO9001: (2000 - 2008) since 2002. Every year in October we set quality and programmatic goals and objectives and then monitor to ensure that we meet our goals.  When we started we did this so that we would continue to get certified, but after a while we saw the value in the exercise, and did it for us... to keep CMPT on path and on track.  And it seems to actually be effective.

So it started to make sense that if we can do this positively and painlessly for a proficiency testing program, we should be able to do the same thing for the Program Office for Laboratory Quality Management, and for my teaching commitments, and also for the medical laboratory at which I worked as a medical director for Quality. And again, the experience reinforced itself by actually being productive. 

Go figure.  Those guys like Deming and Crosby actually knew what they were talking about.

And now that MMLQR goes though its first New Year,  it is time to start setting some objectives for it too.  Actually MMLQR has only been running for 6 months, but this is sort of like setting or re-setting an organization's fiscal or operational calendar.

Just to make sure we are on the same page, I use the term Objective to mean a large scale outcome that may take a number of steps to reach, and I use the term Goal to identify the individual steps.  To be credible the objectives should be achievable and the goals should be measurable.

So here are my goals and objectives for MMLQR for calendar year 2011

Objective 1:

MMLQR will be recognized as an active and credible and readable website to promote diversity of opinion and discussion for the full range of issues that surround quality management of medical laboratories.


Goal 1
To meet the measure of "recognized" I will promote MMLQR to support current readership and to encourage a broader audience.

Goal 2
To meet the measure of ``active``, I will generate at least one new entry each week.

Goal 3
To meet the measure of ``credible`` I will actively seek review and comment by others with long term interest in medical laboratory Qualitology.  This might be in the form of another shot at an electronic survey, or in the form of an external-internal audit.

Goal 4
To meet the measure of ``readable`` I will reduce the number of spelling and editing errors per entry.  (This one will be tough because I am terrible at proof-reading).

Goal 5
To meet the measure of ``diversity of opinion and discussion" I will invite and publish comments and commentary of differing opinion (as long as words like "jerk" and "pinhead" are not included) . 

Goal 6
To meet the measure of "full range of issues that surround quality management"  I will expand the topics covered including more commentary on politics and quality partners, as I see it.

So that is a good start with an achievable objective and a series of measurable goals.  MMLQR is a young start-up which has met reached a certain level of fragile stability (similar to how they describe the Canadian economy).  Going to the next step will take the discipline of setting some objectives and goals and PDSA.  We will see how I do by the end on the year.

See you in 2011.

m

Big enough to fail?

WITH APOLOGIES, THIS IS ANOTHER RANT.  RECENT EVENTS TELL ME THAT SOME THINGS ARE VERY RESISTANT TO CHANGE, EVEN WHEN WE KNOW BETTER.  IT'S KIND OF LIKE SMOKING.

Question 1: How many laboratories in Canada (or indeed anywhere) have been closed down because they did not get a perfect score on their proficiency testing challenges? Answer: None.  Never.  Notta. Zip. Zero.

Question 2: How many laboratories have been allowed to remain open, but lost their ability to bill their provincial medical services program for services rendered because they did not get a perfect score on their proficiency testing challenges.  Answer: see above.

Question 3: How many laboratories in Canada “game” their proficiency challenges by holding the sample back until the right technologist is available, or do repeat testing, or do extended testing, or send the sample to a referral laboratory.  More than one, disturbingly a lot more than one. 

Not to belabor the issue, but what is the point of the exercise?  Are we really that insecure about our professional competence that we have to “cheat” when there is nothing on the table, nothing to gain.  No gold stars, no extra cookies, no scholarship, nothing.

What we do lose is the opportunity to check that our standard operating procedures are getting us to the right answer.  What we do lose is the opportunity to do a competency check on our operating systems.  What we do lose is all the extra time, effort, energy and money is doing the extra testing, and scheduling. Consider that  finding a single weakness through PT can save you poor quality costs equaling your laboratory's total PT costs for a whole year, or more.

There are solutions or work-arounds that can be put into place, but they are either expensive or inconvenient, or create increased, and from my perspective unacceptable risk.  

We have been toying with the possible linking proficiency testing turnaround times to clinical sample turnaround times.  If a sample should pass through the clinical laboratory in less than 24 hours, then that becomes the upper limit for the P.T. challenge.  If it should take five days, then the PT turnaround limit is five days.  It would not be particularly difficult to do, for programs with on-line entry of results.  For paper or fax entry it may be a little more difficult.   It would result in more paper work on both ends and that would result in some inconvenience and added cost.

Another solution would be to create a link between the P.T.  provider and the laboratory information systems, so that reports would be automatically generated and sent tot he provider.  This would take some initial set-up time and save time on the laboratory side, but would, in most P.T. programs, cause increased time requirements to transfer results to the data base for analysis  with an inevitable increase in cost.  Additionally, it is stunning how unstandardized our reports are.  But that is a topic for another time.

Or we could disguise the samples completely and have them submitted as clinical samples.  But that would cause all sorts of challenges with getting site specific requisitions from each laboratory and creating patient names with appropriate identification numbers.  And then we would have to sort through the problems created with billings.  (A number of years ago when I was a resident, a microbiologist in the hospital created a  throat swab with C. diphtheriae.  It was a brilliant idea except that the result got reported to public health and much chaos ensued).

Or we could just get rid of proficiency testing, but most laboratories would lose an essential quality assessment tool and a major source of continuing education.

There is, I think, a more reasonable solution.  Laboratory management including the quality manager decide that as of this day we do things differently.  No more overwork, no more processing by the QC technologist.  Routine processing only.  It's worth a try.
Yes?

m

PS:
The POLQM Weekend Workshop is coming together well.  For those interested in doing a poster or podium presentation, register early and send your abstract to ubcpolqm@gmail.com

www.POLQMWeekendWorkshop.ca

Heresy?

 American Society for Quality has a number of  journals, and some excellent, and others pretty good.  One of the latter category, at least in my opinion, is the Journal for Quality and Participation.  Without wanting to be harsh, I tend to find articles, while generally interesting,  tending to be more  opinion than fact.  (The irony of me, an opinion oriented blog writer making this distinction is not lost!).

Nonetheless there were three interesting articles in the October 2010 edition that I received today.  One was “Improving Project Performance with Three Essential Pieces of Information” by Portnoy, and another “Creating a Self-Confident Workforce” by Denton.   The last one is  "Training on Trial” by Kirkpatrick and Kirkpatrick.  

I don’t intend to go into any (the journal is available at www.asq.org/pub/jap) in detail other than to say that the first article made the point that when designing a project briefing (the deliverable) it is useful to make it brief and unambiguous.  The point was that the more the number of words and the more jargon included, the more variable is the document's interpretation.  The training article was making the point that training can have a lot of challenges demonstrating that it actually provides a service that will address significant business results.  And the third article made the point that workers are more self-confident with less stress when they are empowered to make certain decisions on their own.

I can support all those points.

Which brings me to the heresy. 

At a laboratory where I was working, I often found myself in conversations that suggested that some of the standard operating procedures (SOPs) were so detailed and so “precise” that in my opinion, they were largely unfollowable.  Even with an adjoining process map they were unfollowable.  They were better when pictures were added in,  but especially better when pictures were used in place of words.  In the process of trying to make SOPs that were all encompassing, I felt we were laying the foundations for error.

And so I started to think that maybe it is not so important to tell microbiology technologists how they have to hold and streak a petri dish, but to let that happen on its own.  And defining precise colony counting methods was so rigid that it likely wasn’t followed anyways.  And trying to define all the combinations and permutations of bacterial growth was confusing.  

Now there are many procedures involving many pieces of highly precise equipment that do need precise instruction (I understand that) but if we pollute those instructions that are challenging to follow, I think we run the risk of some documents  that need attention and clarity getting lost in the shuffle.  

So my point is that SOP writers and trainers and supervisors need to take a closer look at the procedures that they create to make sure that they actually are useful for training, and more importantly allow the business purpose of the procedures to come through.  Its not only about the value stream, but also creating documents that give technologists the professional autonomy.  Smaller and selective documents, it  seems to me, make the procedure and much of the decision making process both more efficient and more effective.

And how heretical is that?

m

Quality Confab and Disconnection

I attended Robert Michel’s Quality Confab in San Antonio this week.  For those who do not know about the Confab, it is slowly become one of the sentinel Quality Meetings for those interested in medical laboratory quality.  (More on the other sentinel meeting shortly).  Lots of good speakers giving lots of good summary presentations.  Enough material for lots of folks to learn.  Enough material for lots of folks to discuss, ergo the title “confab”.  I gave a presentation about the challenges associated with examination phase error.  I will post the presentation on www.POLQM.ca.

But that is not what I want to talk about.  For me the most interesting and intriguing 10 minutes of the whole 2-day meeting, and perhaps for the year, was a brief discussion by Michael Astion (University of Washington) on the concept of Disconnection.

Michael is a long time leading Quality Guy, with a variety of insights on laboratory error, and as it turns out a lot of common sense concepts on Management theory and Human Resources.  In previous meetings he has talked vividly about human slips and foibles that contribute to error.  But this time he addressing error from a broader management perspective.  One point that jumped out for me was that one of the reasons that laboratory workers  make errors is because they have become disconnected from the clinical reality, and that being disconnected contributes to more focus on the self and less on work contribution.   

A solution for this is to reconnect and revitalize by bringing patients to the laboratory and the laboratory to the patient.

This sparked about whole slew of images for me. 

In many microbiology laboratories, not only is the technologist disconnected from the patient, they are disconnected from the specimen and even the requisition.  In some laboratories the technologist working on the culture doesn’t even get to see the patient gram stain.  For them the whole patient care experience is looking at some petri dishes.  Not only does this contribute to formulaic microbiology, it is also extremely difficult to sustain a sense of clinical perspective if you are completely eliminated from any vestige of the customer and patient care. 

The same is probably the case for chemistry and haematology technologists as well, although I suspect being involved in blood transfusions or smears with leukemic cells may snap folks back to something closer to the clinical realm.

A number of years ago there was a lot of discussion that there could be a lot of value in taking a technologist off the bench, and have them make ward rounds with clinical staff to assist with laboratory and testing issues.  The concept was essentially developing a laboratory equivalent to the clinical pharmacist.  By putting a laboratory person on the ward would be beneficial for the patients and clinical staff because they would gain insights from the laboratorian, and the laboratorians would benefit from the clinical exposure.  It was a great idea, but never seemed to take off.  I think it was just a too far ahead of its time.

So this notion of disconnection as a interference that could be reversed has been around for a while, and it is still an intriguing today.

On the other hand, laboratory folks are not the only workers stuck in the ME generation.  Someone once said that hospitals changed for the worse when  they stopped primarily being places where unwell people would go for care and attention, and started being places whose primary focus and function was to hire nurses.  There is lots of clinical staff who have all sorts of access to the patient care experience, and who still focus most of their time and effort working and worrying mainly about themselves. 

So count me intrigued by the concept of disconnection.  I have a lot more thinking and hopefully some reading on the topic.

More on the Confab shortly.

 

m

PS - With respect to the other sentinel meeting, eserve June 18-19, 2011 for the UBC Program Office Quality Weekend Workshop in Vancouver.

Selecting PT Challenges

We are in CMPT Annual Meeting Challenge (more on this later) and one of the important tasks that needs to be accomplished is the selection of challenges for the next programmatic year.  Since our program year starts in May, the challenges we selected now go through to April 2012.
Selecting challenges for Clinical Microbiology Proficiency Testing is really interesting exercise that does not get easier with experience.  It gets harder.

Each year our group of committe participants, all knowledgeable and experienced, some laboratory physicians, some laboratory scientists, and some technologists meet with an empty slide.  By the time we finish we have 12 gram stains, two paper challenges, a variety of wound samples, blood culutres, CSF samples, urine samples, throat swabs, and enteric samples, all selected to address variety, complexity, cover the full laboratory tesing cycle, avoid repetition but allow for sequential testing, susceptibility testing, and try to increase the probability of having samples that will discriminate between strong and weak performers. And making sure that to the extent possible all will have gradable results.  And it needs to get done in under 4 hours, which includes the process of deciding on what the correct answer is going to be.  The fact that every year we get this done is no assurance that we will always be successful.

You would probably not be surprised to know that this is rarely a process that goes smoothly.  There is a lot of discussion, and lot of debate, and a lot of opinion and controversy.  But in the end we always come to a position of consensus, although rarely would it be total and absolute. Not everybody is happy, but at least everyone can live with and support the selection.  I can say that when we get up and leave the table every participant agrees that laboratories will be better having received and processed these samples, and worked through the critiques. 

But for those of you that are participators, and users of the information, I am sure you appreciate that selecting the menu is only the beginning.  Now we have to make sure we have the organisms, and ensure they will function as we expect them to.  We need to create the  mixtures of background flora to go with the challenge target, verify the growth patterns, validate the associated history, and then go through the process of quality control including all the transport issues.  All-in-all there is not a lot of time left over once we have worked through all these steps, so that we can ship them out on-time and go through the process of receiving and grading the results.

So why do we do all this.  First and foremost, laboratories and their accreditation bodies as well as the other quality partners expect that the samples are well thought out and will work to provide quality answers.  Second, if we don't produce quality samples, it becomes really hard to convince programs to continue to support us.  And third, it is actually a fun intellectual exercise that many would like to participate in, if ever they get the chance. 

For those of you that have the interest in promoting quality laboratory practice, working with your local PT program can be a positive and satisfying activity.

And for those in our neighbourhood, we will be doing this again next October. 

And then we go through the same exercise for our Mycology and Enteric Parasitology, and Water Bacteriology programs

m

Some easy and cheap things that you can do that will improve laboratory quality (Part 2)

I previously mentioned the Juran Quality Cost Model which points out that doing small things to improve prevention and assessment, have a big impact on to Quality spending, because they drive the costs of failure down by reducing the amount of failure.

I think that the model has merit.

The extension of the model is that inexpensive and easy to perform improvements can save TEEM (time, effort, energy and money).  As much as I am truly fatigued of the term, think about the “low hanging fruit” that will improve Quality. In part 1, I mentioned simplifying procedures, and improving procedure communicability, and introducing Quality discussion. 

So, continuing on the discussion: 

Create your own personal Quality Checklist.

There are a bunch of things that you know you should do on a regular basis, but for the most part they usually don’t get done until something official comes along.  Maybe its an upcoming accreditation, maybe it is a post-complaint investigation.  I know that we are all well meaning, but we can be busy or distracted.

So set yourself a check list (aka “to do” list or “personal audit” list).  Don’t wait for someone to make one for you (when it comes from your spouse, it becomes a “honey do” list).

A few things to put on your list:

1:         Have I checked the procedures that I am working on now in the last 3 months for changes?

2:         Have I checked to see if my personal short notes on the procedure are still consistent with the changes that have occurred?

3:         Did I update my own short notes?

4:         Did I check to see if there are short notes attached to my bench or analyzer, and have they been similarly kept current?

5:         Did I have one incident during the last month or three months that would quality as a learning opportunity or opportunity for improvement?  Did I make a personal notation in my own OFI book (more on this later.)

6:         Did I have at least one continuing education activity in the last 3 months, and did I record it.  That might include:

•         Read a book or article or website or see a video related to my work
•        Attend a seminar or meeting or interest group related to my work
•         Participate in a continuing education related course either in person or on-line

Keep the checklist in a private place, but check it at least once every 3 months.  It will take no longer than 2 minutes to check, and should generate no more than 10 minutes of activity.   But in a year you will have 4 checks of 6 points (that’s 24 check points) and in two years you will have 48.  

Do one internal audit a month.

We all know and understand that working in a laboratory is a lot like working in forestry.  Most of your time is spent jumping from one fire to another, and soon all you are doing is stomping out fires.  That is really important work, but some of those fires are self-induced because you never got back to check that the fire was actually put out.  That is what internal audits are for.

I find that so many of us like to think BIG.  That’s good for dreams, ambition, and goals.  For internal audits, thing SMALL.

An internal audit does not have to be much more that taking the personal checklist as above, and make it a little broader.  We need to be checking to make sure we are on track.  It’s just part of the Plan-Do-Check-Act thing, but make it really narrow and make it really specific.  And don’t take anymore than 30 minutes to get it done (45 minutes tops).  For example ...

1. Check the benches to confirm they are neat and clean at the end of the day?
2. Check the reagent kits to confirm that some one recorded the “open date” and the “expiry date”.
3. Check the equipment temperature recording charts to confirm they are being filled in.
4. Check the Proficiency Testing results to confirm that someone looked at them, and signed them off.
5. Check the SOPs to confirm that they have been reviewed on time.  (If you set that to happen with a few review times each month, then you don’t have the burden of doing them all year’s end).
6. Check to see if the preventive maintenance schedule is being followed on time.

Then write the results down and give a copy to someone in laboratory management.  That is all you need for an internal audit report.  You can draw up your own list, but keep it fewer than 12 (if the list gets too big, most will just drop it).  Once again, if you did each of these once every 6 months, at the end of one year you would have 12 completed internal audits and at the end of two years you would have 24.  If your list had 12 and you did them each twice a year, then at the end of a year you would have completed 24 internal audits.  That is huge!

The reality is that most of our colleagues would like to focus on doing better, and doing error free work, but we tend to make Quality tedious and excessive and overwhelming.  Too many rules and too many requirements.  And administration sees it as expensive.  So try this as something different.

More cheap and easy later.

m

 

The Phlebotomist and Front End Error

As laboratories focus more time and more energy on quality improvement and error reduction, one thing seems clear to me; the phlebotomist does not have a chance. What appears on the surface as a simple task is  one of the most complex in the whole of the laboratory process.

A person has to greet the patient, check their identity (which includes catching the errors of the people before), check the list of tests, select the appropriate tubes, put them in the right order, check the arm for accessible veins, prepare the vacuum tube apparatus, put on the tourniquet, puncture the skin, draw the blood keeping in mind that too little is a problem, as is too much. Then they have to mix the tubes with additives, not too much and not too little, at the same time as changing tubes. Keeping the tourniquet on too long is a problem.

When the needle comes out, make sure they don’t puncture themselves, or the patient, and the apply pressure to try and avoid a haematoma.

Then check the requisition to make sure again that the right tubes were collected in the right order for the right tests. And then they have to get the labels right.

All this is happening in the milieu of elderly people with small and weak veins, athletes with thick skin, children who are nervous and often crying and pulling away, and drug users who have shot their veins, and mom being distracted by the kids crying or running around.

And then they have to go through it again, time after time, 40-50-60 times a day.

And if a patient decides to complain because they felt rushed, or some discomfort, then we stack on more tension.

And then we have the ICU and the Emergency Department situations with all their own inherant complications, distractions, and tensions.

No wonder we have front end error as the greater proportion of significant laboratory error (40%) reported in most series around the world. 
James Reason would call most of the problems that occur in phlebotomy either as uncogntive slips, or maybe training issues. But I disagree. I don’t think that more training can help here. This is an interesting task that combines a highly complex series of steps that need to be done with mind numbing repetition and speed, in a distracting environment, with the constant reminder of zero tolerance for error. I think that the reality is that it is a near impossible expectation.

There is a site called IVteam.com which had a very short article a year ago (September 9, 2009) that discussed the development of a phlebotomy performing robot under development at Department of Mechanical Engineering at Imperial College London. (http://www.ivteam.com/phlebotomy-robot).
Now I know, as do you that machines are not ever perfect and there will be many arms that don’t work with the robot as well. But a robot is less likely to pick up the wrong tube, or get them in the wrong order, or under-mix or over-mix, or get the labels wrong. So for the laboratories that can afford it, we might one day see a mix of skilled phlebotomists and robots. For most places and most situations, we will continue to see phlebotomists sans machine.
I think that Quality folks should be really up on this and follow along. Other than doubling or trebling the phlebotomy staff (like that is ever going to happen!) this is likely going to be the only way to really address pre-examination error.



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