PT Bonus Opportunities: would your laboratory benefit?

PT Bonus Opportunities: would your laboratory benefit?

Frequently we talk about the benefits of Proficiency Testing as a method for the detection of systemic error in laboratory testing, especially as part of the examination phase.  Once you accept that Proficiency Testing challenges have been thoroughly quality controlled and are highly reliable, then it becomes, as my old calculus professor used to say, intuitively obvious that the greatest probable cause of deviation between a clinical laboratory’s result and the PT program’s result is some form of problem within the clinical laboratory.  It likely is a slip or distraction by someone in the laboratory’s testing chain, but it may reflect a larger systemic error that is otherwise is being not recognized or is under-appreciated.  Discarding deviations in PT performance can be lost opportunities for improvement.

But recently we had two interesting results come to light that reinforce that systemic error in the testing pathway detectable with proficiency testing materials can come from all sorts of places. 

As per our normal routine, our PT coordinator was checking the laboratories that had not yet sent in their results 48 hours before the due date, and found one such laboratory and contacted them.  [As an aside we can provide that extra level of service because we are a small program.  Large programs with thousands of participants could never provide that extra assistance.]

The laboratory checked their records and came back on the phone and said that the problem was on our end, because the laboratory had never received our samples in the first place.  We were the problem.  So a check was made through the courier service and what was found was that the samples had been delivered on time as committed, and that the delivery way-bill had been signed off within the laboratory.  A call-back was made and sure enough, the box was sitting in the refrigerator where they had been placed, un-opened.

The story has two messages.  First, if this happened with our package, this could have been a one-off by someone who simply forgot (call that a human slip) or perhaps this happens more commonly than the laboratory is aware (call that a system error).  Second, our system informs the laboratory on the day the package goes out.  If there is going to be a problem it would be captured within 48 (max 72) hours.  If someone had called us and checked, the box would have been found immediately.  That this didn’t happen either means that a distraction resulted in the call not being made, or that the laboratory has an inventory-control problem which needs checking. 

Either way the point is that even without being tested, this PT shipment has resulted in detection of two problems (is it OK to call them errors?) that the laboratory now has the opportunity to check-out.  Either they were a chain of simple human foible, or they were a manifestation of failures in the delivery handling and monitoring procedures. 

A second story is similar, but starts not from us contacting the laboratory, but the laboratory contacting us with an apology for a 5 day delay in submitting results.  Apparently, there usually was a Quality technologist whose job it was to submit  PT challenges reports, but that person had recently retired and no one had yet been appointed and so the job was “slipping through the cracks”. 

We understand that people do retire; that is called “business as usual”.  But if the PT reports are not being submitted, are there other tasks that are not getting done.  If quality control testing is being delayed, and reagent defects are not being identified, then how many hours are going to be lost having to remediate erroneous test reports?  Or worse, what if quality control testing isn’t being done at all?

My point is that PT samples are more than just a material to challenge the examination phase of laboratory testing.  They are known and traceable and regularly received materials that can be used to monitor every aspect of the laboratory cycle.  Usually everything works as it should, and sometimes it does not.  It is when things do not go well that these “safe” opportunities arise for checking for system error. 

Opportunity accepted or opportunity ignored?

Quality and the Pre-examination delemma

In my last post I commented on our recent  Quality Seminar in which there were two papers on a new standard being developed to help laboratories improve their pre-examination procedures.   

The problems are well established.  The pre-examination phase of laboratory testing is a highly manual, person intensive group of procedures that address collecting, transport, accessioning and storing of patients’ samples.  The system is fraught with error, usually accounting for 70-80 percent of reported laboratory errors. If a laboratory wants to improve their overall performance and contribution to medical care they should focus on reducing their absolute numbers of laboratory error.

The new Canadian Standards Association standard (Z316.7 Primary sample collection facilities and medical laboratories – Requirements for requesting, collecting, transporting, and storing samples for patient safety and quality of care.) is going to be a valuable and informative guidance document.  

I suspect that most Canadian accreditation bodies will pick it up as a good accreditation document, and even if they don’t, laboratories will still find it an invaluable document to support their quality system.  It is broadly inclusive and rich with guidance.  If I have a criticism (and it is pretty minor), it is that some may find it almost too encyclopaedic.

On the other hand the informative annex designed for Microbiology is the opposite of encyclopaedic.  It is compact and more general than specific, but in an invaluable way.  Microbiology and tissue pathology are very different from Chemistry and Haematology because microbiology and pathology samples are rarely collected by laboratory trained and supervised personnel.  The annex makes it clear that that samples for each laboratory need to meet a specification  set (proper technique, correct container, accurate information, proper handling and transport) and if they are not met, the sample will likely be damaged and the quality of the sample impaired.  

The collector needs the information before collecting (afterwards is too late) and if they do not know the information for this specific laboratory (each laboratory is 
different) then check the correct manual or CONTACT  the laboratory BEFORE you collect the sample. 

Commonly microbiology samples are collected by nurses or physicians, and sometimes by the patient or their family.  The physicians and nurses that collect these samples are all professional, and caring, and knowledgeable in their field, but the reality is that few of them are informed about what to consider when collecting a sample for the laboratory.  Few actually look at a collection manual, and assume the way they learned it back in school is still the right way.  Some (not many) still work with“Just get it to the laboratory.  They’ll figure out what to do with it.” 

All too often we have not been clear enough about our message:  if you didn’t do it right, then you did it wrong and the laboratory can’t undo the damage.

The challenge to us is how to communicate the message.  We can write collection manuals, but when you consider how many pre-examination error occur, that does not appear to be particularly effective.  In some special facilities some of the information can be embedded in the laboratory information system, but again the information is usually seen after the collection when it is already in a wrong container, or in the refrigerator.  And none of this addresses the sample collection that goes on in all the family practice offices, and walk-in clinics, and homecare settings.  

The new standard makes it clear that as much as we have allowed the other people to collected our samples, we are responsible for the overall quality and we need to take more responsibility in ensuring that the pre-examination phase is done properly. 

All this brings us back to how we teach adult learners.  Adults learn what they understand is relevant to them.  They want it delivered clearly and concisely in a format that makes sense and in a manner that allows for communication and clarity.  

Experience tells us that writing memos or newsletters or posters are not sufficiently effective.  Holding workshops and seminars doesn’t seem to hold a lot of interest.  Non-motivated adults choose to not learn.  Positive motivation works better, but sometimes so does negative motivation.

If we are responsible for the creation of laboratory information, then at a certain point we may eventually have to become more aggressive in ensuring pre-examination requirements.   More hard lined.  Samples will not be accepted unless we can confirm they were collected in the proper fashion, and put in the appropriate containers and handled for transport in the appropriate fashion.  Fewer samples will be processed, but our confidence in the reliability of outcome for the ones that are will be higher.

In the coming era, soon if not now upon us, when reports go directly to patients with increasing expectation for accurate and meaningful results, then our choices are getting fewer.

So with apologies to Philip Crosby, welcome to the new version of DIRFT:  Do It Right Or Don’t Do It At All (DIRODDIAA).  

It would be enough to get Demining to roll over in his grave.   

   

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.

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.



m