Saturday, February 25, 2017

Take chance on me (Musings on transfusion professionals collaborating)


Stay tuned: Revisions will occur
February's blog was stimulated by the planned transition of an informal mailing list of Canada's Transfusion Safety Officers (TSOs) to the CSTM website. I've been the list manager and moderator since the list ('transfusion')  was created in 2000. The blog is shorter than usual, which is likely a good thing.

As part of the move, we did a survey of 'transfusion' subscribers, many of whom do not have the job title of TSO, but perform many of the same functions. Historically, mainly for financial reasons, most subscribers are Canadian but we've had a few foreign subscribers, including ones from Ireland, Switzerland, UK, and USA.

What is this blog about and why might you want to read it? Many other transfusion-related communication mechanisms (workshops,conferences) exist but today it's often electronic communication, such as websites with discussion forums. In transfusion medicine, PathLabTalk comes to mind, whose BloodBankTalk participants are mainly USA and UK medical laboratory technologists / medical lab scientists. 

Similarly, professional associations like AABB and BBTS offer discussion forums and my experience is that most posts are by technologists.

In contrast, Canada's TSO list includes medical laboratory technologists and transfusion nurses, including blood conservation nurses, and even a few physicians.

That's a huge advantage because transfusion service laboratories and nurses who administer blood transfusion really do need to learn more about each other and appreciate the role each plays.

The blog's title derives from a 1978 ditty by Sweden's ABBA.

HISTORICAL PERSPECTIVE
For decades I've been privy to the views that med lab techs/scientists have on nurses, based on anecdotal experience in hospital transfusion services.

Common themes (misconceptions?) are that RNs do NOT
  • Understand quality control procedures and lack competence to do Point of Care Testing (POCT)
  • Truly dig the importance of patient identity and understand what can go wrong. Hence they're not that concerned if patient identities on specimen labels do not EXACTLY match those on blood transfusion requisitions, because, hey, they took that sample and know it's the patient.  Hence they think the lab is being anal-retentive on what they see as minor. 
It's possible that nurses have views of their colleagues in transfusion laboratories that are not always complimentary and may be based on sterotypes. I'd love to hear some. 

PARTICIPATION
Transfusion nurses have come relatively late to transfusion organizations. But physicians have belonged for ages, indeed from the get-go. They tend to dominate proceedings as evidenced by talks at annual meetings.

Yet few physicians participate in transfusion lists and forums, or on Twitter. Why not? My guess is that some think of social media such as forums, lists, and Twitter as beneath them. Perhaps some can't be bothered to interact with the hoi polloi, meaning lab techs and nurses or is that too harsh? 


Or, unlike the laboratory and nursing trench workers of the transfusion community, most physicians are too busy (can't bother?) to talk to anyone but other physicians, and only at medical rounds, conferences, etc.? Please advise. 

Three Transfusion Pros Walked Into A Bar
To illustrate my point about stereotypes among transfusion professionals, I created a joke. Yes, it's satire with a smidgen of truth.
A female doctor, medical lab technologist, and a nurse walked into the bar. Oh, great said the bartender, we have a contest tonight and you are just the ones to play it. Out came 2 glasses and the bartender said, 'Guess which one is British and which is Canadian.'
The doctor considered herself a beer aficionado and passed on asking the age and history of the brews. Feeling more knowledgeable than her colleagues, and somewhat infallible, as she often did at work, she immediately stated, based on her gut feeling: Pale lager is Canadian, dark is British.
Canada

Britain
The nurse took and recorded the vital signs, including colour and temperature. She recalled Canadian beer was more likely to be pale yellow and served cooler and that Britain had dark ales. Her guess was the same as the doctor's: Pale lager is Canadian, dark is British.
The lab tech asked if a historical record existed of the samples in the glasses and which bottles they came from, and then demanded it. When told that would be cheating, the technologist replied, 'Sorry, we in the lab don't guess about identity.'
Correct identity thanks to the lab technologist (You knew this was coming):
Canada
Britain

BOTTOM LINE
If only med lab techs/scientists, nurses, and physicians could get to know each other better, transfusion medicine would be a better world. I've been lucky in Alberta, Canada, thanks to the Med Lab Sci program at University of Alberta, to have taught several students who went on to become hematopathologists. Their lab background is a huge plus. 

And I know from the TSO 'transfusion' list that technologists and nurses have benefited from learning the issues and challenges each has.

For interest: In 1994 when the Internet became available at my workplace, I created a mailing list 'MEDLAB-L' for medical laboratory professionals of all disciplines. I could have gone with a transfusion list but am so glad to have opted to be inclusive. Over the years lab professionals (med lab technologists / scientists, PhD level scientists, and physicians) in all clinical labs have benefited from learning about each others' issues.

FOR FUN
The song I chose is a 1978 ditty by Sweden's iconic ABBA. It's meant to say to nurses and med lab techs and physicians to talk to each other on social media, break down stereotypes, trust each other, because we're all in this together.
As always, comments are most welcome.

Saturday, January 28, 2017

Four strong winds (Musings on trends identified by Malcolm Needs' 3rd CSTM blog)

Updated: 29 Jan. 2017
This month I'm going to feed off CSTM blogs on the career of the recently retired UK's Malcolm Needs (Further Reading). 

Typically, in the CSTM 'I will remember you' series of blogs, I offer my musings on what the featured author writes. But for January I've developed comments originally written for Malcolm's third CSTM blog (not yet published) into a stand-alone TM blog. So in a way this blog will foreshadow Malcolm's upcoming blog on regrets, concerns, and challenges, and serve as an advertising 'teaser' for it.

The blog's title comes from a 1963 song by the iconic Canadian duo, Ian and Sylvia. The blog is organized as a take-off on the song's title.

Strong Wind #1: AUTOMATION 
In his upcoming third blog, Malcolm mentions automation in the context of how it has changed the skill mix of staff employed in transfusion hospital laboratories. I've written about automation often including in 2010:
  • Goldfinger's filings, a customer's toolkit: Musings on business intelligence (Further Reading)
In the July 23, 2010 filing of its FORM 10-K Immucor (Form 10-K reports, which public companies file with the U.S. Securities and Exchange Commission, offer comprehensive business overviews of a registrant's business, such as history, competitors, risk factors, legal proceedings.) , one maker of blood bank automation (Immucor) writes:
'Our long-term growth drivers revolve around our automation strategy. We believe innovative instrumentation is the key to improving blood bank operations and patient safety, as well as increasing our market share around the world.'[Note they put improvements and patient safety up front, but increasing market share is their prime concern.]
'We believe our customers...benefit from automation. Automation can allow customers to reduce headcount as well as overtime in the blood bank, which can be a benefit given the current shortage of qualified blood bank technologists.' [Reduce headcount is a nice euphemism for get rid of staff and their costly benefits. Diagnostic companies also tout automation as freeing lab technologists/biomedical scientists to do more interesting tasks. And of course, if you can remove the human, you remove most of the error, or so it is said.]
  • 'We believe that instrument placements are the most effective way to gain market share ... Because our business operates on a “razor/razorblade” model....' [A razor/ blade model means give them the instruments relatively cheaply, because we can soak them with reagents costs, which continue forever.]
'In the new field of molecular immunohematology, we are currently developing the next generation automated instrument for the DNA typing of blood for the purpose of transfusion, which we believe will be the future of blood bank operations.' [And, by gawd, if a demand doesn't exist, we'll create one. See Strong Wind #4 below
Aside on automation: As a long-time transfusion science instructor (1974-99), graduates often told me they chose to work in hospital transfusion service labs because of the hands-on testing, correlating test results with patient diagnosis and history, and problem solving. They didn't choose clinical chemistry, in particular, because that clinical lab was heavily automated. Loading patient specimens on instruments and relying on software to flag abnormal results struck them as not nearly as engaging as transfusion science, or clinical microbiology, for that matter. 

Other grads obviously loved the highly automated clinical labs, and not just because job opportunities were more abundant. Of course, those who went to work for the blood supplier - on the 'dark side' as I affectionately call donor testing, where I enjoyed working in prehistoric days - inadvertently were sucked into the world of automated, mass testing of donor samples. 

Indeed, transfusion service labs whose test volumes warrant it, have moved into automated testing big time, as shown in the 'Goldfinger's filings' blog.

Strong Wind #2: LEAN
In his third blog, Malcolm also mentions LEAN. LEAN is a biggie in NA too, touted as an industry 'saviour', developed in Japan by the American Deming. LEAN expanded into health care ages ago. LEAN is promoted as allowing clinical laboratories and component production facilities to do more with less. 

For example, Canadian Blood Services (CSB) cooperates with Toyota and makes videos about  it. CBS higher level staff sport Master Black Belts in Lean Six Sigma. Jargon (~bafflegab) abounds as LEAN, Kaizen, and Six Sigma run together in a blur. 

Moreover, LEAN consultants make a great living by marketing it to health providers and training staff in-house. 

In 2008 I wrote a blog on automation and LEAN: 'Morning becomes Electra' (Further Reading). Refer to my views on whether automation and LEAN are progress, given that progress generally means improvement or growth, whether for individuals, organizations, societies, or humanity. 

Bottom line: Add automation and robotics to LEAN hospitals and soon we'll have gotten rid of all the non-value-added waste in the health system, as well as most of the health professionals. But is it progress?

Strong Wind #3: STANDARDIZATION
In his upcoming blog 3 Malcolm mentions that, in an effort to streamline how laboratories work, and to standardise (Brit spelling - grin) the work, a 'one size fits all' campaign was instituted in all NHSBT reference laboratories. 

From talking to colleagues in the field, I sense that standardized operating procedures (SOPS) are now 'SOPs on steroids'. Some hospital transfusion service lab SOPs are now so complicated that even long-time transfusion specialists must consult them often as they perform routine procedures they've done 100s of times. Do 'busy' SOPs increase patient safety? To me it's likely staff lose focus on patients due to the extreme emphasis on paperwork. 

Whenever a national blood supplier in any country tries to standardize work across laboratories or regions, my initial reaction is Beware! In his blog Malcolm explains the ways in which standardization doesn't always fit. My guess is that frontline staff aren't consulted enough initially and the head office folks writing the SOPs don't have the experience to realize it's a no-go from the get-go. 

Later the organization may ask for feedback on the SOPs that have been rolled out but seldom acts on it. Staff may even stop offering feedback because they've learned it's useless. 

I saw staff giving up firsthand in my brief stint as 'assman' at CBS (1999/2000). Staff tolerated nonsensical inaction from head office, because their feedback was met with a brick wall of silence and un-returned e-mails. Perhaps more senior people on-site knew little, too, because they were never told. Frankly, I shook my head in bewilderment at how dedicated, talented staff had come to accept the unacceptable. But, being naive, I went up the chain at head office until I found someone with real authority, who, when told what was occurring, fixed it immediately. 

About nation-wide SOPs:
  • Sometimes it seems as if they've been written by folks who have never performed the procedure, at least not currently;
  • Or maybe the writers know one lab's methods and don't understand that it won't fit others, a version of the cliché, 'a little knowledge is a dangerous thing';
  • Or perhaps standardization is a significant someone's current hobby horse;
  • Or, and here's the crux of the matter, standardization will save money in writing and revising. Never mind that they won't work operationally for every laboratory.
What's going on with SOPs in hospital transfusion service labs is a mystery. But I suspect it relates to government regulation and inspections by Health Canada (HC). 

HC regulators presumably gather input from all the stakeholders before new standards / regulations are instituted. But how much medical lab technologists / scientists play a role is debatable. 

My sense is that HC inspectors of transfusion labs have little, if any, first-hand knowledge of working transfusion medicine. Their concern focuses on documentation that processes have been validated and paperwork exists, regardless if it adds to patient safety, or even if they don't truly understand what it means. 

Strong Wind #4: MOLECULAR RBC GENOTYPING
Also in his third blog, Malcolm welcomes blood group genotyping as long overdue in immunohematology labs. 

As with any new technology, many constraints to widespread adoption exist, including staff expertise and cost. In the USA an added roadblock has been convincing government to pay for special DNA blood grouping when some of it is hard to justify with evidence. Naturally, patients with the money can get it. 

Again, see my 2010 blog, 'Snip, snip, the party's over?' for an overview of the issues (Further Reading). I see genotyping as a great innovation, but decry the increasing move to expand its uses beyond what can be justified clinically as a return on investment (ROI) in the technology. 

Moreover, I understand why, given that some folks have built their careers on it, and also dig the seductive lure of 'personalized medicine' (typical, over-the-top Rah!Rah! snake oil).  

For interest, see the UK's 'Red Book' (incredible resource) on 'Clinical applications of blood group molecular typing'.

LEARNING POINTS
In his upcoming third blog, Malcolm identifies concerns and challenges and shows hope for the future of TM labs. The issues he identifies are significant forces. Automation, LEAN, standardization, and molecular blood grouping are 'four strong winds' currently shaping transfusion medicine laboratories worldwide. At their heart, I see these 'winds' as deriving from 
  • Vested commercial interests;
  • Cost constraints and the need to do more with less;
  • Government regulation gone amok.
FOR FUN
Given Malcolm's four topics, I decided the 1963 song by Canadian icons Ian and Sylvia was too good to resist. Of interest, in 2005 this song was voted the top Canadian song of all time, quite an honour given that Canadians have written many great songs. 

The song is a reflection on a failed romance, but the phrase, 'if the good times are all gone' resonates with me. Of course, even the earth's seas and mountains change over time, nothing is forever. Also, as an Alberta resident for ~40 years, I can attest there is plenty to do here all year round. 

Not sure, however, just who all these TM changes/trends benefit. As always, I hope the blog is 'food for thought' for readers. Watch for Malcolm's multiple blogs at CSTM. His second will be published this weekend (Jan. 28-29) and third in Feb. 2017.
  • Four strong winds (Ian and Sylvia 1986 reunion concert)
    • At end see Murray McLauchlan, Judy Collins, Gordon Lightfoot, Emmylou Harris (left to right) join them on stage.
Four strong winds that blow lonely, seven seas that run high,
All those things that don't change, come what may.
If the good times are all gone, and I'm bound for moving on,
I'll look for you if I'm ever back this way.

Comments are most welcome.
FURTHER READING

Thursday, December 29, 2016

Don't worry, be happy (Musings on decreased government funding as a TM disruptive force)

Updated: 2 Jan. 2017 

Last December I got a bit mushy and wrote
  • Islands in the Stream (Musings on how love of transfusion medicine unites us) [Further Reading]
This year I'm not as sentimental and am okay with being a grinch who stole Christmas. Besides Dr. Seuss's tale has a happy ending. Not saying it applies to this blog, though it may. You decide.

Continuing the series on disruptive forces that affect, or will affect, the practice of transfusion medicine (TM) is hard. Why? Mainly because of all TM health professionals, to date the ones who have been most affected by disruptive forces are medical laboratory technologists / biomedical scientists (whatever they're called in your country). I suspect that an in-depth discussion of laboratory realities would cause many nursing and physician eyes to glaze over.

Including the three main TM professionals is part of the challenge of writing TM blogs. For the most part I try to write about big picture 'poop' that affects all so lab techs, nurses, docs can relate.

So what is December's blog about? It's about the disruptive force of DECREASED GOVERNMENT FUNDING of health care in those nations where universal health care exists, and to a lesser extent in the USA.

USA readers may think the blog is not as relevant because you don't have government-funded universal health care like the rest of the developed world (Further Reading). But from what I've read on medical laboratory and clinical laboratory educator lists, similar things happen in the US, perhaps for different reasons. For example, consolidation is rampant in the blood industry. (Further Reading)

The blog was stimulated by a seemingly odd source:

  • How physicians can keep up with the knowledge explosion in medicine (Further Reading) 
One suggested solution was to create the equivalent of 'paralegals' for medicine. Yes, my mind works in strange ways. More later.

The blog title derives from an 1988 ditty, 
which I've used before, by 10-time Grammy award winner, Bobby McFerrin . 

In an effort to keep the blog short and sweet, well at least shorter, I'll muse on Canada and leave it to you to judge if similar events apply to your country. References for many of the points will not be provided because they are available by doing simple Google searches. For example, in writing a literature review, you do not need to reference facts taken as a given and available in many resources, e.g., Donald Trump will become the 45th US President.

December's blog was also partly motivated by the economy currently tanking in my Canadian province of Alberta because prior governments made us depend on the price of oil to provide government services, including health care. Unfortunately, our economy regularly tanks. Suffering from boom and bust cycles is normal if you depend on others for prosperity, others like Saudi Arabia and the nations that make up OPEC (Further Reading).

The blog reflects on the disruptive force and effects of governments deciding to save money on the backs of health care professionals and the health system, including patients. First I outline the immediate effects in general of decreased funding, then present long term consequences for transfusion medicine.

DECREASED GOVT FUNDING - IMMEDIATE EFFECTS

CLINICAL LABORATORIES
Decreased health care funding began in a big way in Canada in the 1990s. Driven by right wing ideology, provincial governments (responsible for health care in Canada under our constitution) decided to save money in many ways, including by cutting funding to health care, particularly clinical laboratories. 


The result was a concurrent move to regionalize and centralize laboratory testing because it facilitated saving money by eliminating laboratory administrative staff and 'trench workers' alike (See Dianne Powell, Further Reading).

Management gurus tapped into the big government money available to consultants by propounding
 catch-phrases such as 'right sizing' and 'working smarter, not harder'. All in the belief that 'BS baffles brains', which it apparently does when it comes to governments to whom bafflegab is second nature.

'Working smarter, not harder' particularly rankles because it led to managers of transfusion labs trying to do more with less  - in effect, being guinea pigs to government experiments - and considered failures if they couldn't.

Staffing
For example, if five labs became one lab, the first to be axed could be four lab supervisors, now that only one was needed. Similarly, the five trench workers who covered the midnight shift as the sole technologist on duty could become one worker. You get the idea. What happened in Canada due to this disruptive force was many lab technologists, mainly middle managers and trench workers, lost their jobs.

Education programs
Concurrently, med lab technology/science programs closed across Canada, since far fewer graduates were needed. 


In Canada in the 1990s only two programs survived in the 4 western provinces (constituting ~31% of Canada's population) and both were in Edmonton, Alberta, perhaps due to the programs' strength, since Alberta was the province hurt worst by funding cutbacks. I taught in one (MLS, University of Alberta) and was a clinical instructor for the other (NAIT).

Medical lab technologists/clinical lab scientists
Under NAFTA, those with university degrees were lucky to get clinical laboratory jobs in the USA, where shortages had become extreme. Others had to give up the career they loved and had worked at for up to decades when laboratory jobs disappeared.

Clinical placements
Another factor was that government cutbacks resulted in clinical labs becoming under-staffed. Staff could barely keep up with doing core work (patient testing), let alone train students. As a result no one wanted to, or even could, train students, even though it was in their best in interest for succession planning.

Automation
Semi-automated and fully automated lab instruments found great favour and prospered in the era of decreased government funding of clinical laboratories. Instrument manufacturers promised their impressive looking instruments would decrease staff numbers, a tempting advantage since staff had costly benefits such as supplementary health insurance and pensions.

Companies also tried to take the edge off axing technologists by claiming now they could concentrate on more interesting skills and let the instrument do the 'grunt work' (my phrase). Cue a kumbaya moment. Except those without a job wouldn't be singing.

But, oh how pathologists' eyes would light up at the thought of becoming less of a cost centre in the hospital hierarchy. Of course, the more bells and whistles the gizmos had, the bigger the eyes.

No one seemed to care that

  • Government money was sucked outside Canada to multinational for-profits, rather than to staff who worked in Canadian communities, paid taxes and raised their families here. 
  • Lab automation operates on a razor-blade business model
  • Despite promises of smooth integration with lab information systems, automated instruments often had a hidden cost - the need to buy middleware so they could 'talk' to the LIS. And then the fun begins.
NURSING
Perhaps nurses can add to this discussion, at least I hope so. In Canada, decreased government funding of health care led to unemployed graduate nurses being recruited to the USA, Australia, NZ, pretty much everywhere outside Canada. More than 20 years later, Canadian hospitals still suffer because there are not enough nurses to staff operating rooms, emergency departments, etc.

Indeed, the nursing shortage is growing because of an aging workforce (Further Reading). Impending baby-boomer retirement affects all health professions.

MEDICINE
In Canada, decreased government funding did not affect physicians as much as med lab techs and nurses, mainly because physician numbers are much lower. However, in Alberta in the 1990s lab physicians lost jobs and, as might be expected, were compensated much more than other health professionals.  See 'History of 1990s Laboratory Restructuring in Alberta':

DECREASED GOVT FUNDING - LONG-TERM EFFECTS
In a way the long-term consequences of decreased government funding are the same for lab technologists, nurses, and physicians. Here I'll focus on transfusion medicine tidbits.

LABORATORIES
How have TM labs coped (saved money), and with what effect on medical laboratory technologists/scientists, post-government funding cuts?

Regionalization and centralized testing laboratories and increased automation all led to decreased staffing needs. But more than that, automated instruments led to a decreased need for well trained transfusion specialists.

Less educated and specialized staff
Hospital transfusion service labs are more than happy to decrease costs by hiring lab assistants (some with formal educational qualifications but also those trained on the job). Generalist technologists who work in other labs such as chemistry and hematology also play a key role, especially in labs beyond the centralized transfusion service lab and in rural areas.

The result has been fewer and fewer transfusion specialists with more and more staff relying on the few specialists to problem solve and keep transfusion service laboratories functioning safely. When TM specialists retire, who can fill their key role?

Dummy-proofing
For decades, some TM educators have referred to hiring less well educated staff as the 'dumbing down' of the profession. That sounds harsh but does not mean that lab assistants or generalists are dumb because they clearly are not and deserve respect. Rather it means that with the advent of automation and 'mistake-proofing' tools, many staff no longer need to be as educated and trained as before. For example:

Tools
Mistake-proofing is designing processes and devices to help prevent errors and make them obvious at a glance. Synonyms include error-proofing, fail-safing, and the politically incorrect idiot-proofing. Mistake-proof devices are common in daily life. Ex:

  • Beeping alerts when keys are left in cars or headlights are left on
  • Computer dialogue box that asks, "Do you want to save the changes you made...."
Mistake-proofing tools are also commonly used in transfusion processes and include:
  • Checklists for specific processes;
    • Inspection checklists for receiving blood into inventory;
    • Pretransfusion nursing checklists;
  • Colour-coding of ABO antisera;
  • Cross-checking work done by others;
  • Barcodes on donor bag labels;
  • RFID for release of transfusion units from refrigerators and more (Further Reading)
Bottom line - Labs: To make a transfusion lab run safely, some staff  must be well educated transfusion specialists.  How many depends on the locale, test volume, patient mix, etc. My experience is there are too few specialists and they're aging, about to retire in large numbers.

NURSING
How have hospitals and blood suppliers coped (saved money), and with what effect on nurses, post-government funding cuts?

Hospitals
In hospital wards across Canada there are fewer and fewer RNs, also fewer LPNs. Instead we have a new category of health worker, called by various names, including heath care aides and nursing attendants.

In Canadian hospitals, such workers usually have formal qualifications taking about a year to complete, including an internship. They often are the main care givers, especially to the elderly in long-term care.

Besides being short-staffed, the big nursing change within hospitals, discussed in the first 'disruptive force' blog, is the advent of transfusion nurse specialists/safety officers and blood conservation nurses. But they arose from the tainted blood tragedy and government regulation, not government cost-saving measures.

Blood suppliers
In Canada, as a cost saving measure, CBS decided to axe the number of expensive nurses it employs by hiring cheaper on-the-job trained 'donor care associates'.

* Health Canada approves new blood donor screening model (10 Feb. 2013)

This correlates to how USA blood donor centers operate, where  phlebotomists are trained on-the-job to draw donor blood and perform other functions. Having a Certificate of Phlebotomy helps since employers would rather get trained staff to decrease their costs.

Once I joked that CBS may do the same with its transport staff.



Bottom line - Nursing: I've no idea how well 'donor care associates' work at CBS and what effect, if any, their employment has had on nurses, other than fewer jobs available. On hospital wards, nurses suffer from short-staffing and a different mix of staffing, which is stressful.

PHYSICIANS
How have TM labs 
coped (saved money), and with what effect on medical staff, post-government funding cuts? With regionalization and centralized testing labs, fewer transfusion service medical directors exist because one physician fulfills the role for an entire health region. 

And, although all staff have responsibility, transfusion service medical directors are ultimately responsible for keeping patients safe, which becomes more challenging with staff shortages and a different mix of staff.  

In the health care system in general, several strategies have been floated to decrease physician costs, and some have been tried. 


For example, in Alberta a system of primary care networks exists (Further Reading). They work well (I've accessed one myself) and consist of physicians and other health professions, including nurse practitioners, dietitians, respiratory therapists, exercise specialists, etc.

The cost saving derives from the benefits of preventative medicine and using less expensive health professionals as appropriate. Now that Canada has assisted dying legislation, the Alberta government expanded the list of medical professionals authorized to assist patients with their deaths to include nurse practitioners. (Further Reading) 

The news item that caught my eye dealing with physicians:

  • How physicians can keep up with the knowledge explosion in medicine (Further Reading)
The article proposed interesting solutions:
  • Create 'paralegals' for medicine (para-medicals)
    • Meaning let nurses and junior doctors do more
  • Build a learning medical information ecosystem
  • Wow, what a bafflegab mouthful! At first it seemed to mean teamwork between health professionals (always a great idea), but then the authors pivoted to information technology. 
Always the technological solution, eh? Makes me laugh because I know physicians who have difficulty using their office computer system to renew a prescription easily. And some of these docs are not that old.
  • Mutter, mutter...Why won't it let me select renew? Aaargh! (Then writes it in pen on the computer print-out)
And how many physicians resist Twitter as a huge waste of time and don't see it as a valuable tool? Yet they attend medical rounds for the sandwiches (and to be seen) and chitchat or snooze or check e-mails throughout? Or perhaps, just to show how clever they are, ask the presenter an obscure question?  Perhaps I'm being too cynical but that's how it seems sometimes.

Bottom line - Physicians: On a personal level, transfusion physicians have been more successful than lab technologists and nurses in fighting job loss caused by government cutbacks. Or maybe it just seems that way because their numbers are fewer. Of course, medical directors of transfusion service labs feel the full staffing effects of having fewer specialist lab technologists/scientists.

I cannot but smile imagining physicians being told they must concede a significant percentage of what they always considered their health care role to others. But don't worry about it, docs, it's to your advantage. Others will now do the boring 'grunt work'. And you'll be able to concentrate on the interesting, complex stuff you were educated for. Don't worry, be happy.


SO-WHAT? 

LOW MORALE AND MORE
With cost cutbacks, low morale affects all health professions to varying degrees. My experience is morale falls mainly due to uncertainty, lack of control, and feeling devalued

When government cutbacks occur, health systems are stressed to the max and are forced to change. You might think of it as tough love. The change includes finding innovative ways to keep functioning safely. What often results is a series of experiments, experiments in which both staff and patients are the guinea pigs. 

Often outside consultants are brought in to push and implement what is often the hobbyhorse that's become their cash cow. Sorry, couldn't resist the mixed metaphor. They implemented 'the solution' elsewhere and now they're the experts, commanding big money. It's led to the joke
  • 'We're consultants and we're here to help you.' [Sure you are.]
➽In this system-wide experimental laboratory where cost saving rules, the biggest impact on staff is uncertainty and loss of morale. Change is always hard but even 'keeners' can soon become unhappy when they learn that they have no control over events, including job loss. Competent, skilled staff are let go because their positions are eliminated. In a unionized environment sometimes the 'best and brightest' lose jobs due to lack of seniority.

Moreover, staff who survive the cuts often feel guilty. The 'Why me, not them' syndrome. Suddenly folks you've worked with for years are gone, perhaps needing to change careers they love, and you're left for no apparent good reason. Some may even need a job to care for their families away more than you do but....

In such an environment staff invariably begin to feel devalued. Unfortunately, this is one of the most long-lasting invidious effects of cost restraint in which it matters not how capable someone is, how dedicated or how loyal. Staff begin to feel like checkers being moved around a board, where any checker will do. 

Effects such as low morale take a long time and much effort to reverse. It seems that some feelings are branded into people's souls, and not in a good way. 

The other long-lasting invidious effects are mistrust and cynicism about the intentions of governments, that with a limited money pot, make choices that cripple a health system and leave it with a lasting hangover. This happened in Alberta, Canada in the 1990s.

Similarly, where massive funding cutbacks lead to significant job loss, internal disruption and re-organization, distrust and cynicism invariably extend to the administrators who lead the health system, whether those at hospitals or the blood supplier. 

The health care system becomes similar to a dysfunctional family with some of its characteristics
'One or both parents exert a strong authoritarian control over the children. Often these families rigidly adhere to a particular belief (religious, political, financial, personal). Compliance with role expectations and with rules is expected without any flexibility.'
In the case of health care, the de rigueur belief system includes cliches such as 'do more with less', 'work smarter, not harder', the lean business model and its many variants rule. Oh, and by the way, no dissent allowed

One final tidbit: The long-term effect of decreased government funding leading to less educated and trained staff is disconcerting because 
  • A little knowledge is a dangerous thing. 
The most dangerous folks in any profession are those who do not know what they don't know. And that plays out daily on hospital wards and in transfusion services labs, where we can only hope there are enough well educated specialists to catch errors leading to patient harm. 

SUMMARY
In this blog I muse about the short- and long-term effects of the disruptive force of decreased government funding for health care and transfusion medicine in particular.It's happening everywhere.Will governments have a

It's doubtful. Today governments still do not consult frontline workers enough, or at all, about coming cutbacks and give them an opportunity to participate fully in a transparent change process.

Changing government policy is difficult and analogous to Newton's First Law of Motion:
A body at rest will remain at rest unless an outside force acts on it, and a body in motion at a constant velocity will remain in motion in a straight line unless acted upon by an outside force.
A sufficient outside force hasn't acted because professionals in the health system tend to accept whatever poop falls on their heads and do everything to make it work. Don't rock the boat, yes, this worries us, but let's wait and see. Somehow we'll muddle through, even if it creates much stress to us.

That's the thing. Physicians, nurses, lab technologists/scientists in transfusion service labs make the system work, regardless of the personal cost to their health and well being. And those in charge, physician-administrators
 (see below), bureaucrats, politicians alike, seem happy to let them. 

FOR FUN
This song has been used before because it fits some of the blogs and, face it, I obviously like it.

For interest, in 1988 McFerrin's song was used by 'Bush 41'  - a one term President - as his official campaign song without McFerrin's permission. McFerrin protested, stated he'd vote against GHW Bush, and dropped the song from his performances. Ouch!

Anyway, given recent political events in the USA, you can likely guess my take on Donald Trump. Similarly for the long-term effects of government cutbacks, I could slit my throat (figure of speech) or sing this song and I choose the latter.

Here's a little song I wrote
You might want to sing it note-for-note
Don't worry, be happy
In every life we have some trouble
But when you worry, you make it double
Don't worry, be happy Don't worry, be happy now


As always comments are most welcome.

FURTHER READING

CSTM blog: I will remember you: Dianne Powell on lab restructuring

Dec. 2015 blog: Islands in the Stream (Musings on how love of transfusion medicine unites us)

How physicians can keep up with the knowledge explosion in medicine (19 Dec. 2016)


The rise of the hospital administrator [Reality is that hospital administrators railed at in the article are often physicians who've become 'suits'.]

Alberta's Primary Care Networks | Edmonton Southside PCN

Alberta government expands medical professionals authorized to assist patients with their deaths, by including nurse practitioners (12 Dec. 2016)

Truth about the nursing job market

USA blood industry consolidation

Blood industry shrinks as transfusions decline (2014)
Blood centers should position themselves to be agents (not victims) of change (2014)

U.S. health care from a global perspective

U.S. spends more on health care than other high-income nations but has lower life expectancy, worse health
Middleware revolution bridging automation gaps

UK health agency plans RFID trial to staunch transfusion errors (2006)

The case for RFID in blood banking (USA perspective, 2016)

Saudi's destructive oil freeze (March 2016)

Thursday, November 24, 2016

Don't stop (Musings on government regulation as a TM disruptive force)

Updated: 25 Nov. 2016
November's blog was stimulated by a Dark Report about an Australian conference on medical laboratory professionals exploring disruptive forces in healthcare (Further Reading). 

This will be the first in a series exploring disruptive forces that have and still affect, or will affect, the practice of transfusion medicine (TM) and its diverse practitioners. Each blog will deal with one disruptive force and its related aftermaths.

What is this blog about and why might you want to read it? It requires more than the cursory scan you no doubt give most of the info overload you receive daily. But if you want to understand, truly 'dig' current transfusion realities, please consider giving it a read.

Executive version (over the long haul of all the blogs in the series):
  • At heart, the blogs are designed to combat 'BS baffles brains';
  • Because disruption affects all transfusion professionals, I hope you see its relevance to your practice;
  • Sub-aims include being able to 
    • Differentiate disruptive forces from normal progress;
    • Identify beneficial forces from those worth resisting;
    • Make the most of positive disruptive forces to improve patient care and safety.
In the 'management speak' ubiquitous in blood supplier annual reports, the last aim would be to leverage disruption and create a centre that drives not just leading or bleeding edge innovation but innovation that leads to transformative change.  

The blog's title derives from a 1977 ditty by the Brit-US rock band, Fleetwood Mac.

INTRODUCTION
Disruption has been in the news a lot lately given the unexpected UK Brexit vote and Donald Trump's election as US President. A recent search of Google news stories for ''disruptive forces'' yielded 8,830 hits.

For decades now we've seen disruption in many aspects of our daily lives. A few examples, and I bet you can name even more:
  • Personal computers disrupt mainframes;
  • Apple's Macintosh WYSIWYG OS disrupts command-driven MS DOS; 
  • Internet disrupts everything;
  • Cable TV disrupts the networks;
  • Google disrupts libraries and the publishing industry;
  • Streaming services like Netflix disrupt DVD rental stores;
  • Apple's iPod disrupts music industry;
  • Uber disrupts taxis;
  • Airbnb disrupts hotels.
The list is endless. Disruption is big in the business world too, witness a new McKinsey Global Institute (management consulting firm) report, Ordinary Disruption: The Four Forces Breaking All the Trends: (Further Reading).

No doubt disruption is now established as the next big thing. But it's not new. Disruptive forces have affected clinical laboratories for decades. 

DISRUPTIVE FORCES
So what the heck are disruptive forces? The OED defines disruptive as 'innovative or ground-breaking'.

According to the UK consulting firm, Tomorrow Today Global:
A disruptive forces is not a force that results in incremental changes, improving products or services one step at a time. Rather disruptive forces result in a breakthrough or a step change that transforms society forever. Sometimes the disruption is complete and swift. 
The key here is a true disruptive force does not affect change in baby-steps but rather consists of a big step (innovation) that changes things forever. 

DISRUPTIVE FORCE #1: Tainted Blood Massive Screw-up
Being a medical laboratory technologist who became a transfusion science educator, I found it so tempting to begin with - you guessed it -  either laboratory automation or its latest iteration, molecular typing of red cell antigens and its kissin' cousin, personalized medicine. But I've resisted. 

The first blog will discuss the worldwide 'tainted blood' tragedy of the 1980s and '90s, which resulted in the related disruptive forces of 
  • Krever Inquiry (Royal Commission of Inquiry on the Blood System in Canada);
  • Vein-to-vein responsibility for blood transfusion;
  • Government regulation migrating from blood supplier to hospital transfusion services.
The focus will be on Canada because that's what I know best. But I suspect the transmogrification of blood suppliers and hospital transfusion services was similar in other countries, albeit some progressing faster, some slower than Canada. 

Note that I am an oldster (see 'Life as a blood eater' in Further Reading) and my recall is not perfect. If I inadvertently omit significant events or get things wrong, please comment below or e-mail me. My personal take on the highlights of these disruptive forces follows.

BLOOD SUPPLIERS
In Canada, the Krever Inquiry - 1993-1997 (Further Reading) -  resulting from the HIV and HCV 'tainted blood' scandals, had a huge impact on the blood supplier, the Canadian Red Cross Blood Transfusion Service (CRC-BTS). Krever was an earth-shaking disruptive force that eventually resulted in Canada creating two new blood suppliers in 1998

Goodbye CRC-BTS, hello CBS and H-Q!
THE FALL GUY
Think about it. The blood supplier that had managed Canada's blood system from the get-go in the 1940s was to disappear under a cloud of suspicion. 

In exchange for not bringing the case of Canada's tainted blood scandal to trial, the Red Cross pleaded guilty to violating the Food and Drug Regulation Act by distributing a contaminated, drug (Factor VIII concentrate). The $5,000 fine was the maximum penalty for that charge under the Act. 

Other court cases proceeded against individuals but with no convictions:
In effect,the CRC-BTS was the fall guy (not its complicit government paymasters) for the entire tragedy. Two factors at work were the typical physician sin of paternalism and government secrecy. The panacea was to create new organizations at arms-length from government that would be more transparent. 

Only something NEW could restore the faith of Canadians in the blood system. 

The reality was that the new blood suppliers had many of the same transfusion professionals serving as leaders (medical directors), and the trench workers were the same, mainly medical lab technologists performing blood donor testing.  It's not like experienced, skilled personnel were hanging around like low-lying fruit waiting to be picked.

Regulatory Compliance Project
Meanwhile, in the mid-1990s the Canadian Red Cross initiated a Regulatory Compliance Project whereby standard operating procedures (SOPs) to encompass all operations were to be written and used in all CRC-BTS centres. To implement the SOPs and to maintain the system, a training component was included. SOPs were to comply with current Good Manufacturing Practices (cGMP). 

During this time I taught at University of Alberta, but after hours participated as an external consultant in developing training materials. 

It's worth noting that the transition to SOPs and training - a huge undertaking - happened on the 'disgraced' soon-to-disappear Canadian Red Cross's watch.  

HOSPITAL TRANSFUSION SERVICES
Despite the long history of Quality Systemsthe first I became acutely aware of QSE (Further Reading) and their implications for hospital transfusion laboratories was at the CSTM 2000 annual conference in Quebec City. 

The Canadian province of Quebec had created transfusion safety officers (TSO), initially with both a medical technologist and nurse for 20 designated centres.  [Right click and select 'Translate to English']:
In 1999, following the report of the Krever Commission, a complete reorganization in transfusion medicine was initiated in the province of Quebec. To improve transfusion practice, roles and responsibilities were established for the professionals involved in the management of blood products from blood donor to recipient
Ontario, particularly at the McMaster University Medical Centre in Hamilton, had a few TSOs (CSTM blog - Gagliardi: Further Reading) who had become specialists in QSEs and writing standard operating procedures (SOP). 
And it was at this CSTM meeting I learned of the existence of the BC Provincial Blood Coordinating Office (PBCO), Canada's first PBCO, which had been created ~1998. 

A friend (CSTM blog - Chambers: Further Reading) introduced me to its then medical director as a 'geek' who could potentially manage and coordinate resources for its TraQ program (one of the luckiest days of my life).  

Soon I became aware of the extensive help the PBCO gave to transfusion services throughout BC to help with writing SOPs and training materials. The BC PBCO was ahead of the curve - way ahead of the curve. 
It's fair to say that these BC manuals served as templates for transfusion service SOPS written across Canada and perhaps beyond, particularly in developing nations since they were generously shared online.

Then in 2004 - a huge disruption - The Canadian Standards Association (CSA) published its Standards for “Blood and blood components” (also known as Z902-04). I wrote about it for the BC PBCO's Blood Matters newsletter:
INTERNATIONAL ASPECTS
It's worth noting that the UK's blood system, while not having a Krever-style commission until much later, was quite active and early in producing guidelines for transfusion services via the Red Book.

And the UK and Australia were leaders in creating transfusion safety officers: 
In the USA the AABB had its excellent Technical Standards but being AABB accredited was voluntary. Nonetheless, the AABB Standards served as best practice.

As in Canada, the government (FDA) regulated blood suppliers. I'm unaware about the U.S. situation, but in Canada, until the Krever Inquiry report on the tainted blood tragedy, inspections, if they occurred, lacked rigour. That's the politically correct way of saying government oversight of the blood supplier was a joke. For example, in my 13 years at CRC-BTS in Winnipeg, I cannot recall one inspection having happened. Maybe they did but I doubt it. These days, every staff member in a blood centre is ultra-aware when inspections and audits are to occur.

U.S. regulation and accreditation of blood transfusion labs is a quagmire of multiple bodies, e.g., AABB, FDA, CAP, CLIA, The Joint Commission, ISO 15189, COLA, and many others. Perhaps unfair but my best guess of the on-the-ground situation in U.S. hospital labs in the 20th C comes from graduates of the University of Alberta Med Lab Sci program, when so many went to work in the USA in the 1990s due to no jobs in Canada. 

First, U.S. employers loved them, probably because of their solid experience rotating in clinical labs, generally significantly more time than U.S. grads received. Second, I'll never forget their often humorous transfusion anecdotes. One example: 
  • 'My gawd, Pat they don't even label the test tubes for pretransfusion testing.' 
No doubt the situation is much improved today. Also worth noting is that the USA never had an inquiry into tainted blood scandals similar to Krever. And the U.S. was also late to adopt TSOs and hemovigilance.

SO WHAT DISRUPTION OCCURRED?
First, be aware that before Krever even blood suppliers in Canada did not have SOPS or follow cGMPs. I worked for the CRC-BTS for 13 years as a bench technologist, supervisor, and clinical instructor and the methods used to test donated blood were unwritten. Methods used to crossmatch blood for patient transfusion were also unwritten. New staff learned as surgeons traditionally did: 
  • See one, do one, teach one (Further Reading)
  • Sidebar: After 6 months in Jamaica more or less goofing off, and longing for cooler climes, I wanted to return to CRC-Winnipeg but had to first substitute for a vacationing staff member in CRC-Calgary returning to her family in South America for an extended vacation. 
  • Spent one day watching a technologist perform pretransfusion testing (method was quite different than Winnipeg's) and was asked to do one. Afterwards the lab manager asked my supervisor if I could do the job and her reply was, 
    • 'She's good to go.' That was it. I was now the sole night technologist for CRC-Calgary.
The Winnipeg CRC-BTS also performed pretransfusion testing for all city hospitals (unique in Canada) and many rural ones in Manitoba and NW Ontario. 

Re-SOPs, once I became a clinical instructor for Winnipeg CRC-BTS I spent an entire summer holiday writing SOPs for the transfusion lab. None existed and it seemed a good thing to do, not only for staff but also for students during their clinical rotation in the one transfusion service lab in town. 

What follows focuses on the disruptive impact to hospital transfusion services due to vein-to-vein responsibility for transfusion safety.

SOPs and Competency Training - Med Lab Technologists
As noted post-Krever Canada's blood supplier underwent a tremendous disruptive transformation to cGMPs and training. To those who worked pre-Krever, post-Krever was a different universe. 

The disruptive requirement in transfusion services to have written SOPS and related competency training at first, at least in Canada, applied mainly to medical laboratory technologists. This spawned an entire industry, first via government-funded PBCOs and their equivalents and soon by the need for hospitals or health regions to hire TSOs to educate and train the 'trench workers', whether technologists or the nurses who administered blood transfusions.   

The cost to the public purse was huge (new PBCOs and TSOs), as was the disruption to the daily lives of affected professionals. But having SOPs and training was wonderful because 
  1. They standardized lab methods - learning no longer depended on who taught you.
  2. Your competency - knowledge and practical skills - were documented;
  3. The system became much safer.
Some, like the USA's talented Lucie Berte capitalized and built a successful career around QSEs and SOP development with diverse global clients.

SOPs and Competency Training - Nurses
Soon nurses - those who administer blood transfusion - were affected by the disruption of regulatory requirements. Indeed, hemovigilance programs (also a disruptive force) such as the UK's SHOT show that many errors continue to be clinically related due to human error failing to ensure 'right blood to right patient' at the bedside. 

Checklists and clinical audits of administering blood transfusions are now the norm in many locales. But SOPs and checklists only work if humans follow them.

SOPs and Competency Training - Physicians
The one profession seemingly least affected by the disruption of regulatory requirements are the clinicians (physicians) who prescribe blood transfusion. Blood supplier medical directors, and especially transfusion service medical directors, are affected because they are ultimately responsible for ensuring patient safety. 

Physicians continue to receive minimal education in transfusion medicine (typically a few hours as medical students). Ordering practices may be somewhat controlled and monitored by computerized test-order-entry systems requiring laboratory data to justify ordering blood products and hospital transfusion committees. But do physicians actually do this or do they often leave an order for ward staff to perform? 

In some jurisdictions, more rigorous monitoring of expensive blood products such as IVIg exists. 

But from all I know, despite such monitoring, if physicians want a blood product, they usually get it despite poor clinical indications, especially if they are 'grand poo-bahs' in their hospital. 

That said, blood education is ongoing and jurisdictions such as the NHSBT's Patient Blood Management program report good progress.

SAY WHAT?
I've heard from colleagues that transfusion-related SOPS may have run amok in some locations. Specifically, they now include so many steps and documentation requirements that medical laboratory technologists can get lost in the trees and lose sight of the forest. It's complicated by centralized laboratories in which even staff in the main lab automatically default to asking the transfusion specialist to handle any problem, large or small. But that's a topic for another blog. 

Main point is that too much of a good thing can quickly go wrong.

SUMMARY
In Canada the tainted blood scandal was a disruptive force that led to the Krever Inquiry and the creation of two new blood suppliers as well as the related disruptive force of government regulation, resulting in vein-to-vein monitoring of the entire blood system and the creation of SOPs and competency training for most involved in blood transfusion. 

I say for most because the one profession that's been least affected are the physicians who order blood components and products. They've been affected, more or less so, depending on their locale, but 'least' is the operative word. Correct me if I'm wrong. Why do physicians largely merit a get-out-of-jail-free pass on blood transfusion? 

Medical laboratory technologists and nurses receive SOP training and must show competency before they can perform tasks independently. Every aspect of their technical and clinical job performance is regularly audited. Physicians not so much...

Canadian Blood Services has a great resource, its Clinical Guide to Transfusion. The first chapter explains everyone's responsibilities:
The ordering clinician's first duty is 'To carefully assessing the clinical need for each order'. How effectively is this monitored, I wonder? 

Because of a tragedy that killed 1000s, life as transfusion professionals changed forever in the 1990s. In Canada, the Krever Inquiry led to government regulation requiring SOPs and competency training, which eventually extended to vein-to-vein monitoring of the blood system.

These disruptions were good for all concerned and promoted patient safety, because that's what it's ultimately all about. 

As always, comments are most welcome.

FOR FUN
Couldn't resist this 1977 song by Fleetwood Mac, written by Christine McVie, which became the campaign song of Bill Clinton in the1992 US Presidential election. 
Don't stop, thinking about tomorrow,
Don't stop, it'll soon be here,
It'll be, better than before,
Yesterday's gone, yesterday's gone.
Don't you look back.

FURTHER READING

Dark Daily: In Sydney, Australia, Medical Laboratory Professionals Gather to Explore Disruptive Forces in Healthcare and How Labs Are Using Innovation and New Leadership Approaches to Successfully Transition to Value-Based Care

CSTM blogs - I will remember you:
Canada's Krever Inquiry

Life as a blood eater

Quality System Essentials (in brief)

Kotsis SV, Chung KC. Application of the "see one, do one, teach one" concept in surgical training. Plast Reconstr Surg. 2013 May;131(5):1194-201.