Sunday, December 11, 2011

You're so vain: What we've got here is failure to communicate (Musings on the CBS-NB 'blood feud')

See Update below.


This month's blog features a 'blood feud' in New Brunswick (NB), Canada, following a 2009 decision by CBS to close its blood component production and distribution centre in Saint John, NB. Instead, blood collected in NB will be processed and distributed by a CBS plant in Dartmouth, Nova Scotia, a neighbouring province.


NB has 3 options:
  1. Go it alone with an independent NB blood service
  2. Partner with Héma-Québec, Canada's other blood supplier
  3. Stay with CBS
The blog's title comes from Carly Simon's signature hit You're so vain and an ironic, hilarious quote from Cool Hand Luke.(Roger Ebert's 1967 review)

If you are not Canadian, the blog should still appeal since its themes are not so much the specifics of the argument (interesting in themselves), but musings on poor communication and arrogance, my take on how such a soap opera could arise between Canada's national blood supplier and the province of NB and its physicians.

Frankly, it's an embarrassing farce that is all too common elsewhere (not specifying where) but rarely occurs in the Great White North. Am I showing my arrogance?

Because of the planned Saint John closure, NB is considering breaking away from CBS, the national blood supplier. On the surface it seems a no-brainer to stay with CBS, one of the most respected blood suppliers in the world. So what went wrong?


According to my musings, the main cause is
  • Communication failure, against a backdrop of
  • Cost constraint and consolidation
  • Arrogance and non-responsiveness
  • Concern for patient safety and loss of expertise
  • Parochial politics
Disclaimer
Over many years I worked in multiple capacities for CBS and its predecessor, Canadian Red Cross BTS, which means nothing except that I know the organization, have biases (pro and con) because of that, and have friends who work there. The same applies to colleagues who work in hospital transfusion services. Admittedly, I sometimes use hyperbole as an attention-grabber.
Rest assured that anything written in blogs is not personal, but not 'strictly business,' either, since I blog for fun. Rather the ideas are, as the blog's name states, musings, i.e., the results of personal contemplations that flow across the universe, which may or may not be unfolding as I think it should. (grin)
As to this blog, I have no inside knowledge of the particulars and muse solely from what's in the news and what I perceive from afar about the players involved. I could be 100% wrong. 
BACKDROP - Cost constraint and consolidation
In brief, CBS has been consolidating services (its core 'business lines', as it likes to say) for many years as reported in Performance Review of CBS (2002). See section 2.6. 


At the time CBS priorities included (p.65):
  • Implementation of MAK Progesa
  • Creation of a National Donor Contact Centre
  • Consolidation of Testing Centres
  • Consolidation and Specialization of Production
  • Implementation of a Change Control System
  • Unrelated Bone Marrow Donor Registry
  • Implementation of SAP HR/Payroll
Most of the projects have now been completed, the exception being 'Consolidation and Specialization of Production.'

Perceived (or real) arrogance and non-responsiveness
Clearly, based on their experience over closure of the Saint John processing and distribution facility, NB health professionals perceive CBS as arrogant. Quotes:


Non-Partisan Task Force. Reversal of Canadian Blood Services’decision to consolidate blood production services to Dartmouth, Nova Scotia. Report to the Legislative Assembly of New Brunswick, April 16, 2010
1. Under Outcomes of a meeting June 15 -16, 2009 with CBS: "The task force and stakeholders expressed concern with the lack of preparedness and the condescending tone of CBS officials."
2. Under Oct. 2009 meeting content: [Note: Margaret Ann Blaney is a Member of the NB Legislature and co-chair of the task force]:
Margaret Ann Blaney suggested that the task force write a letter to the CBS Board of Directors expressing the concern that the task force has with the manner in which the task force and the medical community have been treated by CBS staff. The feeling is that the CBS staff has been patronizing and has a predetermined agenda that will not be changed.
Margaret Ann Blaney expressed that Dr. Graham Sher, the CEO for CBS, has truly abdicated his responsibility and the consolidation of production, lack of public consultation and the condescension demonstrated by Dr. Sher goes against the recommendations made in the Krever commission report.
Concern for patient safety and loss of expertise
The plan to close the Saint John production facility has been protested from the start by NB health professionals on the basis of patient safety and loss of local expertise:
In 2010 the head of the Medical Staff Organization for the Saint John region carried these concerns to CBS headquarters in Ottawa and reported that CBS clearly had no intention of reversing its decision.
"We have the provincial cardiac surgery program and all of the surgical tertiary care: complex orthopedic surgery, vascular surgery, neuro surgery, general surgery, complicated head and neck surgeries for cancer . . . .
We have blood production facilities right across from the hospital that are second to none where we can access product and where they can call in donors when needed and produce the blood right here rather than having to contact someone outside the province who doesn't know our needs and, frankly, would probably be taking care of other needs first." (Dr. Andrea Garland)
Parochial politics
Politics is a common lurker in any fight involving locals and a big "other." Local politics cannot help but be involved anytime a national organization decides to withdraw services from a region.

Saint John newspaper supports dropping CBS
"In the opinion of many physicians, leading businesspeople, such as Gerry Pond, and former CBS manager Dan Connolly, New Brunswick gets insufficient credit for its substantial contribution to this national blood system."
'The empire strikes back'
Forced by their own actions into being reactive, CBS responds with a multi-pronged counterattack:
BOTTOM LINE
So, what to make of it all? To me, the key factors (root causes) are



1. CBS failure to communicate the validity of the planned change and how it will benefit the people of NB, not just CBS.

We assume that CBS leaders are excellent communicators. They
  • Manage a staff of 1000s
  • Spend a kazillion hours in meetings (presumably not comatose)
  • Liaise with diverse levels of government, private sector suppliers, colleagues in hospital transfusion services, the public, and more
  • Speak at local, national, and world congresses
  • Get elected to high office in leading professional associations
But perhaps they have communication weaknesses, as shown by the NB fiasco. 

When you're the top dog, the acknowledged experts, perhaps you think that you don't have to be flexible, empathetic, good listeners, to say nothing of being humble?



2. CBS arrogance
Based on feedback from the NB physicians, it's possible that CBS did 
  • Not sufficiently listen to the concerns of local physicians
  • Not convey respect for the views of health professionals on the front lines in NB
  • Not truly listen to others, due to believing in the absolute correctness of its position
What is arrogance? It can be defined as 
  1. Insulting way of thinking or behaving that comes from believing that you are better, smarter, or more important than other people (source)
  2. Someone who believes they are always right, and better than everyone (source)
In a way, it's easier to dislike arrogant people who are smart than those who are dumb, as cleverly stated by Nietzsche:
  • "Arrogance on the part of the meritorious is even more offensive to us than the arrogance of those without merit: for merit itself is offensive."
And when proud, competent people perceive arrogance in others, they get their backs up and tend to think, "I'll show that arrogant 'bleep'!



In this way, arrogance does the arrogant in. Because they believe they are always right, they don't truly listen to differing opinions and give them credence, despite celebrating that they do. Put another way, they do not walk the talk. Accordingly, they seldom, if ever, modify decisions, once taken.



Fact is, arrogant individuals in positions of power seldom focus on the needs of others, seldom have and show empathy, seldom validate the opinions of others.

When caught in the act by fellow health professionals, CBS has been  reduced to sending open letters to the people of a province.

Hence the blog's title:
FOR FUN
Another Strother Martin quote from the same film, this one about understanding the rules of the game. Maybe NB docs didn't understand the rules, i.e., CBS decides without consultation and is obeyed?
Songs that come to mind:
As always the views are mine alone. Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice. 


I'll update the saga as it evolves. My guess is that NB will opt to stay with CBS, as it's a no-brainer. 


Update


Wednesday, November 09, 2011

Only in the UK & Down Under? Pity! (Musings on hemovigilance)

The UK's Serious Hazards of Transfusion (SHOT) report for 2010 became available in the summer, and I thought a blog on its key findings was in order before 2011 ends.

As I got into it, I realized that something was amiss. Such reports simply do not exist in my own country (Canada) nor the USA, with which we share the longest border in the world between any two countries.

The blog's title comes from an old, iconic Red Rose tea commercial in Canada. Only in the UK and Down Under refers to the English-speaking world.

As most transfusion professionals know, SHOT, established in 1996, is the mother of all hemovigilance schemes and an exemplary example of transparency for blood transfusion systems worldwide.

It's also worth noting that blood transfusion in the developed world is safer than ever. When you examine hemovigilance reports you realize that Pogo was right. We have met the enemy and he is us.

Despite improved screening to prevent transfusion-transmitted diseases and the tainted blood tragedies of the 80s and 90s, and despite the massive effort to implement quality systems, we humans remain the challenge. The education and training of all health personnel is the single most crucial QSE.

SHOT 2010

Like all hemovigilance schemes, SHOT IS voluntary and gathers and investigates reports of adverse events, near misses and physiological reactions that may be linked to transfusion. Investigation of reported cases generally concludes, based on available evidence and its quality, that the adverse event (interpretations are mine)
  • Had little if anything to do with transfusion (no evidence)
  • Possibly resulted from transfusion (low-level evidence)
  • Likely resulted from transfusion (good evidence but inconclusive)
  • Definitely resulted from transfusion (strong evidence)
So, what are the highlights of SHOT's 2010 report?

DEATHS

The worst first. SHOT 2010 includes 13 transfusion-related deaths, 3 in which transfusion directly and solely ('definitely') contributed. The putative contributory causes include:

  • TACO: 6 (1 definitely, 3 likely, 2 possibly)
  • ATR (acute transfusion reaction)*: 3 (1 definitely, 2 possibly)
  • HTR (hemolytic transfusion reaction): 1 (definitely)
  • Under-transfusion: 1 (possibly)
  • Delayed transfusion: 1 (possibly)
  • TRALI: 1 (possibly)

* ATR: Acute reactions occurring up to 24 hrs post-transfusion, excluding cases due to IBCT (incorrect blood component transfused), HTR, TRALI, TACO, TAD (transfusion-associated dyspnea) and bacterial contamination.
MAJOR MORBIDITY

As well there were 101 cases involving major morbidity, 57 of which were classified as acute transfusion reactions.

CLASSIFICATION

Classifying cases is complex since adverse events and errors can be classified along multiple lines. Overall, of the 1464 cases in SHOT 2010, most (88.8%) fell into these categories:
  • Acute transfusion reaction: 510 (34.8%)
  • Involving anti-D immune globulin (RhIg): 241 (16.5%)
  • Handling and storage errors: 239 (16.3%)
  • Incorrect blood component transfused: 200 (13.7%)
  • Inappropriate, unnecessary, under or delayed transfusion: 110 (7.5%)
Another way to look at incidents and cases is to assess if they originated in clinical areas or transfusion service laboratories. I encourage you to read these sections of the report, which contain many valuable tidbits, or 'learning points' as the report calls them. Two examples:

 Clinical: Lack of correct final identity check leads to an HTR (p. 21)
A patient with a haematemesis was in need of an urgent blood transfusion. The patient’s wristband was contaminated with blood and could not be read, and as a consequence the electronic bedside checking system was not used. The compatibility form filed in the patient’s notes, which belonged to another patient, was used to provide the identifiers for collecting the blood. The patient, who was group O RhD positive, was transfused with >50 mL of A RhD positive red cells prior to the error being recognised. The patient was admitted to ITU with intravascular haemolysis and renal impairment. 
Laboratory: Cord blood group allocated to wrong computer record, resulting in delay in administration (p. 65)
A cord blood group was correctly tested as RhD positive, but the result was erroneously uploaded to the maternal record on the laboratory computer system by a shift BMS [lab technologist] who did not normally work in transfusion. The error was only spotted when the clinical area enquired as to why there was no cord group available and why the maternal group was now showing as RhD positive.
For fun: Related to incorrect blood components transfused, guess which area (clinical or laboratory) decreased its errors most compared to 2009. (Answer on p. 1 of the report)

DOWN UNDER

Both Australia and New Zealand have active hemovigilance systems that publish detailed public reports.

Australia

Australia produced its first report in 2008. The 2010 report deals with transfusion errors and adverse events that occurred July 2008–June 2009. The Oz hemovigilance system is not as mature as the UK system (no system is, at least in the English-speaking world) but the clear reporting and detailed case studies make for fascinating reading.

New Zealand

The Kiwis produced their first report in 2005 and have a more advanced system than Australia's. For example, the NZ 2009 report includes antibodies involved in delayed hemolytic / serologic reactions and also donor adverse events.

For fun: Guess which two antibodies lead the delayed transfusion reaction list? (Answer on p. 24 of the report)
USA

The USA's Biovigilance Network was initiated only in 2006 and, so far as I know, has yet to publish public reports similar to SHOT, although data for individual diseases such as Chagas are available to AABB members.
Of note, before 2006 the USA was one of the only developed countries in the world without a national hemovigilance program, just as it's one of the few without universal health care.

CANADA

What about my own country? On paper we seem to have a national hemovigilance system called TTISS but upon closer examination TTISS appears to be smoke and mirrors.

For example, the last published TTISS report available on the PHAC website is the
What gives? Either we have a national hemovigilance system or we don't. Is it another case of phantom transfusion committees that meet now and then to document they exist but never really do anything of substance?

Did the federal government decrease PHAC money at some point, so that it could not implement original plans for the hemovigilance system? Did PHAC decide hemovigilance was low priority compared to other public health issues?

Who knows? It's never discussed. Everyone just pretends.

Whatever the reason, Canada's blood system leaders may pretend that the emperor has new clothes, but it seems that TTISS has no clothes, much like Hans Christian Andersen's emperor.

Provincial government blood coordinating offices have TTISS programs and routinely state on their websites
  • Data are disseminated regularly to stakeholders through TTISS Program Reports.
Really? The links go to the PHAC site with the most recent report the one for 2004-5. To call them 'reports' is farcical as they consist of an introduction and table of contents. Who is kidding who?

BOTTOM LINE

Kudos to the UK, Australia, and NZ governments and their respective blood systems for stepping up to the plate with hemovigilance.

But why do Canada and the USA lag behind when it comes to hemovigilance?

 
You can somewhat understand the USA situation. Unlike most countries in the developed world, it has a competitive, fragmented blood system involving multiple players.

As well, hemovigilance systems elsewhere are largely funded by governments, something some Americans on the right (or maybe even most Americans) equate with "socialized medicine" or worse, i.e., supported by delusionary 'commie pinkos' (big grin)

Still, the USA has a well developed blood system and it remains the richest country on earth. That its hemovigilance system is barely off the ground in 2011 is worrisome, if not to say pathetic.

But Canada's TTISS is inexplicable. Frankly, I'm embarrassed that we pretend to have a national hemovigilance system when we don't.

Maybe it's not that surprising. When it comes to hospital-based transfusion services, the feds have always employed smoke and mirrors.

In the early 2000s there was a big kerfuffle about government regulation of the blood system extending beyond blood suppliers to transfusion services. I even wrote about it:
At the time the TM community believed that CSA Standards applicable to transfusion services would become government regulations within approximately 2 years. That did not happen and has not happened yet, 7 years later.

We do not know why, but I suspect it's the government wanting to save money combined with a belief that transfusion service regulation is low priority, given that transfusion services must comply with standards to be accredited by provincial colleges of physicians and surgeons. This viewpoint may or may not be a valid argument.

But why the smoke and mirror pretence about hemovigilance? It's cheating. Makes me wonder what other deceptions our blood system leaders are conning us with.

JUST FOR FUN

Some golden oldies that seem to fit the federal government's modus operandi:
Will those responsible ever say "I'm sorry"? I doubt it.
ADDENDUM

15 Nov. 2011: Just read an editorial in the Dec. issue of the BBTS journal, Transfusion Medicine:
  • Roberts DJ. Public policy, blood safety and haemovigilance. Trans Med 2011; 21(6):357-8. Pub. online 14 Nov. 2011.
The editorial discusses the focus of the Dec. issue, i.e., SaBTO's recommendations on
  • accepting male blood donors who have had sex with men;
  • desirability and practicalities of obtaining formal consent for blood transfusion.
The author concludes:
"Both these recent decisions and the means to implement them depend directly or indirectly on a good quantitative analysis of the risk of blood transfusion. There could be no better illustration of the practical importance of reliable and comprehensive haemovigilance schemes. Establishing and maintaining such systems must be a priority for the development of safe and effective transfusion and transplantation services globally."
As usual, the opinions are mine alone. Comments are most welcome.

Further Reading

UK
SHOT 2010 Educational Symposium (14 Oct. 2011):
"Transfusion - Are we over-reacting?" (Alison Watt, SHOT Operations Manager)
Stainsby D, et al. Serious hazards of transfusion: a decade of hemovigilance in the UK. Transfus Med Rev. 2006 Oct;20(4):273-82.
Canada
Global shift towards increased biovigilance surveillance system. (CMAJ 2010. DOI:10.1503/cmaj.109-3195).
Pilot projects lay foundation for national tissue surveillance and traceability system
GLOBAL

Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice. 

Saturday, October 08, 2011

Where's the beef? (Musings on 2 transfusion-related iPad apps)

Where's the beef? is a follow up to an earlier blog, Tough Titty and other iPad apps (Musing on 'revolutionary' apps for TM; Jan. 2011). The title derives from a TV advertisement initially shown in 1984.

A second blog on iPads was inevitable when I finally caved and got one last month after much pondering of the question, "What does an iPad do and why would you want one?" My answer comes at the end of the blog.

So, 18 month after the launch of the iPad in April 2010, how many transfusion-related apps exist for it and similar devices (Blackberry, iPhone, other tablets)? Unfortunately, not many judging by a quick scan of Apple's iTunes app store.

Number of iPad / iPhone apps:
  • Total: 140,000+
  • Medical: 100s if not 1000+
  • Transfusion-related (in the broadest sense): 10-15
  • Transfusion-related for TM professionals: ~4
Disappointing, but not surprising: Transfusion-related apps for the public (as opposed to transfusion professionals) predominate. Examples (all costs in US $):
MUSINGS
A few thoughts on two free TM apps for transfusion professionals:

#1. Transfuse (Mayo Clinic)

Although not a physician, I tried a few clinical scenarios and did okay compared to others who had played (could be anyone). For one scenario I made no choices and pressed the Next button for everything and scored close to the others who had tried it. Hmmmm.....
Pros: Interactive; nice graphics
Cons:
  • Choosing the number of units to transfuse from a list of blood components and drugs soon becomes repetitive.
  • Ditto for the laboratory / physiologic thresholds to transfuse a particular blood component.
  • Minimal feedback except for comparison to the score of others.
    Bottom line: Having been interested in computer-assisted learning (archaic term) for decades, I find apps like Transfuse to have the same fatal flaws as earlier e-learning efforts:
    • Inflexible, repetitive, and borrrring
    Apps is a sexier term than computer-assisted but cannot compensate for intrinsic flaws in learning design. Educational tools like Transfuse are suited to convey basic learning such as knowledge and application, but more of a challenge for higher level skills such as analysis and evaluation.

    Because it's an iPad app from the famed Mayo Clinic, and one of the first apps for TM, Transfuse has glitz but does not quite deliver, at least by my educational standards.

    As an e-learning tool, it ranks near the more primitive end of the spectrum - a fancy package that may leave users asking, "Where's the beef?"

    I would love to hear from others who have used Transfuse but
    #2. IVIG Guidelines & Calculator (ORBCoN, Transfusion Ontario)
    Initially developed for smartphones, ORBCoN's IVIG app is lean and mean, i.e., has no unnecessary elements. The interface is attractive with easy navigation.

    The app's purpose is to make IVIV guidelines easily accessible at the bedside and in patient care areas since access to a PC on a clinical ward is generally limited and docs use smartphones.

    The ORBCoN app is a handy reference tool for IVIG guidelines and dose calculations that comes without pretensions and delivers on its promise.

    Bottom line: Keeping with a meat analogy, the IVIG app is more like lean turkey than a fatty beef patty in a fast-food burger.
    • Definitely 'Good vibrations' (Beach Boys 1966 classic)
    • #6 on Rolling Stone magazine's "500 greatest songs of all time"
    LEARNING POINTS
    1. Many medical apps exist for the iPad and similar devices, but when it comes to apps for transfusion professionals, the shelves are almost bare.

    2. The paucity of TM apps makes sense. Transfusion medicine is a relatively small field that barely finds time in the medical curriculum, despite the fact that many physicians prescribe transfusions.

    3. To produce worthwhile educational apps is costly. It requires a team of subject matter experts, experienced educators and instructional designers, graphic designers, IT professionals, and representative users. That's just to develop a basic prototype, to say nothing of piloting, evaluating, revising, etc.

    4. Stand-alone educational tools must be much better designed for clarity than face to face learning where a user's questions can be answered immediately.

    5. Given today's health care funding, funds for even basic professional development such as attending conferences has all but disappeared. Transfusion-related tablet and smartphone apps are a stretch even if they support (i) cost saving and (ii) patient safety initiatives such as improved blood product utilization (or 'blood management', the preferred term of the TM consultants).

    6. Accordingly, many transfusion-related apps are meant for the general public where expectations are minimal. Indeed, current apps tend towards the nutball territory of how your ABO blood group can affect personality and diet.
    ADDENDUM

    "What does an iPad do and why would you want one?"

    What does an iPad do?

    Initial reaction to the iPad ranged from "a product without a use" to embarrassing fawning over the latest addition to Apple's family. I fell into the skeptical first camp.

    Now that I have one, the iPad allows me to check my twitter feeds and the latest news much more quickly than turning on desktop or laptop computers. It's oh so EASY.

    Best of all, producing videos is an absolute snap. Touch the camera icon, slide option to 'video', select which camera to use (front or back), frame your subject, touch the start/stop video button (and again to end recording). Four screen touches in <4 seconds and you can create a crystal clear video.

    Recently I used the iPad to videotape a group of apartment-bound seniors giving messages to a friend in hospital and then showed them her videotaped response from her hospital bed. Priceless!

    Why would you want one?

    Frankly, I bought an iPad on intuition without knowing the answer, but now it's clear. The gadget is FUN. Pure and simple fun. That it speeds up tasks I used to do anyway is a value-added goodie.

    THANKS

    Thanks to the Mayo Clinic and ORBCoN -Transfusion Ontario for offering their TM apps free of charge. Such generous sharing is much appreciated.

    And here's to you, Mr. Jobs. Autocratic egomaniac, visionary, genius? Probably.....
    P.S. I love my iPod nano too....

    Other TM Apps
    As always, the views are mine alone. Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice. 

    Monday, September 05, 2011

    With love from me to you - Blood buddies (Musings on staff shortages & succession planning in transfusion medicine)

    This blog was stimulated by the August 2011 issue of AABB News, which explores laboratory workforce shortages soon to be exacerbated as baby boomers* retire in large numbers. (*Boomers are generally anyone born between 1946 and 1965, meaning they will reach 65 between 2011 and 2030 and 60 between 2006 and 2025). I particularly enjoyed "Where have all the blood bankers gone?", the focus of this blog.

    The title derives from an early Beatles song that illustrates the blog’s ‘big idea’.

    Although the blog deals with medical laboratory shortages, I encourage physicians and nurses to read on and assess how the discussion applies to them since pathologist and nursing shortages are well documented. Recent Canadian examples:
    Saskatchewan regulation breach linked to pathologist shortage (CMAJ, 9 Aug. 2011)s
    LABORATORY WORKFORCE SHORTAGES

    In my area of the world, and perhaps in yours, we've struggled with a lab work force shortage for close to 20 years. See an old record I wrote about events in Alberta as they happened:

    ABBB News covers many of the salient issues related to lab staffing shortages but the proffered solutions seem like treading water to me. Perhaps I'm skeptical but, as the French say, plus ça change, plus c'est la même chose.

    In particular, I wish the AABB article had mentioned one of the most pertinent consequences of staff shortages and the impending exodus of the boomers: loss of expertise, especially the 'tacit knowledge' missing from text books or journals.

    If tacit knowledge can be transferred, it is likely transferred by ongoing close interaction between experts with tacit knowledge and those who lack it. More on this later.

    To my mind, what's needed is a big idea to supplement the series of bandaid solutions currently on offer. First, let's examine some aspects of the AABB News article, "Where have all the blood bankers gone?"

    STAFF RETENTION
    On the issue of staff shortages related to technologists leaving the profession, "Where have all the blood bankers gone?" reports that poor salary is acknowledged as the main reason people leave and offers these additional factors:

    1. Stress
    2. Scheduling
    3. Limited potential to advance
    4. Increased workload as staff numbers decrease
    5. Lack of recognition as a profession

    To combat these ‘drivers’, several strategies are proposed:

    1. Evaluate wages & benefits

    Musings
    In an age where mergers are increasingly common to save entire organizations such as blood centers, are the wages of medical technologists likely to be high on management's agenda?

    As noted in the round table discussion in the July 2011 issue of Journal of Blood Services Management, the CEOs who arrange the mergers seem able to keep their positions, perhaps renamed but at similar salaries (in the $300,000 to $500,000 range judging by those publicly available).

    Fact is, one executive salary could likely pay for 5-10 additional technologists, thereby reducing stress and workload and helping to retain staff. Or one CEO salary could increase the annual salaries of 5 senior technologists by perhaps $50,000 each (or 10 technologists by $25,000/yr), thereby motivating them and those who succeed them to stay on the job. Similarly, one executive salary could fully pay for 60 or more staff to attend annual conferences (or 5/yr for 12 yrs). Or subsidize 50% of the cost for at least 5 people to attend for 24 yrs.
    But that ain't what's happening or likely to happen, is it?
    2. Engage & empower staff with learning opportunities

    Musings
    Good strategy, but hard to institute given today’s cost constraints.
    When staff struggle with inadequate time to do the actual work, setting aside time during the work day for good stuff like journal clubs becomes increasingly difficult. Also, when staff feel devalued, motivation to learn outside of work time wanes significantly. Doesn't make it right, and is short-sighted, career-wise, (we are all responsible for our own learning), but there it is.
    As well, in the current climate funding for attending conferences has dried up for all but the most senior staff. Some enlightened organizations partially fund congress attendance for one of more junior staff but this is fairly rare today.
    3.. Develop career ladders for professional growth and advancement

    Musings
    Using USA terminology, creating special programs for MLTs/CLTs who want to move to the "scientist" level is a good idea, but how many universities are currently interested in creating NEW programs with limited enrollment? How many MLTs/CLTs can fund additional education? How many can leave work and family, even for short hands-on sessions to supplement distance education study? Some can but many cannot.
    4. Create efficient work flow processes

    Musings

    'Lean' is supposedly not about reducing staff but about reducing waste and the need for skilled staff to do rote or manual tests so they are free to perform more skilled, interesting tasks.
    Rote is one thing, but as someone who started in the profession when most blood bank testing was manual, that was one of the benefits of working in blood bank, as opposed to clinical chemistry where instruments have ruled for decades.

    If Six Sigma & other lean management programs reduce waste and free up worker time, in the article’s context, lean can help reduce stress and workload and therefore act to retain staff.

    But it's all pretty theoretical. Lean can assist many desirable outcomes, but has anyone seen a paper whereby, post-lean, laboratory staff retention rates are shown to improve significantly?

    Who knows - maybe lean is like IVIg, the cure-all for every disorder known to humankind.....
    5. Integrate automated solutions

    Musings
    Of course, automation has now infiltrated even the manual bastion of the transfusion service.
    Like lean, blood bank instrument manufacturers promote automation as a way to free staff from routine work so they can do more interesting things. However, at the same time automation is promoted as a way to lessen the need for knowledgeable staff so that cross-trained techs, who are not transfusion specialists, can do the work. As well, manufacturers always note the number of staff that can be eliminated by their marvelous machines often named after characters in Greek mythology.
    So which is it?
    • Automation enhances staff retention by freeing them from boring manual tasks and letting them do interesting things? Any studies on this?
    • Or automation helps eliminate the need for knowledgeable, specialized staff?
    • Or both? That is, automation has the potential to be totally liberating, liberating staff from boredom and ultimately from their jobs, all the while making clinical laboratories lean, efficient and error free.
    TRAINING PROGRAMS

    The AABB article also discusses the decline in medical laboratory science training programs. From my experience in Canada, here's what happened:

    1. Governments withdrew funding from health care and laboratories in particular. See 'History of 1990s Laboratory Restructuring in Alberta'
    2. Faced with decreased funding, health care organizations instituted lab restructuring, regionalization, and automation, which led to a dramatic decrease in the need for medical laboratory technologists (and pathologists).
    3. The same trends made it increasingly difficult for laboratories to find the staff and time to train student technologists.
    4. The drop in demand, along with decreased funding for educational institutions and the inability to find adequate internship placements, led to schools closing.
    5. Move forward several years and severe shortages appear, exacerbated by the lack of training programs and non-existent internship spots, as well as the reality that skilled health professionals take years to educate and train.
    Now we're in catch-up mode, as described in the AABB News article. Proposed educational strategies include career ladders (discussed above) and online education to obtain sustainable numbers with decreased cost.

    Unfortunately, new or expanded programs are a hard sell in most locales, especially with the rise of automation, regionalization, and centralized testing, all designed to require fewer highly skilled staff.

    Increased awareness of the profession is also discussed in the AABB piece. Although worthwhile, improved recognition for medical laboratory science as a career is such a long goal I will not discuss it here. Medical laboratory science professional associations and education programs devote much time an effort to this elusive goal.

    BIG IDEA?

    So, while we stumble along with bandaids, the hemorrhage of knowledgeable lab staff continues and with them the tacit knowledge that cannot be found in print.

    If the number of training programs and clinical placements magically increase, will there be any specialized transfusion experts left to pass on knowledge missing from textbooks and journals to the next generation? I doubt it. Not without adding a big idea to the bandaid mix.

    So what's mine? I suggest an old idea that has never been fully adopted by the transfusion medicine community - a succession plan for transfusion professionals as a whole based on mentorship.

    Granted, mentoring still happens informally to varying degrees some of the time but mentoring has decreased in recent years.

    Mentoring is not a solution to staff shortages per se but rather an adjunct to help with succession planning for the profession as a whole.

    And just because it's a big idea doesn't mean it cannot be implemented in baby steps by far-sighted leaders.

    BLOOD BUDDIES

    Call the mentoring program something catchy, a name that reinforces that's it's fun and unpretentious, e.g., Blood Buddies.

    Funding
    Employers, governments, professional associations, manufacturers. Time they 'walked the talk', don't you think?

    How?
    • Get by-in from local power brokers
    • Recruit newly close-to-retiring and retired experts willing to act as mentors*
    • Identify workplaces willing to test the concept
    • Generate topics where tacit knowledge is the norm
    • Assess mentee needs with their full participation
    • Develop prototypes and pilot projects to test the idea ("proof of concept")
    • Draft ways to evaluate pilot projects, including measuring outcomes
    * Why older workers? Because they know what the current generation does not know that’s important to know. Because many are motivated to transfer knowledge as a parting gift ‘with love from me to you’. Oldie goldies have a wealth of experience to share.

    Once mentoring program details are fleshed out, ask newly retired professionals (nurses, medical technologists, physicians), those with the respect of colleagues, to contribute one day a month, or whatever works for them, to pass on to the next generation what they see as the most important lessons from their careers, to include scientific, clinical, managerial, educational, and political aspects.

    Solicit not just the 'big names' that speak year after year at conventions but respected professionals who have toiled out of the spotlight, the unsung heroes, as it were.

    Think Global

    Facilitate communication between retired transfusion professionals across the globe to discuss mentoring ideas and international mentoring sessions using the Internet.

    Why not? The technology is there for free face-to-face sessions between individual and small groups.

    Based on my experience, there are many experts that, depending on your country, you may not have heard of.  I know from MEDLAB-L that we can all learn from each other, regardless of profession and country.

    SCENARIOS

    So, what could 'Blood Buddies' look like?
    • Medical technologist, nurses, and physicians participating in interdisciplinary mentorship programs
    • Local, regional, national, and international programs
    • F2F: Series of informal, interactive workshops at local blood centers and hospitals, focused on practical aspects of key lessons learned over a lifetime. Notice I did not say presentations and topics would be co-generated by mentors and mentees.
    • Online: Individual and small group learning facilitated by Skype and similar free tools.
    • Integral components would be case studies to illustrate tacit knowledge.
    BOTTOM LINE

    Staff shortages of transfusion professionals will worsen in the coming decades. We can continue to apply the same bandaids, even though many do not appear to be working well. Best to evaluate their effectiveness to assess which ones have made a difference.

    Will transfusion leaders - the powerful physician-CEOs and medical directors who run TM - do what it takes to improve staff shortages and the loss of tacit knowledge? I doubt it. Most of the talk in professional newsletters like AABB News about staff shortages is so much smoke and mirrors.

    I'll know everyone is serious when

    1. Post-merger, some extraneous blood center CEOs are let go and a proportion of their salaries is applied to wage raises for medical technologists or new hires or CE funding.

    2. CEOs, VPs, and assorted medical directors at the top of the food chain voluntarily forego some of their salaries to make those of medical technologists more competitive (Okay, stop laughing....But as CEOs earn 5-10 times as much, or more, as technologist, why not, especially if they are serious about solving shortages.)

    3. Employers, especially the pathologists who run transfusion laboratory services, actively and forcefully lobby governments to strengthen existing medical laboratory science programs

    4. More medical directors donate some of their CE funding to allow technologists to attend conventions.

    5. Employers designate more funds for educational initiatives for medical technologists.

    6. More medical technologists volunteer to participate in CE programs on their own time.

    7. Governments fund more MLS educational programs and provide funding for more clinical training placements.

    Unfortunately, the 'movers and shakers' have NOT taken serious action yet and likely never will.

    Call me an idealist but these are the things that concern me when reading the fuzzy thinking and hypocrisy that passes for expert opinion about staffing shortages in AABB publications. This sounds harsh, and it is. But if I wrote only nice things, readers would soon be comatose. Just like a 'goody-two-shoes' police inspector in a mystery, 'nice' has no legs.

    Mentoring by near and recent retirees is a suggestion to supplement current bandaids. Mentoring addresses a real knowledge loss, one that is happening now and will continue to worsen as more people retire.

    Maybe it doesn't matter that tacit knowledge is lost. We probably won't know until it's too late.

    In the meantime, enjoy

    Two ‘beauties’ from my 2010 post on mentoring:

    As always, the ideas are mine alone. Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice.  - see several  Comments below.

    Further Reading on mentoring

    1. Saskatchewan nurses
    2. CLMA
    3. Women in leadership
    4. Beck SJ, Laudicina RJ. Passing the torch: Mentoring the next generation of laboratory professionals. Clin Lab Sci. Winter 2001.
    5. Beck, SJ, Laudicina, RJ. Mentoring tomorrow's leaders in education. Clin Lab Sci Winter 2001.
    6. Kapanka ARH. Journey to the millennium: mentoring in the clinical laboratory. Med Lab Observer, May 1998.
    7. Laudicina RJ. Mentoring for retention and advancement in the multigenerational clinical laboratory. Clin Lab Sci. 2001 Winter;14(1):48-52.

    Wednesday, August 03, 2011

    If you could read my mind (Musings on 'acceptable risk' & who pays the price)

    This month, seeing as it's the 'dog days of summer', I'll muse on multiple related items about transfusion risks and economics that made me ponder days gone by. The blog's title comes from an old Gordon Lightfoot song.

    Everywhere you look these days, transfusion journals and newsletters are filled with discussions on cost-effective and how organizations need to find ways to reduce costs while maintaining or improving blood safety. The clichéd business jargon of the 1990s is pervasive in the TM literature, now used by physicians in suits (as opposed to lab coats) to whom it has come, albeit late.

    I've long been an advocate of risk management as applied to test rationalization in the transfusion service and taught students about the health care piggy bank not being bottomless. Choices must be made and, when we fund some tests and procedures, it automatically means others cannot be funded.

    But something about the current discussion on cost, benefit, and risk as applied to protecting the safety of the blood supply disturbs me.

    1. AIDS AT 30

    June's issue of AABB News features '30 years of fighting AIDS' and focuses on major advances in blood safety resulting from nucleic acid amplification testing (NAT).

    Michael Busch notes that 99.999% of HIV cases are being detected and "The risk curve is approaching zero, but it's never going to be zero exactly."

    AABB president James Aubuchon  is also quoted in 'AIDS at 30':
    "We should congratulate ourselves on what we have accomplished...in our approach to infectious diseases and these accomplishments have allowed us to turn our attention to other problems such as bacteria in platelets and TRALI."
    Presumably "our approach to infectious diseases" includes applying the precautionary principle to blood safety.

    2. RISK-BASED DECISION MAKING

    A consensus conference on risk-based decision making for blood safety was held in Toronto in Oct. 2010 and will be discussed at the 2011 AABB meeting in San Diego. The proceedings were published in July.
    Also see
    In this paper, Wilson, who also participated in the consensus conference on risk-based decision making, offers the following factors as a standardized way to decide which type of precaution, if any, to implement for a given transfusion risk:
    1. Is the extent of the exposure large?
    2. Is the consequence of the exposure serious?
    3. Is the consequence of the exposure irreversible?
    4. Is there minimal cost associated with the removal of the exposure?
    5. Is there a minimal negative health effect associated with removing the exposure?
    Assuming that definitive data are available (not always possible), using these guidelines presumably means do something if a big exposure, serious and irreversible consequences exist (e.g., HIV infection). How cost and negative effects on the donor supply influence decisions and interact with the other factors is less clear.

    The precautionary principle, while improving blood safety, has inevitably produced increased blood costs and led to 'push-back' in the form of questioning whether it has gone too far.

    As noted in an earlier blog, "The principle implies that there is a responsibility to protect the public from harm if research discovers a plausible risk, especially if it is a severe risk. But the proof of harm need not be certain, and cause and effect do not need to be fully established."

    To me, the report on the consensus conference (Risk-Based Decision Making for Blood Safety) indicates the direction of future decision making:
    • Cost is becoming increasingly important and the precautionary principle as applied to transfusion medicine will be shaped to fit what is financially desirable.
    3. COST REDUCTION
    Ongoing evidence exists that blood suppliers are in trouble and need to reduce costs.
    June's AABB News also features a report on the 9th Annual National Blood Foundation Leadership Forum held in April 2011 in Miami. Richard Gundling, VP of Healthcare Financial Management Association, is quoted as saying that
    • organizations that merge or form partnerships "can benefit from higher margins, greater expense control and economies of scale."  
    The July issue of Journal of Blood Services Management (published with Transfusion) includes this article:
    • 'A roundtable discussion: from thoughts on supply and demand to what keeps us up at night' 
    A sample comment:

    Each merger is unique, but in general, mergers are driven by a rationale to lower costs, grow geographically and access hospital markets that are crossing current blood center lines. Often it's about pricing strategies. (Stacy Sime, President and CEO, LifeServe Blood Center)
    4. HISTORICAL PERSPECTIVE

    In this 1998 CMAJ article written on the eve of CBS taking over the blood system in English Canada ("Concerns mount as transfusion medicine loses its lustre"), Noel Buskard and other luminaries in Canada's TM firmament discussed not only the legal risks involved in transfusion medicine but also a trend toward
    • "a 'pharmaceutical model' in which the physician is based in-house, reports to a CEO-style business manager and doesn't have a connection to patients or other institutions."
    What would the physicians quoted in this 1998 article think of the current emphasis (ascendancy?) of the economics of transfusion medicine, especially when juxtaposed with managing risk? If they want to thrive in the current system, I imagine they would keep pretty quiet.

    Today the guys who get air time at AABB and other conferences are those who promote strategies to achieve cost-effectiveness.

    From Jeffrey McCullough's presentation (Consensus Conference on Risk-Based Decision Making):
    • In response to a variety of developments over the past 25 years, the culture and structure of blood organizations have evolved. These organizations have moved from a medical model involving individualized decision making resembling patient care to a systems-based pharmaceutical manufacturing model, with new approaches to quality assurance. Organizational structures have been transformed; and new kinds of leadership are now valued, such as manufacturing and business expertise.
    • Governed by the principle that “safety of the blood supply is paramount”, these organizations have achieved significant improvements in blood safety. However, that paradigm is evolving and potentially conflicts with other principles, such as the notion that “decisions…will be made within a health risk management framework, which places on an equal footing the 3 critical elements of cost, benefit, risk”. (Words in quotation marks are from referenced sources)
    REMEMBERING
    Noel Buskard was the medical director of Vancouver's Canadian Red Cross blood centre during the early years of the AIDS tragedy in which 1000s across Canada and around the globe were infected with HIV and hepatitis from blood transfusions. He quit the Red Cross in 1991 saying it had developed a "fortress mentality" when confronted with the AIDS tragedy.
    Noel was the President of the CSTM (1998-2000). For speaking publicly about safety issues throughout his career, he was awarded the 2001 Whistleblower Award from the B.C. Freedom of Information and Privacy Association.

    For a fascinating trip down memory lane, see
    5. PATIENTS - RISK BEARERS WHO PAY THE PRICE
    Lest we forget:

    Reading the current papers on blood safety and talk of 'acceptable risk', and balancing risk and cost, I cannot help but remember this interview of the daughter of a Manitoba hemophiliac, Ed Kubin.

    Many moons ago when I worked at the Winnipeg Red Cross, Ed and his brother Barry would regularly pick up their supplies of cryoprecipitate from the lab. (Yes, it was just pre-factor VIII concentrate)

    Writing this blog brings to mind this gem by Canada's Gordon Lightfoot
    I'm pretty sure you can read my mind on where I stand on the issue of 'acceptable risk' and who pays the price.

    BOTTOM LINE
    So, what is it about the current discussion on risk management and the safety of the blood supply that disturbs me? It's that those doing the talking seem to be leaning towards cost being the main determining factor, despite the lip service paid to safety.

    We know that credible evidence is needed to show that an intervention to prevent a given risk may add to blood safety, but evidence need not be overwhelming, according to the precautionary principle. Did the AIDS and HCV tragedies not teach us that? Unfortunately, emerging threats to the blood supply do not often come with good data on how large the true exposure is and evidence is often unclear in the early days.

    If cost is given too much weight, as seems likely, we are doomed to commit the errors of the past. And it isn't the docs making the decisions who will pay the ultimate cost.
    ---------------------------------
    As always the views are mine alone. Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice.  This blog was updated 7 Aug. 2011.

    Sunday, June 26, 2011

    "Shine a light" (Musings on what we take for granted & shouldn't)

    This month's blog is a 'twofer.' Both parts arose from reading the May issues of AABB's Transfusion and AABB News. The blog's title derives from a Rolling Stones ditty of the same name.

    MUSING #1 - On detecting mom's antibodies in babes

    The first musing was stimulated by
    The paper shows something true about many, if not most, transfusion medicine policies, namely that they are not evidence-based.

    During a long teaching career, I'd often discuss with medical laboratory science students that what we do is based on many things, but seldom evidence. Shaikh and Sloan's paper illustrates the point perfectly.

    Students are routinely told that newborns do not produce detectable ABO antibodies until about four months of age and, if ABO antibodies (isohemagglutinins) are detected, they are of maternal origin. The corollary is that maternal ABO antibodies can be detected in newborns up to 4 months of age, with implications for transfusion compatibility.

    For example, AABB Standards specify that neonates up to 4 months who are not group O require testing for maternal anti-A / anti-B in order to receive ABO-specific RBCs. Instead of testing, most transfusion services simply issue group O RBCs to infants up to 4 months of age.

    Shaikh and Sloan's study of ~1309 infants showed that 6.4% of infants up to 1 month of age had detectable maternal isohemagglutinins, while no infants 2-4 months of age had them. The practical implication is that infants who are at least 2 months old can safely receive ABO-specific RBCs without testing for maternal anti-A or anti-B, thus freeing technologist time and increasing the supply of group O RBC.

    How refreshing to see some of our long-held assumptions tested and revised based on evidence....

    Rh immune globulin (RhIg)
    Many other TM policies lack appropriate evidence. One of the classics is the guideline to inject RhIg into Rh negative females within 72 hours of delivering an Rh positive (or weak D positive) newborn.  Like many transfusion-related policies, administering RhIg within 72 hours of delivery arose by happenstance and was not based on evidence:

    In the USA initial experiments with Rhig involved ‘volunteers’ from Sing Sing prison. ('volunteers' is used loosely since it is debatable that anyone in prison is truly a volunteer.) Male prisoners were injected with various volumes of D+ red cells and later given different doses of RhIg to see what prevented them from making anti-D. Because researchers were allowed in the prison only from Monday to Friday, there was a subgroup that got a red cell injection on Friday but only received RhIg on Monday. It was from this group that the 72 hour recommendation arose.
    Fortunately, the 72 hour guideline for RhIg seems to work. Would 96 hrs. or another number of hrs. work just as well? We do not know.

    OTHER GUIDELINES

    Similar well established guidelines with minimal evidence include to

    (i) Begin transfusion within 30 minutes of removing RBCs from a temperature-controlled environment (4oC refrigerator)

    (ii) Complete transfusion of RBC within 4 hours of removing them from a temperature-controlled environment
    .... and many similar guidelines.

    My sense is that, if providing a specific number enhances patient safety and helps transfusion professionals rather than handcuffs them with impractical requirements, and, if historical guidelines seem to work, sticking with them makes sense.

    Policies that offer simple specifics are especially prudent for staff who may lack the in-depth knowledge and experience often needed to assess individual cases. With increased hiring of casual and part-time staff (nursing and laboratory), increased use of generalist technologists rather than transfusion specialists, and physicians with little transfusion medicine education in charge of rural laboratories (and those ordering blood anywhere), simplified policies are needed and appropriate.

    MUSING #2 - On spinning and valentines

    Two items caught my eye in the May issue of AABB News:

    (1) The Pall advertisement on p. 15 (Take a greener approach to whole blood processing) promotes its transfer bag for cryo pooling. The ad has a lovely photo of lily pads and a frog against a green backdrop but it struck me as spinning the meaning of green almost to what's known as greenwashing.

    As elusive as greening is to define, it's generally considered to include a constellation of these practices:

    • Reduce consumption, especially reduce use of resources like water and fossil fuels
    • Transition to renewable energy sources
    • Reduce waste, particularly waste that's not biodegradable, eg., plastic bags
    • Minimize pollution
    At its essence green means being friendly to the environment and protecting the pale blue dot for future generations.

    More efficient use of a product like a plastic transfer bag (even allowing that Pall's transfer bag increases efficiency) doesn't necessarily equate with being green, except in the broadest sense, so as to make the term almost meaningless. The problem with misleading advertising, even when claims are inflated relatively benignly, is that such spinning undermines  customer confidence that the company is transparent in other areas.

    (2) The second item was "Mergers and acquisitions on the manufacturing side," a priceless valentine to the manufacturers interviewed for the article (Haemonetics, CaridianBCT, Novartis Diagnostics). The industry reps who were interviewed (top brass like CEOs and VPs) were allowed to spin their mergers without comment and in the process smoothly managed to insert the benefits of their services and products.

    According to the piece, in all cases it seems that mergers are good: (my comments in brackets)

    • Good for the companies (for their bottom lines due to goodies like economies of scale and bulk purchasing but always kumbaya-ville for the two corporate cultures - I doubt it)
    • Good for their employees (at least before staff are let go or vacant positions due to retirement,etc., are not filled forcing remaining staff to do more, often with less)
    • Good for customers (until less competition and more oligopolies influence pricing in favour of manufacturers. As an example, has the oligopoly of Immucor and Ortho Clinical Diagnostics, with their razor-blade business models, led to lower reagent prices? )
    Mergers create oligopolies. Many outcomes are possible but one is that oligopolies drive prices up. Increased competition is supposed to be advantageous to consumers since it drives prices down and is a major rationale for the benefits of free enterprise. Less competition, by extension, is bad, especially for customers.

    The AABB, by allowing industry's rosy win-win claims to go unchallenged and by publishing self-promoting descriptions of products, gave the companies thousands of dollars of free advertising. The organization depends on its industry advertisers, but that's quite the valentine, nonetheless.

    The musical ending to this blog and the source of its title is the Rolling Stones' rock-gospel song:
    It's worth noting that Shine a light was originally titled Get a line and was about the worsening drug addiction of then band member Brian Jones.

    As to Shaikh and Sloan's research on how long mom's antibodies are detectable in babes, how about this Beatles classic?
    And just for fun, to give the moon its due, one of my favorite songs:
    As always, the views are mine alone. Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice.