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The technologist's role in quality management of off-site testing.

The technologist's role in quality management of off-site testing

Medical technologists seeking to shift their professional orientation and provide meaningful help to off-site testing facilities must understand some of the educational, technical, and management differences between those facilities and conventional laboratories.

Most technologists work in large laboratories, performing specialized analyses within a hierarchical management structure. The focus tends to be on managing technology rather than managing people. Work life is greatly determined by policies, procedures, and protocols that dictate what staff members should do, when they should take their breaks, and how they should dress and behave on the job.

To some extent, the training of technologists is geared toward forming the obsessive-compulsive behaviorial characteristics that insure they will follow policies, procedures, and protocols, which is accepted as essential for producing reliable results and maintaining a safe workplace. Technologists generally have had little responsibility for developing these policies and protocols but are expected to carry them out.

In contrast, staff members who perform off-site testing have little understanding of the stereotyped behavior required to produce consistently reliable results. They are usually trained by a technical or sales representative from a manufacturer or distributor, with emphasis on performing a specific procedure. After a system is installed, newcomers may be trained by a departing employee or another staff member.

By and large, off-site tests are performed intermittently and with frequent interruptions because the staff has other duties. The top priority is direct service to the patient or physician, not the production of reliable test results.

There's a tendency to use "black box' technology at off-site testing facilities. The operator merely applies the specimen and sometimes pushes a button. Results are usually read or interpreted directly from the analytic system. For example, one pregnancy test shows a plus or a minus sign to indicate that chorionic gonadotropin has or has not been detected. Some pregnancy test systems also verify that the reagents are active and have been added in the correct sequence.

Most kits currently used in physicians' offices do not include these safeguards, however. As a result, the staff generally does not have a simple way to check an analytic system's day-to-day reliability. When a system malfunctions, the off-site testing staff requires assistance to recognize and deal with the problem because of its limited technical competence.

Physicians and nurses who supervise off-site testing are not likely to have much, if any, training in laboratory medicine. Like their staffs, they do not understand that stereotyped behavior plays an important part in production of consistently reliable results. Their responsibility for tests processed by others is only incidental to the major focus of their responsibilities--direct patient care activities.

Most off-site testing supervisors believe their facilities produce high-quality results. They don't know about analytic variability or the extent of the resources that conventional labs devote to insuring precise results. The prevailing belief seems to be that laboratory quality is built into the box. They don't understand the staff's role in maintaining laboratory quality and thus see no reason to invest in quality management.

Off-site testing supervisors also have limited experience questioning sales representatives about potential problems in installation, operation, and maintenance or repair of analytic systems under consideration. Lacking confidence in their understanding of these areas, they frequently need assistance in providing their staff with appropriate training.

Guidelines for approaching quality management. If you are a medical technologist seeking to upgrade an off-site testing facility, you must first learn the priorities of the staff and managers as well as the work flow (see Figure I). At the outset, probably no one will be as interested as you are in test-related issues or in altering procedures.

It helps to identify staff members' primary responsibilities, how they believe testing relates to these responsibilities, and whether they have any problems performing tests. We expect that they will perceive testing to be a small part of their work. Some will feel that performing tests is inappropriate; others will see it as an extension of their patient care duties. The majority, though, will agree that accurate test data are important and will frequently assert that their results are reliable.

One of the best ways to help off-site personnel realize that a problem exists is to have them repeatedly analyze pseudo-specimens or patient specimens with known constituent levels. When the testing staff and supervisors compare their results with the assayed value, the discrepancies usually engage their attention and make them more receiptive to your offer of assistance.

This, however, is only the beginning. With your help, these staff members must also identify problems that they think are important. It would be easy for you as an experienced technologist to find the trouble spots and fix them if the lab and its staff were under your supervision. The challenge is to help others discover problems that you know exist. Once they make that discovery, off-site personnel are usually ready to search for solutions because they want to provide quality care to their patients.

Finding solutions appropriate to the setting and acceptable to the staff is often just a matter of asking for suggestions. Effective consultation depends on trust and cooperation. The staff is more likely to heed advice when it views the consultant as a partner. On the other hand, if the consultant's involvement is regarded as judgmental and punitive, representing "authority,' effective change will probably be difficult to achieve.

A consultant must be sensitive to the demands of the staff's other duties. Timing is crucial. When the daily routine changes unexpectedly, it is better to reschedule a visit rather than try to work with someone who is distracted.

Sometimes it's useful to spend an extended period of time with staff members to see how they deal with the various demands on their time and where testing fits in. By taking an interest in the broader aspects of their work, the consultant encourages staff members to take an interest in the broader aspects of his or her work. In this manner, both sides may feel united in wanting to help patients better deal with their health problems.

This is not an efficient way to collect information, but in the long run it is a very effective way to understand quality management issues in an off-site testing facility. It also helps if everyone is aware that the laboratory staff's major responsibility is to monitor the testing activity to insure that only reliable results are used in making patient care decisions.

Working with a manager of off-site testing may mean dealing with a nursing supervisor, a physician director, or an administrator who has minimal clinical laboratory training. Specifics of working with these individuals vary with their background and training, the site, and the associated institution. As a consultant, you must respect the myriad demands on the manager's time and recognize that the potential short-comings of off-site test quality are not likely to be a pressing concern --at least not initially.

Explain at the start that you plan to ask the staff to process some pseudo-specimens to document result reliability. These studies can, in fact, be useful for risk management--minimizing the chance of producing erroneous results and minimizing the liability risk if a mistake does occur. Reassure the manager and staff that they will review the survey results.

If they are dissatisfied with the results, emphasize your willingness to help identify problem areas, and note that any suggested changes would necessarily be subject to evaluation, modification, and approval by the off-site group prior to implementation.

Supervision and management of technical issues. When talking about technology, you must remember that the staff and managers of off-site testing facilities have little basis for understanding the underlying analytic principles, analytic variability, or the overlay of quality management tools used to maintain lab quality.

Off-site personnel tend to focus on the simplicity of operation and the projected economic impact of a new technology--that is, until they become convinced that there is, potentially, a significant problem. In dealing with technical issues, you will have to explain and perhaps justify concepts or ideas that seem transparently obvious.

Preventive maintenance, for example, is an accepted principle in laboratory quality management --it minimizes the risk of system failure and the production of erroneous results. Yet in one hospital, the most common problem affecting the reliability of bedside glucose results was a dirty reflectance meter window. Although the dirt was visible each time the meter was used, the nursing staff did not really see it or think it mattered. No one realized that result reliability was being compromised.

It is important to understand and communicate the underlying rationale for the various components of a laboratory quality management program. It does without saying that two key issues are making sure that test results are applied to the care of the appropriate patient and that the analytic system functioned properly during the testing.

This may seem like a trivial statement since extensive specimen identification policies and other quality assurance procedures are widespread in the laboratory field. Records are commonly maintained to document the trail from the patient at the time the specimen is collected to the lab, then back to the patient when the result is reported.

A lab technologist can easily answer an attorney who asks, "How do you know the test result you produced came from a specimen taken from my client?' A related question--"How do you know that the analytic system was functioning properly when my client's result was produced?'--can also be answered easily because the lab has records of day-to-day quality control and corrective action taken when results are out of control.

Citing such questions to off-site personnel will help them understand the rationale for these components of a quality management program.

Off-site testing managers can readily comprehend that the correct interpretation of a test result depends on its comparability to results from their laboratory or other labs. They may not realize that some of the new single-use reagent systems employed in their facility can yield results that are not comparable to those produced by standard laboratory methods. In that case, retesting patient specimens in a reference laboratory will lay the groundwork for a discussion of laboratory variability, bias, and error and the utility of quality management tools.

It is important to remember that laboratory quality is not built into any analytic system. Although reagent systems, electronics, optics, and mechanical systems have improved markedly, result reliability finally depends on the dedication of those using the technology, be it in a large traditional lab or a small off-site facility.

Contemporary quality management programs are the means of maintaining human control to insure the reliability of the laboratory's product: the test result. Information and feedback to operators, supervisors, and managers about their system's reliability can be a significant stimulus to development of new quality management initiatives.

Introducing change is not easy in any setting or under any circumstances. It is even harder for consultants, who lack managerial or supervisory authority. Becoming a catalyst for change requires patience--acceptance that change will not occur rapidly. Developing a plan with realistic goals and a reasonable timetable can help move things along.

We are convinced that staff members and managers would like to produce consistently reliable results that can be used with confidence in patient care. They generally cooperate once they understand the basis for quality management and how it will improve their performance.

Skills required to assist with quality management. As we have noted, in an off-site consulting assignment you can expect to work with staff members supervised by someone else. You will therefore need to be sensitive to the interpersonal dynamics that exist among you, the staff, and their supervisor. This requires good listening skills, a talent for engaging off-site personnel in the process of identifying and solving problems, and the ability to present approaches to problems rather than your answers. The staff's involvement in the problem identification and solution process and its "ownership' of corrective interventions are critical to the success of your consultative efforts.

Pay particular attention to your language. Off-site personnel generally have a limited background in laboratory medicine and may not be able to follow the vocabulary you use when discussing technical matters. For example, the "normal range' to a technologist is the middle 95 per cent of results found in an otherwise healthy population. Most other people, including physicians and nurses, think "normal' is a synonym for "healthy.'

You can close such communication gaps by rehearing a discussion of a particular issue with friends or family members who have no technical training. If they understand what you are saying, so will the off-site testing staff.

The idea is to use descriptive rather than technical phraseology in defining potential problems and answering questions. Training of off-site personnel should be practical but also include enough background information and concepts for the staff and supervisors to become gradually more knowledgeable about their testing responsibilities.

The basic level of testing performed in off-site facilities will require you to modify other aspects of your professional development. It is likely that you may be employed in a departmentalized laboratory where you work with a limited spectrum of specialized tests. To serve as a consultant, you will have to review the ABCs of laboratory medicine in order to teach them to the off-site testing staff. This will be especially important in dealing with quality management. You will need to understand the fundamentals of and basis for laboratory quality assurance and quality control to be able to develop useful, economic strategies for the off-site testing facility.

Your role as a technologist consultant --defining and providing the support services required by off-site testing facilities--is critical to the success of the quality management program. To market your services, you should reinforce the positive aspects of your contributions, which will encourage the off-site group to retain you beyond the initial trial perid. In addition, success in one site often opens up consulting opportunities at other off-site facilities.

Changing your role from servicing technology to providing consultative support for testing performed outside a conventional laboratory can bring significant economic, personal, and professional rewards. The success of this transition depends to a large extent on development or refinement of interpersonal, technical, training, and marketing skills. This kind of growth, and the effort to influence the way others perceive and deal with problems, can be exciting.

In next month's issue, we will review the tools for quality management at off-site testing facilities, including optimal space design, written procedures and policies, proficiency testing programs and split-sample testing, and records documenting validation of test methods, calibration, quality control, instrument maintenance, and successful participation in a proficiency testing program.

Photo: Figure 1 An off-site testing facility primer for the technologist consultant
COPYRIGHT 1987 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1987 Gale, Cengage Learning. All rights reserved.

Article Details
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Title Annotation:part 2
Author:Belsey, Richard; Baer, Daniel M.
Publication:Medical Laboratory Observer
Date:Oct 1, 1987
Previous Article:Managers need strokes too.
Next Article:A guide to marketing your lab's services: launching the sales effort.

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