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Simplifying the blood bank?


Kathy

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This job is slowly driving me bonkers.  Every day I find things that the techs have missed such as forgetting to return units in the computer, not logging them into the computer, not changing the current lot number of reagents in the computer, putting the units on the wrong shelf, not cleaning up, leaving paperwork out....I could go on and on.  I am getting frustrated and am beginning to think that maybe this isn't the best position for me to be in. I'm not sure if I am an ineffective leader or if I am just dealing with a normal problem that is part of this job.  I do talk to the techs, and it doesn't look like it is the same tech making the same mistake all of the time.  My techs are mostly generalists. I know that the blood bank is a very complicated department and if you don't work there all of the time, it is easy to forget the details. 

 

The problem I struggle with is the fact that we have rules that must be followed.  There are A LOT of rules.  Is it reasonable to expect a generalist to remember all of those rules?  Is there a way to simplify things for them (checklist, charts, etc?).

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Out of curiousity how big is your institution and what kind of population do you support?  What is your specimen testing and transfusion load?

 

I would probably go insane if we had generalists. Is there any hope of you getting dedicated blood bankers, at least for the heaviest shifts?

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Kathy,

I can sympathize.  Add to the headaches the fact that we do not utilize a blood bank module, so everything is paper!  My experience having generalists is that they are apt to forget details as they do not work exclusively in one department and remembering all the details is practically impossible.  Things that are common across other departments (like the lot number changes) I would be more irritated by since this is an integral part of the job.

 

Examine your processes to see if there is any way to streamline things for the generalists (it has helped me at times).  Sometimes you can spend more time "catching" the inconsistent errors than taking the issue as a whole and handling it (day shift reviews all charges here for this reason).  Encourage people to leave detailed notes attached to paperwork they leave out, or put the paperwork away.

 

Yes, it is like herding cats at times!  Hang in there and find a rhythm that allows you to be productive and not spin your wheels feeling as if you are chasing details all day.

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Some things, like cleaning up and properly filing paperwork, I think, are just a professional courtesy for the techs following you. Every lab professional, regardless of what department they work in, should know that.

I think that checklists and charts do help. They not only serve as a reminder, but also enforce accountability. When I worked at ARC, I had to sign my initials so many times everyday, I felt like I had to initial a form to go to the bathroom.

I found that when someone new comes to the blood bank it helps to not only explain the rules, but explain WHY that rule is in place and some possible negative consequences that could occur if these rules are not followed.

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Kathy,

I was in the same place last year when I took over here...I have streamlined a lot of the procedures (doing away with alot of obsolete tasks).  There are several notes posted as reminders for things that were getting missed often.  I have a couple tha say "ABSOLUTELY NEVER DO..." and the techs know that if they do they will be in deep do do with me.  I came in and personally talked to every one of the techs when I took over and let them know what I expect and that if there is a pattern of not following the rules they will no longer float through BB.  My Lab Manager and the CFO have fully backed me and told those techs that if they were banned from BB they would be terminated.   It is amazing I do not get near as many errors and when I do just a quick "meeting" and it is resolved.

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Join the crowd . . . there is nothing like working with a dedicated team of blood bankers. I also have all generalists and the same "aggravations" you are encountering. Like Deny, we are totally paper driven (after Hemocare was sunsetted). There is not much you can do about forgetting to do stuff in a BBIS. I feel that most of the non-conformances I find should be resolved by a BBIS and hope to have one again in the near future. All you can do is keep reminding and driving home the importance of consistently following policy/procedure. I have found that FDA inspections provide a powerful reminder of this need . . . even to the effect of saying "NO" to docs who want us to go outside of policy.

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It might also help sometimes to "catch them being good".  Notice when they do good things and mention them. Many techs bust their bums to take care of a bleeding patient which we all have come to see as "just doing their job" but if we at least recognize the importance of their work to the good of the patient I think it helps them feel valued and sometimes more motivated.  Of course, streamlining and creating systems where things pop up at the right time can help.  An example of the latter is that we have to QC the Rad-Sure indicators when they come in but then might not open that box for months.  When we do, we need the QC info to be on the log sheet for irradiated units.  So, when we get in a new lot and QC it, we record the QC information on a blank log form and wrap it around the box of indicators.  When they open the box of the new lot, they have to take the form off to get it open so they remember to put the new form in the log notebook and start using it with the new lot number on it.  It seems silly, but it has worked.

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Thanks for all of the suggestions and I love the reference to herding cats. We have 289 beds, transfuse about 480 units of products per month and process about 300 type and screens per month. The hematology supervisor reports having similar problems and one of my best techs tells me that the prevailing attitude seems to be that someone else will take care of it.  I would LOVE to have dedicated BB techs, but I don't know if that is reasonable.  I think it's time to really crack down.   There is really no excuse for some of the stuff like putting the unit on the wrong shelf or putting the older unit toward the back, where it doesn't get used first.  I like the idea of putting the paper on the stuff that needs QC and leaving notes about important things.

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I am all for making Blood Banking simpler. I was actually there when I worked in a paperless Blood Bank. When I moved to my current health system, there was the paper again. We have a computer system but they want the transmittals to have ABO Rh and screen results for downtime. I recently moved to another hospital in our system and I am astounded at how much they want documented on the paper along with rules for every different situation. If a seasoned Blood Banker like myself struggles to remember all the rules, I can just imagine how a generalist would do.

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Hi Kathy,

We too have rotation of non-dedicated BBers through the dept. We do have BloodTrack as a good tool for tracking not only the blood, but the actions of our scientists. I have just read a good article in TRAQ on "nudging". I have followed up with other reading (plenty of references in Govt, financial world etc) on the subject.

I have for a while been keeping a matrix, with names on the vertical list, error types on the horizontal. I complete this for each month (for those found or reported to me). I then anonymise for all other staff members (keeping just the name of the one you give the matrix to). This is done for all staff and they can easily see if they are outside the norm. This has lead to a kind of competition among staff (so I have been told) and this has "nudged" them into better compliance with requirments. I try to keep them to really important requirments, but will consider expanding to other niggles (like not doing daily QC' on a new batch when old batch is likely to run out on next shift).

 

Bit of work, but I have found it worthwhile.

 

I do the same with minor specimen / form errors (labelling, lack of information etc) from around the hospital  - and graph shows a definite reduction in non-compliant requests / specimens after its introduction. Majors go through the CAPA system.

 

Cheers

Wayne 

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Hi Kathy,

We too have rotation of non-dedicated BBers through the dept. We do have BloodTrack as a good tool for tracking not only the blood, but the actions of our scientists. I have just read a good article in TRAQ on "nudging". I have followed up with other reading (plenty of references in Govt, financial world etc) on the subject.

I have for a while been keeping a matrix, with names on the vertical list, error types on the horizontal. I complete this for each month (for those found or reported to me). I then anonymise for all other staff members (keeping just the name of the one you give the matrix to). This is done for all staff and they can easily see if they are outside the norm. This has lead to a kind of competition among staff (so I have been told) and this has "nudged" them into better compliance with requirments. I try to keep them to really important requirments, but will consider expanding to other niggles (like not doing daily QC' on a new batch when old batch is likely to run out on next shift).

 

Bit of work, but I have found it worthwhile.

 

I do the same with minor specimen / form errors (labelling, lack of information etc) from around the hospital  - and graph shows a definite reduction in non-compliant requests / specimens after its introduction. Majors go through the CAPA system.

 

Cheers

Wayne 

Hi Wayne ,

 

I think your monitoring system is a great. It is non punitive and constructive to get the employees pay attention.

Can you share a copy of your form.

 

Thanks,

 

Eva

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Kathy, our hospital BB seems to be simular to yours in volume. Most of our BBers are generalists. In fact, other than Micro, we have only about 3 or 4 people in the whole lab that only work in one area. I know of few small to medium-sized hospital labs that are not almost wholly staffed by generalists - including BB. The larger medical complexes and reference labs can afford to have techs doing the same things over and over day after day, but to provide appropriate care in this day and age we must have a steady supply of good generalists for staffing.

We have few problems like you describe in BB. When I see comments here like "the prevailing attitude seems to be that someone else will take care of it" I wonder if, in general, the techs are sort of, setting a bad example for each other?

Like with teenager discipline, I would think for starters, you have to pick your battles. Whether or not units are always put in order by outdate on the shelf is probably not going to result in a inspection citation or a patient injury. Not properly documenting test results is an issue that must be dealt with .

Consider in the future, that if one tech makes an error, that there are probably a few others doing the same thing that you just have not caught yet. So be proactive when these "individual" discrepancies pop up. Don't just have a quick man-to-man with the one you know about. Use it as a learning opportunity for all your techs.

Also, techs need to get it right "in the first place". Whenever we start a new policy or procedure, besides having the appropriate training, we have the techs sign off on it by initialling a memo. Then, once a month, all BB techs must review the memos for the provious month and sign off again.

Document your deficiencies. You will have to discipline repeat offenders, per your lab policys.

Good luck, Scott

Edited by SMILLER
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I am actually scheduled to work exclusively in BB.  It is very important to have one or more regular employees dedicated in the department because of the complexity of the work.  It also gives the generalist who may rotate through BB another contact in case they need advice or help.  The one thing that I can point to that other generalists working in the Lab do not have is the sense of "ownership" that I have working in BB.

 

I have been given my own list of duties that I am responsible for to help maintain the department.  There is no "wait for the next guy to do it" because it is MY responsibility.  I have other supervisors tell me that my supervisor is lucky to have me because he doesn't have the lack of commitment from the generalists that they do.

 

Why not give generalists responsibilities?  If every Tech had "ownership" of certain tasks, perhaps there would be an opportunity for more committment from the employees.  How about assigning one generalist to maintain one instrument?

 

Just a thought... 

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I find that the resounding reason things do not get done in our facility in all depts., is that everyone is too busy.  The reason is supported by managment, and yet it is not addressed.  I find that I have become the BB nag.  I would stop if I felt it was falling on deaf ears, but our staff does care and they don't want to be sloppy. If I can get away with it, I will leave the task for them to complete. Eventually they get it and we move on to another issue.

 

It is interesting that we are increasing our safety by adding more testing, but we are decreasing our safety by decreasing our staffing.   

 

Our management has decided if they move their desk closer to the lab then staff will work harder. Hmmmmm, I guess we will see, but I am skeptical.

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We are half your size and have all generalists.  Lately I've made things like this a question of respect for the job and our hospital coworkers.  We expect excellence from phlebotomy and nursing in regards to specimen collection and transfusion of products.  No questions, hesitation or excuses.  We expect excellence from our blood suppliers in regards to safety and quality of products.  If something's not perfect, we're not using it.  How can we do that with a straight face if we do not expect excellence from ourselves?  If someone calls me a BB nag I agree with them and just tell them that we need our actions to match the excellence we expect from others.

 

They're starting to get it and starting to trust that anyone who rotates through there gets it, too.  Blood Bankers have always been called "different" and that's a good and necessary thing.  Any generalist who is in our blood bank that day is, indeed, a "Blood Banker."

 

It's annoying to nag most days but if you keep at it, it will get better!  Or the ones who get tired of you will leave.  Oh well.

 

Good luck to you!

 

Becky

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Eoin,  I too am going to be a theif...It is an excellent idea!!  I can see it being a great motivational tool. I think I am going to expand it and use it with the transfusion "errors" that I report to the nursing units.  I can see some of the nursing managers here being very competative to make sure their numbers are better that the others.

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".....I think I am going to expand it and use it with the transfusion "errors" that I report to the nursing units.  I can see some of the nursing managers here being very competative to make sure their numbers are better that the others."

 

Another excellent idea!

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When I came here , there were very lazy, sloppy habits from the techs...all generalists.  I got the endorsement from the lab director and pathologist to do what it took to get the dept running efficiently and with out CAP problems.  There were 30 phase II the inspection before I came here.  Everyone had to be retrained with a no tolerance policy.  If they don't work in BB and their shift or job description requires it, they'd be terminated.  I have very few problems today but it takes time.  Also, I had to cross train in several areas, so empathy with generalist about the hundreds and hundreds of things to remember for each department goes a long way.

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Like with teenager discipline, I would think for starters, you have to pick your battles. Whether or not units are always put in order by outdate on the shelf is probably not going to result in a inspection citation or a patient injury. Not properly documenting test results is an issue that must be dealt with .

Document your deficiencies. You will have to discipline repeat offenders, per your lab policys.

 

I think this is a very good way of describing it: "pick your battles." I try not to sweat the small stuff and focus on the bigger issues. Once the bigger issues are squared away I've freed up more time to discuss the smaller issues.

 

Documenting deficiencies is also extremely important albeit time consuming.

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An interesting topic thank you.

 

I had the daunting task of managing a hospital blood bank some 20+ years back. The entire team started with ZERO experience .

Step 1 - Training - Make sure the staff know what to do and why. Whenever possible demonstrate the consequence of an action. Remind that there is a person within the test tube.

 

Step 2 - I compiled a flow-chart headed "Do it correctly the first time". The process started with the Doctor's Requisition and sample from the patient, leading into grouping patient, selecting  donor blood, performing the compatibility test, issue of compatible blood and finally the paper work. This chart was located where it was easily accessible to both "lab-rats" (as they called themselves) and hospital staff. This chart  proved a solution to preventing and avoiding short-cuts particularly during the inevitable "emergency" cases. Tasks such as reagent QC controls and inventory management were allocated to low work load shifts.

 

Step 3 - Support - the staff knew that there was always someone available at any time and that they would receive the appropriate level of support.

 

An interesting challenge still exists for managers  who today have the opportunity to use supporting technology such as remote internet access and mobile phones.

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Hi

Got a solution for not putting donor units into inventory if you have Meditech. After RBC units are entered into inventory the techs make an inventory list, scan the units just entered before they go in the fridge.  If in inventory a list is generated by scanning each unit. If a tech missed entering one it is immediately apparent as the unit will not go on the list. It's saved me a lot of headahes over the years. Let me know about Meditech and I'll send you our process. Also try check lists of daily or weekly duties so everybody knows a job got done because it is checkmarked.

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Great suggestions from everyone.

 

Mabel - I like your idea of putting the new lot QC with the actual product that needs QC.  I am going to see if I can make a combination order/receive/QC checklist to go with each supply/reagent.

 

Eoin - Funny how people think alike.  Before I read your response, I had been compiling offenses and good things about each of my techs.  Recently, I took the offenses and placed them on the horizontal axis.  I put the techs on the vertical axis, and then I put dates of each offense.  So basically I did the first part of what you mentioned.  I like your idea about giving each tech a report so they could see how they compare.

 

Smiller - I agree with you that techs set bad examples for each other. I remember before I was promoted I was told that it was fine to leave received units and elutions for the next shift.  Maybe misinformation is being spread.  I will need to put a stop to that.

 

whbb - great idea about giving people tasks so that they can feel a sense of ownership. I will see what I can come up with.

 

LabCare - do you still have the "Do it correctly the first time" chart?  If so, would you mind sharing?

 

Jamie - We aren't having trouble with individual products being entered.  We have problems with whole shipments being put in the bottom shelf of the refrigerator and not being entered.  I think your idea about printing out a received list is a good one provided we were having trouble with a random units being missed.

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For some reason I am having trouble posting this - we'll see how this goes.

Wonderful advice above. You are not alone. I have 1 core blood banker, 19 generalists and 2 per diems. If I may add:

Make sure your SOPs are well organized, detailed and clearly outline every step of every test, process and procedure. They should be a working reference, there to be used and not just to look pretty every other year for the inspectors. Consider it a great success to have to replace the binders from time to time because they get beat up by use. You may find it handy to condense some things down to a Cliff Note (do they still have those?) version to be at the workstation or on a clipboard. For instance, we have condensed instructions for our daily morning LIS reports on the clipboard with the checkoff list. (I am a big beliver in checkoff lists.)

Eoin's variance list is a great idea. I maintain an Access QA database for the whole lab. Consider some sort of database - it will make it much easier to crunch numbers, identify your problem areas and progress or lack thereof improving them.

I include pet peeves in a yearly written competency eval if multiple techs seem to be making the same error. I also include items that do not come up frequently. (For instance, we have a policy for furnishing blood emergently if the lab has to be evacuated, not exactly a daily occurance.) It's a good place for reminders.

Have periodic (and brief) inservices where you discuss a few of the heavy hitter issues.

If techs are inattentive and sloppy by choice, this is a culture that needs immediate change. But I think most would like to do the right thing, and just need the encouragement of management and the example of their peers, and as much help as you can provide via your systems. Don't despair, don't give up, and be thankful you're not a nurse manager with 10 times as many cats to herd.

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Working in blood bank is like walking on a tight rope, a little imbalance and off you go taking everything with a toss. Getting motivated techs to work with is like a myth. With generalists -small & silly annoyances have to be put up with daily and rectified. That said, it is still the only place I love working in. :bonk:

 

Great suggestions from everyone and thanks Kathy for summing them up nicely.

 

As an aside -- going through all these posts I was reminded of a story about Anybody, Nobody, Somebody, and Everybody

 

You’ve heard that story ?

 

"An important job had to be done and Everybody was sure that Somebody would do it. Anybody could have done it, but Nobody did it. Somebody got angry about that because it was Everybody’s job. Everybody thought that Anybody could do it, but Nobody realized that Everybody wouldn’t do it. It ended up that Everybody blamed Somebody when Nobody did what Anybody could have done." ;):lol::haha: 

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