Addressing management issues

Feb. 1, 2009

Edited by C. Anne Pontius, MBA, CMPE,

Not following protocol

Q Our lab just
finished an unannounced inspection. The hematology department was not
cited with any significant deficiencies. Our manager was pleased. After
the celebration, I started working on the current quality monitor, which
was looking to see if the instrument flags requiring manual
differentials were always being followed. The first month the variance
rate was 3.7%. The second month was not bad overall, but one
second-shift tech was not reading any manual diffs. In a three-day
period, she released 25 CBCs without manual diffs. I reviewed her work
from August 2008 and found 17 CBCs that needed manual diffs on one day.
The tech in question has been on medical leave and just returned to
work. I do not think we can retrain this employee.

A Alton B. Sturtevant
suggests, “My concern would begin with what the written policy relating to
performing manual differentials (diffs) states and how the staff was
educated on the policy. Is the training relating to the policy documented so
as to prove that all techs read and understood the policy and the related
criteria? Does the written policy require manual diffs be performed based on
the same criteria as the instrument flags? How long has the policy been in
place? Have other audits been performed to document compliance with the
policy? Was there a diff result released that ended in a clinically relevant
error? Has this tech violated other written policies? These questions are
posed in an effort to stimulate your thought process in both the
implementation of policy and judging this tech's performance, not to grade
the severity of the policy violation.

“My approach to handling any policy violation is to
confirm it and determine if the violation was willful (i.e. the person
understood and there was documented evidence that the policy was properly
communicated to all concerned). Some policy violations are deemed to be so
egregious that immediate termination is justified. I am not sure that this
is the case with this violation.

“As far as retraining, I would attempt to retrain any
tech that has demonstrated the willingness and ability to learn the
procedure. Training a tech on staff is preferable to hiring and training a
new one. Begin by talking with the tech, explaining your findings and asking
for a response from her based on the facts presented. Review the policy and
documentation of her training. Explain that there is to be no exception
allowed in following the policy. Ask her to read the policy and set a time
(i.e. the next day) for her to report to the appropriate person for training
and evaluation.

“Train her in the procedure, and document all of the
above in a proper counseling form that stipulates that further violation of
the policy will result in disciplinary action — up to and including
termination. Have her sign the counseling form, and inform her that
continued monitoring of compliance with this policy will be performed for
all techs to ensure that proper procedure is followed. If she is unwilling
to participate in training or refuses to follow the policy, then I would
agree that termination is justified.”

In Marti Bailey's opinion, “It looks like you have
identified a real problem, but you need to support your case with additional
information. You seem to have overall departmental data and then data on
this one technologist who is at issue. You need to develop information for
each tech, the same as you did for this one. Then, you will have
documentation that supports your impression that this particular tech's
error rate is way off the average.

“After you have documentation that a problem exists
with this tech and not with other staff, you need to review the
information with her. Have available the individual cases where she failed
to follow the protocol to perform a manual differential. She needs to know
what the average rate is for the department and what her own rate is, and
then be able to look at the detail of her errors to help determine why the
failures occurred. She needs an opportunity to understand what the problem
is and how she is deviating from the norm, as well as being able to review
specific cases.

“You seem very quick to jump to the conclusion that
she could not be retrained, so I do not know if you are withholding
additional information about her performance or work history. You cannot
draw any conclusions until you talk to her and hear her take on the issue.
She might not understand the policy; she may have forgotten one critical
aspect of it; there might be a systems failure. Try not to make judgments
before you have gathered all the information and had a chance to discuss it
with the person because, often, things turn out not to be the way they seem.

“After you learn from her how and why she had all
these protocol misses, you should have a much better feel for whether she is
retrainable or not. But whether you think she is or not, she needs to have
you tell her what she did wrong and what she needs to do to bring her
performance up to standard. All this should be documented, along with the
stated time frame for correction and how her performance will be monitored.

“Think of this as a positive rather than a negative.
You have implemented a system that allowed you to successfully identify a
quality issue. What remains is for you to successfully handle the
performance issue uncovered.”

Larry Crolla says, “I think you need to bring the
situation to the attention of her manager which I assume happens with your
QA review via the QA committee. The hospital policy for disciplining an
employee needs to be followed while, at the same time, making sure this
employee does not repeat the problem while she is working in hematology
(i.e., more vigilant supervision of her work).

“As for the need to retrain, only her manager can
determine that. It may be required as part of the hospital's disciplinary
policy, no matter what anyone thinks. This employee must meet the
requirement of testing for CLIA high complexity since reading a manual diff
requires such credentials. Depending on her qualifications, this employee
may be able to perform only high-complexity testing under the on-site,
direct supervision of a general supervisor qualified under SS493.1461 of CLIA
regulations. All this has to be reviewed before a solid remedy can be

Bottom line: The issue with the employee
has nothing to do with the inspection process. Inspectors are only able
to review a sampling of all your lab's operations and policies;
therefore, it is incumbent upon the lab to implement policies for
quality-assessment activities, training, and competency assessments that
can identify incompetent staff. To best serve patients, this individual
should be counseled appropriately to determine if additional training
would remedy the issue. If, after appropriate training, the staff member
does not perform accurate testing, then you have grounds for dismissal.

Anne Pontius is a senior medical practice
consultant with State Volunteer Mutual Insurance Company in Brentwood,
TN, and president-elect of CLMA 2007-2009. Send questions to Ms. Pontius

[email protected]

MLO's “Management Q &
provides practical, up-to-date solutions to readers' management
issues from a panel of laboratory management experts. Readers may send
questions to the
Anne Pontius at
[email protected]
. Unless otherwise noted as “confidential” by
readers, all queries will be considered for publication without further
notice to them. Names, institution, city, and state will be removed
before publication. The following panel of laboratory directors,
managers, and supervisory technologists have provided their input in the
answers given in this column: Marti K. Bailey, MT(ASCP), work unit
leader, Pathology, Penn State Milton S. Hershey Medical Center, Hershey,
PA; Lawrence J. Crolla, PhD, consulting clinical chemist, Departments of
Pathology and Respiratory Care, Alexian Brothers Hospital, Elk Grove
Village, IL, West Suburban Medical Center, Oak Park, IL, and Northwest
Community Hospital, Arlington Heights, IL; and Alton Sturtevant, PhD,
laboratory director, LabCorp, Birmingham, AL.