Foreword
I did not know whether to name this the “parable …”
or the “fable …” Webster's says that they are about the same, except
in a fable, speaking animals may be involved. In each case, however,
there is a simple story to illustrate a moral truth. In this case, that
truth is the “6-P” principle — which is a useful principle that can be
applied to almost any dilemma a lab manager may encounter.
Situation
It is three hours into an 11 a.m. to 7 p.m. shift,
and the technologist on duty has just received a sample from the ER. Her
normally reliable mega-analyzer has been having minor problems for a
couple of days, and a review of the QC shows that the high control was
outside of the 2 SD range (but only slightly) for the third time. You
(the lab manager) have in place the Westgard Rules in some form or
another, with Levey-Jennings charts posted or in a notebook somewhere
for the inspector. The test is for something critical (hemoglobin and
glucose do not count because the ER should be able to do quick checks
for these on its own). Your SOP says not to turn out lab results that
fail to meet the QC criteria. Let us say the patient result is a BUN of
60, a creatinine of four, or a CK that is three times the upper limit of
“normal.” (Sure, some places do not even run the test if the QC is out,
but that can be either part of the problem or part of the solution.) The
lab manager (you) is out of town, and the pathologist said he would take
calls (but he is at his parents' house and they are sick). The ER staff
is screaming because they need to decide whether to admit, transfer, or
discharge this patient. The tech is authorized to send the sample out to
a reference lab, or she can send it to the hospital lab across town (but
only with management approval).
The dilemma(s)
- Does the tech turn out the apparently critical
results? With or without a disclaimer? After all, she is pretty sure
that the results are “close.” - Should she try to call the out-of-town
pathologist and kick the decision upstairs? - Does she call the ER doctor and explain the
situation? - Should she put the sample up and wait for the
service guy who is supposed to be in at 8:00 a.m.? (I thought about
throwing in a snow storm that would delay the service guy but that
may be too much even for a parable — although many of us have had
something similar happen at one time or another.) - Does she try to weigh the criticality of the
test result and use that to decide about #1 through #4 above (i.e.,
what can wait and what cannot)? (After all, like it or not, the tech
on duty is the de facto pathologist on site.)
The process
The person in charge — regardless of the title — can
only delegate authority, never responsibility. This is the all-important
and first great principle of command. (CYA may be the second great
principle of command.) It therefore behooves those in command to make
sure to try to identify as many situations as possible, and to train the
staff up to the limit of their education and experience, as well as to
the level of the authority you feel comfortable delegating, in how to
deal with these situations. (Remember, as lab manager, you will retain
your responsibility, although additional responsibility may ultimately
be shared both up and down).
This is not an unreasonable scenario, so have a game plan that addresses at least these issues:
- Equipment problems (as opposed to equipment failure).
- Equipment back-up. (If you have it, is it working?)
- Availability of a back-up lab. How long would it take a sample to get there, and by what means?
- Identification of which tests are absolutely “must have” for the ER. (This should be a negotiated list and very limited.)
- Under what circumstances can, should lab results that meet specific, pre-approved criteria, be “communicated”
to the ER? (I hesitate to say “released” because that gets into legalities.)
The solution
I am not going to give you one. After all, it is your
lab, your license, your ER, your pathologist, your staff, and maybe your
backside if it all falls apart. What I am going to offer is the benefit
of more than 40 years' experience in doing exactly this — trying to
identify under what, pre-identified and pre-approved circumstances,
where variations from the “normal” SOP may be acceptable. It may turn
out that you are not comfortable with any variations or deviations from
the “normal.” You will also find, as I have, that you can never identify
all of the situations that may come up. If you try to plan for every
occurrence, the “special” SOP will become bigger than the “normal” SOP.
Determine and train for the “normal,” address the variations from
“normal” that are most likely to occur, and identify the acceptable
deviations to “normal” with which you are comfortable.
Afterword
The above came to me (lacking spell-check, of course) in a dream one
night. Those of you who are about to retire, or hope someday to retire
from the laboratory game, should realize that you have been scarred for
life — hopefully in a good way — by working in the laboratory. You will
be able to make decisions for both major and minor crises when faced
with what to most other people would be information overload. Your
dreams will sometimes bring you back to the laboratory, even if you
think that once you walk out that door, you never want to see another
microscope. As a retired lab manager, who spent many years in the Army
and then many more years in civilian labs, in my dreams, I am sometimes
in uniform — but that is the only difference. Oh, and if someone had to
explain what “6-P” is (Prior Planning Prevents Piddly Poor Performance),
they probably also will be able to explain what FUBAR and SNAFU mean.
But that is another parable.
