Disconnection from Patients and Care Providers
A Latent Error in Pathology and Laboratory Medicine
An Interview with Stephen Raab, MD
Unlike nurses, lab workers are one step removed from patients. Does this disconnection hinder quality improvement? This question and answer with Dr. Stephen Raab addresses the relationship between disconnection and error. Dr. Raab is a nationally recognized expert in patient safety including the application of Lean to pathology services. He is professor of pathology, vice chair of quality, and director of anatomic pathology at the University of Colorado, Denver. Michael Astion, MD, PhD conducted this interview.
Q: Why do you think it is worthwhile to decrease disconnection between lab workers and patients and between lab workers and direct care providers?
A: I think connecting to the patient’s experience, either directly or through the patient’s care providers, helps the lab develop empathy for the patient. This connection gives urgency to lab quality improvement.
Q: What ideas are you pursuing regarding connecting lab staff directly to patients?
A: We are experimenting with the concept of bringing the patient “into” the lab. For example, for Pap smears, patient photos now appear on the requisition that accompanies the specimen. For pathology services involving case signouts, we are experimenting with having a patient photo accompany the specimens we are examining.
Q: What else have you tried?
A: The most difficult thing we have tried is actually bringing in, as speakers, patients or their family members who have experiences with pathology errors. For example, we brought in a woman who spoke to lab staff about the experience she had with her husband, who died because of a miscommunication between pathologists and her husband’s clinicians.
Q: What is the effect of having patients speak to lab staff about the implications of errors in lab services? Does it energize and give urgency to quality improvement?
A: Our results of using patients in this manner are complex. Overall the effects on quality improvement are positive and the presentations capture the attention of lab staff, and it helps them realize how much quality counts in every step of the testing process. However, some staff members are very uncomfortable with the direct patient interaction, and they have powerful, negative feelings about the experience. These feelings might decrease the overall effectiveness of this approach.
Q: What is important in choosing a patient as a speaker?
A: The patient’s manner of presentation is an important determinant of the success of this intervention. Patients are at different stages regarding feelings about errors they experienced. The woman I referred to has a positive perspective, is eloquent, and now leads a patient advocacy group regarding medical errors. She was very effective. In contrast, some patients are angry. You want to avoid patients who are in an angry stage as this tends to produce negative feelings among those listening to the talk, and it takes away some of its effectiveness.
Ways to Enhance Connection Between Care Providers and Lab Workers including Pathologists
- Increasing the number of work encounters between lab workers and care providers (e.g., conferences at the multiple-headed scope; meetings to observe each other’s work; joint participation in QI projects related to lab services).
- Having the lab worker or pathologist present for the collection of particular types of irreplaceable specimens (e.g., fine needle aspirates, specimens collected surgically or by interventional radiology).
- Having the lab worker or pathologist call physicians more frequently when they have particular diagnostic findings that are clinically very important, but not necessarily listed as a “critical value” (e.g., likely new diagnosis of an unusual disease).
Q: What is your recommendation regarding patients telling negative stories directly to lab staff as way of fueling lab quality improvement?
A: There is no doubt that this is one tool that brings urgency to quality improvement. If you need to convince staff that there are problems in the lab, then bring them negative outcomes. They should hear these stories. But for this tool to be used successfully, you need the right patient, and the workplace culture can’t be too defensive. In addition, it is helpful to have a balanced approach to discussing quality that also emphasizes some of the positive aspects of lab service.
Q: How do we take a positive approach?
A: I think we can learn something from industry. For example, at construction sites, there is often a sign stating the number of days without an accident. This is a more positive way of promoting quality. Similarly, in the lab, we could state things in a more positive way. We could post the number of error free days or the fraction of specimens handled correctly. Then when we need to talk about a negative case, we at least come to the conversation with a positive attitude, rather than a despairing one.
Q: Can you describe some of your efforts to enhance communication between lab professionals and care providers about the collection of specimens, especially irreplaceable ones?
A: One example is that we have enhanced communication, and thereby decreased disconnection, between cytotechnologists and the care providers who collect Pap smears. The basic elements of this method are: 1. care providers are assigned their own personal cytotechnologist, thereby establishing a relationship with two-way feedback; 2. care providers are given a brief checklist on which they state their opinion (self-assessment) regarding the quality of the collected Pap smear specimen; and 3. the cytotech calls the care providers within 1 day of receiving Pap smear specimens if there are problems with the specimen quality. Problems are defined as either a poor quality specimen or a discrepancy between the care provider’s assessment of the specimen quality and the cytotechnologist’s assessment.
Q: Does this improve specimen quality?
A: Yes, the quality of the specimen improves using this method. This has been the case with fine needle aspirates, as well as Pap smears.
Components of a Patient Safety Culture
- Acknowledgment of the high risk, error-prone nature of an organization’s activities
- Blame-free environment where individuals are able to report errors or close calls without punishment
- Expectation of collaboration across ranks to seek solutions to vulnerabilities
- Willingness on the part of the organization to direct resources to address safety concerns
From Pizzi LT, Goldfarb N, Nash DB. Promoting a culture of safety. Chapter 40, In: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Shojania K, Duncan BW, McDonald KM, Wachter RM, eds. AHRQ Publication No. 01-E058; July, 2001. Available on the NIH website. Accessed February 11, 2009.
Q: Is the feedback provided by the cytotech to the care provider perceived in a negative or positive way?
A: Since the cytotech and the care provider perceive themselves in a mutually beneficial relationship, the feedback about problem specimens tends to be perceived in a positive way.
Q: Do you think this particular experience would translate well to other lab settings?
A: Yes, this method should be broadly useful for connecting lab workers to care providers. It will work best for settings in which care providers are collecting the sample, and the sample is deemed irreplaceable because recollection is impossible or causes morbidity. This situation applies to most invasively collected specimens, including bone marrow biopsies, joint fluids, bronchoalvelolar lavages, and tissue specimens for microbiology.
Q: What is your vision for the role of lab professionals in healthcare?
A: I think that a great role for pathologists and other lab professionals is to help bring all the members of the healthcare team together around the diagnosis and treatment of specific diseases.
Q: How might this work?
A: Currently, there are disconnects between the lab and care providers. In addition, specialization among care providers has produced its own set of disconnects between specialists taking care of the same patient. My hope is to find ways to bring together people involved in the diagnosis and treatment of a specific disease, or a related group of diseases, so that they know each other and hold each other accountable. Pathology services could be at the center of this enhanced connectivity. Patients would benefit greatly. For example, you could have the key people involved in caring for patients with tuberculosis get together regularly in the clinical microbiology lab to review lab findings, discuss patients, and keep up to date on all aspects of the disease. You could also do something similar for myocardial infarction, diabetes care, etc. Pathologists and other lab professionals are central to the diagnosis, treatment, and monitoring of these diseases and could be the catalyst for making these connections. But for lab professionals to take on this role, we first have to admit that we currently have a problem in that we are not sufficiently connected.
Raab SS, Grzybicki DM, Sudilovsky D, et al. Effectiveness of Toyota process redesign in reducing thyroid gland fine-needle aspiration error. Am J Clin Pathol 2006;126:585–92.
Raab SS, Andrew-Jaja C, Grzybicki DM, V, et al. Dissemination of Lean methods to improve Pap testing quality and patient safety. J Low Genit Tract Dis 2008; 12:103–10.