I recently took a new job as an evening shift manager at a large hospital lab. I realized when I took the job that some sections of the lab needed significant help. I now fear I’m in over my head. For example, the other day I walked into the lab when it was not busy. People were chatting and when the phone rang, no one answered it. They kept talking and let the call go to voicemail. I retrieved the message from voicemail and found it involved an important patient care issue. Should I quit and beg for my old job back? If I stay, how do I start this turnaround?
There are two simple tests to determine whether you will be able to improve this lab: the free food test and the Vanguard calculation. In the free food test, you sponsor a free meal for the whole shift, the more delicious the better. If more than 50% of your co-workers complain about the free food, quit this job, and beg to return to your old job. To perform the Vanguard calculation, access an online retirement savings calculator. If the calculator indicates you can retire in the next 3 years, quit this job and beg to return to your old job, because if the lab is in bad shape, you will be facing a 4–5 year journey to turn it around.
But as long as there is even a morsel of hope, nurture that hope and persevere. We present some tips for getting started in Table 1. They should help with the first 6 months of this worthwhile project.
To start, there is something going right in this lab, and your job is to find and affirm it. Be sure to praise in public and correct in private. Affirmations should be specific. Let everyone in the lab know that there are no unimportant tasks or unimportant people. Examples of specific affirmations include thanking a lab section for maintaining a low error rate despite unexpected staffing problems, affirming call center employees for a low abandoned call rate, thanking a phlebotomist on behalf of an anxious patient, or thanking a staff member for working overtime to run an urgent test. The key point is to concentrate on the desired behavior and reward the employees who model that behavior. Specific, public affirmation leads to an effect known as nudging, whereby other individuals or groups try to emulate the behavior of the affirmed individual or group (2).
Most employees will get through the turnaround just fine, even though they may have slowly drifted into the lab’s negative culture. A few employees might need performance improvement plans administered with the help of your human resource department. Personnel issues often include disruptive behavior and problems with teamwork (4). However, we recommend you focus on staff attendance first because suboptimal performers often have attendance and tardiness problems. Attendance problems are objective and therefore much easier to incorporate into disciplinary action than problems with attitude, teamwork, impairment, or competence. A focus on attendance also sets the right tone for professionalism and often leads to an early win.
A leader’s physical presence in the lab is a foundation for culture change. In addition to affirming specific patient safety behaviors, institute a daily huddle attended by a representative of each lab section (5, 6). Huddles are supportive and promote teamwork and a shared understanding of challenges in daily operations. They provide a venue to affirm improvements in a public setting while also allowing you to interact with staff individually and as a group when you ask clarifying questions about the day’s status. Encourage the different sections to vary their representatives so that the entire lab experiences the huddle.
Another important tool is a program review in which the manager separately interviews each person in a lab section using the same questions. Keep it simple. Not everything that is measurable counts and not everything that counts is measurable. Ask about morale in the lab. It shows that you care about the staff as people, not just employees. The briefest program review has three questions: describe your job and how long you have been working here, what in your opinion is going well here, and what could be improved? If the list of improvements is long, ask for help prioritizing the top few. A program review will reveal shared beliefs about current problems and help you get to know the staff.
Providing refreshments in the breakroom after a significant improvement enables you to repeat the free food test and specifically affirm something that went well in the lab. This promotes a hard-wired desire for quality improvement. Consider celebrating improvements such as decreasing a particular error rate, implementing a new assay, improving turnaround time, or anything patient-focused. All affirmations promote nudging.
Enhancing the connection between lab staff and the patient experience also motivates quality improvement and boosts morale (7). One way to achieve this is by inviting patients to lab meetings or events. Most hospitals will help facilitate patient visits in a safe and compliant fashion. For example, Seattle Children’s uses the patient and family relations office to link the lab to families that are interested in helping. Other methods to enhance the lab-patient connection include having staff meet more frequently with doctors and nurses directly caring for patients. Lab staff also should visit patient care areas, for example on rounds, as well as invite care providers to tour the lab. Managers should reinforce the connection to patients by providing feedback to staff about lab service-related patient outcomes.
During a turnaround, there likely will come a time when you have to make an unpopular change that nonetheless is important to patient care. Common examples include terminating a bully who also happens to be popular with some of the staff, shifting work hours to match workflow, or implementing an individual productivity metric. It is important to persevere through these necessary but painful, early changes. The reward for doing so is that the path to success will become progressively easier as you continue to make improvements. Good luck, and let us know how it went. Remember the Swedish proverb: “Shared joy is double joy; shared sorrow is half sorrow.”
Michael Astion, MD, PhD, is clinical professor of laboratory medicine at the University of Washington department of laboratory medicine, and medical director of the department of laboratories, Seattle Children’s Hospital. +Email: email@example.com
James S. Hernandez, MD, MS, is an associate professor of laboratory medicine and pathology, and medical director and chair of the division of laboratory medicine at Mayo Clinic in Scottsdale and Phoenix, Arizona. +Email: firstname.lastname@example.org
1. Astion M. Patient safety behaviors: Praise to criticism ratio. Clinical Laboratory News 2014;40(7).
2. Jackson BR. Nudging our way to more efficient care. Clinical Laboratory News 2016;42(4).
3. Astion ML, Messinger B, Ahlin P, et al. Collected wisdom on patient safety. Clinical Laboratory News 2010;36(7):17.
4. Astion ML. Disruptive behavior: How labs can recognize and overcome its negative effects. Clinical Laboratory News 2011;37(7):16.
5. Astion M. A new model for patient safety: Daily laboratory huddles. Clinical Laboratory News 2013;39(4):13–14.
6. Astion M. A new model for patient safety: Daily laboratory huddles, part 2. Clinical Laboratory News 2013;39(7):21.
7. Disconnection from patients and care providers: a latent error in pathology and laboratory medicine: An interview with Dr. Stephen Raab. Clinical Laboratory News 2009;35(4):14–15.
CLN's Patient Safety Focus is sponsored by ARUP Laboratories