The goal of providing quality patient care by the laboratory is not easily achieved without constructing a culture of commitment to quality through team building, consistent systemic communication, constantly updating organizational policies and procedures, continuing education, shared experiences, and competent leadership. This process can only succeed when there is an awareness that quality service is a purposeful dynamic that must be maintained 24/7.
Have you noticed that when you work a different shift, it almost feels like you are working in a different laboratory? Whether we compare day/evening, evening/night, or night/day interfaces, we often have different priorities, different responsibilities and different ways of communicating with our clients. The outside world views the laboratory as a cohesive operation, whether 24/7 or 9/5, and expects the same level of quality, turn-around time and staff expertise, regardless of when testing occurs.
While many laboratories are busiest during the day, especially those that serve physician offices, group practices, and hospitals, there are many that are busiest in the evening or on the night shift, such as reference labs, or Walk In / ER Clinic labs. Test volume and physician need are the greatest determinants of how the lab is organized for each shift; these determine test menus, instrument needs, staffing size and specialty experience, extent of automation for specimen handling, results reporting, data storage, and documentation. Once these are factored, decisions are made as to when it is best to perform instrument maintenance, calibration, quality control, performance specifications, and staff training.
It is important to note that just because another shift may have fewer staff, a limited test menu, and a different set of priorities, does not mean that there should be any less effort to ensure that the staff is properly trained on any changes to the laboratory operation. The continued evolution of laboratory information technology has made data sharing among all shifts easier to achieve, and monitor. However, we cannot overlook the need to constantly monitor staff competency, as well as morale, especially for those who work alone or nearly alone on their shifts. On many late shifts, there may be no supervisor on site, and there is the possibility that the expected competency may not be maintained. In addition, over time, each shift develops its own culture, and in small ways, may individualize how some procedures are performed.
Decisions about the type and variety of work to be done on any shift are based upon test demand, available staff, and a calculated workload per staff during their shift. A recent complicating factor is the shortage of qualified techs for hire. In many instances, laboratories will add responsibilities rather than reduce staff if the workload is unpredictable. Many laboratories will have the night shift prepare and/or run the quality control prior to the day staff coming in; or have the evening shift perform some of the routine instrument maintenance. Any shift might check inventory. All these decisions should be done through a realistic assessment of what can be achieved in the way of routine work, in light of the priorities set for that shift.
Through it all, regardless of which shift is involved, efforts must be made to encourage a sense of community, trust, competency and communication among all the staff. If the laboratory staff is fragmented, or feels that other shifts are treated in a better manner, this will definitely impact the quality of work, as these issues can lead to distrust, miscommunication and lack of teamwork. Misunderstandings are most likely to occur when those communicating between shifts have a different perception of their work performance. More time will be needed to communicate whenever such differing ‘mental pictures’ exist.
Addressing Issues Related to Shift Work
Since each shift is part of the continuum of the laboratory operation for that day, when chronic problems are happening on a particular shift, it is important to determine if the problems are centered within the shift, or are interrelated to the shifts that precede or follow as well.
Below are some of the many factors that need to be considered when performing a root cause analysis of problems that may occur on any shift:
· Total workload per person
· Total workload per person compared to other shifts
· Training and Competency of the staff working each shift
· Permanent staff on each shift? or do staff rotate to/from other shifts
· Presence or availability of supervisory staff during the shift
· Awareness of personality differences and conflicts among shift staff
· Evaluations: are they designed for the specific tasks and responsibilities for each shift and performed by supervisory personnel who are familiar with the operations of that shift?
Policies and Procedures
· Appropriateness of instrumentation for different workloads and test menus
· Shift-specific policies governing routine and STAT orders, including which tests are included in each category, and expected turnaround times.
· Policies for the performance of quality control, calibrations, and maintenance specific for each shift
· Policies for test management when expected testing cannot be performed on each particular shift
· Inventory control
· Shared work between shifts: policies governing testing already underway when next shift begins
· Availability of policy and procedure manuals, other resources on every shift.
· Ability for all staff to participate in laboratory meetings and continuing education
· If rotating staff: proper training and evaluations of competency for work performed on each shift.
· Communication with other departments that interact with the laboratory: ER, ICU, Radiology, Respiratory Therapy, Outpatient.
· Expectations of Physicians, Nursing staff and other professionals for turn-around times for STAT and routine orders
· Have nurses and others external to the laboratory been trained on proper specimen collection, labeling and handling?
· Listen to and act on all complaints and other feedback from laboratory staff, other facility staff, physicians, nurses, and patients as soon as possible.
· Proficiency Testing needs to be performed by staff for each shift
· Quality Assessment performed for each shift
· Review workload changes annually to adjust staffing levels and instrumentation if appropriate.
· Address root causes of conflict among staff both within and between shifts. This may involve counseling, diversity training, and even events encouraging socialization among staff.
These are not all the factors to be considered of course, but for effective corrective actions and the maintenance of quality standards, these make a good start when getting to the root cause of chronic problems occurring on different shifts.