Even if many laboratorians eschewed a liberal arts education, most are familiar with the famous introduction to Charles Dickens’ classic A Tale of Two Cities: “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness,… it was the spring of hope, it was the winter of despair…”
The roller-coaster effect presented by these words could accurately describe the situation of billions of people around the world in the face of the COVID-19 pandemic, but few more so than our medical laboratory directors, managers, and team members who face this challenge first hand. While appropriate and deserving praise is heaped upon the physicians, nurses, EMS technicians, and other first responders and essential workers who are dealing directly with the disease, equal awareness and appreciation should be directed toward the phlebotomists, specimen processors, shipping technicians, medical laboratory technicians and technologists, pathology technicians, and pathologists that comprise our Laboratory Family.
While COVID-19 demands the attention of the medical and non-medical community alike, we as laboratory directors and managers must remain cognizant of our standard duties in ensuring all facets of laboratory operations continue to provide the highest quality services, and the most accurate, timely, and cost-efficient care to our patients. With this in mind, let us review a few important considerations as the COVID-19 pandemic continues its course.
A Top Down Focus
The biggest issue I see for laboratory directors and upper management is in preventing executive leadership, ourselves, and our staff from adopting tunnel vision, whereby the sole operative focus is on testing for COVID-19. With such heavy public concern regarding the number of people being tested for COVID-19 (both initial diagnosis and determination of immune status) it may seem as though this is the only thing being done in our medical laboratories. While this testing is clearly critical, laboratory leaders must avoid missing the forest for the trees by focusing solely on COVID-19 testing and neglecting the myriad other essential tasks and testing required of the laboratory.
Lab leadership also would do well to remember that the staff members we lead are not automatons and they need consideration for their own emotions and limitations during these extraordinary times. We also need to maintain focus on the fact that all testing in our organizations should be built on the bedrock of good laboratory principles and that the crisis we collectively face does not negate nor disregard the sound principles we have followed for decades in the laboratory. For this article, those principles can generally be broken down into practices, operations, staff support, and technology considerations.
It is a natural inclination in a crisis to either ask permission or beg forgiveness for the ability to deviate from established rules, regulations, and processes followed in daily practice. However, a primary role of laboratory leadership during this time is ensuring the laboratory as a whole continues to strictly follow set procedures and meet accreditation requirements, even as testing workloads expand and change dynamically. That said, the various government agencies that set clinical laboratory regulations and requirements have been making regular changes and updates themselves, including CMS’s near-daily changes to reimbursement methodologies and the FDA’s fast tracking of lab developed tests and new drug applications.
While this may seem haphazard and irregular, it is important to remember that each of these variances from their normal bureaucratic processes are in fact subject to their own regulatory policies. During this unique crisis, focus on those tasks that are most affected by good laboratory practices (eg, specimen processing, testing, shipping, result reporting, etc) and use your education and training to stay the course. Make every effort not to succumb to temptation, cut corners, and deviate from procedures to meet your goals, as these will be false accomplishments.
While every area of the laboratory is impacted by COVID-19, certain sections are disproportionately affected. These include microbiology/serology, specimen collection and processing, and specimen shipping/transportation, among others. In addition, LIS operations are compelled to add new tests and modify existing ones practically daily. While these areas are directly impacted, it is important to be flexible with other sections to ensure they are not adversely affected and are included as part of the solution.
This is certainly a time for a communal approach to operations and for cross training MLS/MLTs in other areas to enable added surge capabilities and expand multi-shift operations. As non-COVID-19-related clinical procedures resume, lab sections less directly impacted by COVID-19 are likely to experience greater workload and engagement. Of course, there are some laboratory operations that can be placed on the back burner; I am sure that almost every laboratory either cancelled or dramatically scaled back their National Medical Laboratory Professionals Week celebrations. We also can scale back workforce demonstration processes and non-technical quality improvement and aesthetic projects (eg, ergonomic and cosmetic projects). Above all in operations is the need to remain focused on technical quality, workforce support, productivity, and cost efficiency.
While testing quality is of primary importance, laboratory leadership must seek unique ways to support the workforce and thereby enable these staff members to professionally support the hospital’s patient care mission. Many laboratories are likely feeling the pressure of the pre-existing staffing shortage now further exacerbated by the COVID-19 pandemic. From staff members being placed at risk for infection to dealing with those staff that have to remain home to care for themselves or their loved ones, it is inevitable that staff shortages will only worsen.
Given the normal challenges of on-boarding new staff coupled with the mounting shortage of qualified applicants, there are a few key points to keep in mind. First, maintaining the physical and emotional health of your current staff is critical, perhaps in ways that are not readily apparent to staff members themselves. This includes enforcing strict compliance with PPE policies and screening staff members when they report to work. Anyone with clinical laboratory experience knows PPE can be a challenge to work with, but taking stringent steps to prevent the workplace dissemination of the virus supports patient, staff, and organizational health.
Clearly, executing laboratory operations during this pandemic has been a highly stressful and emotionally draining experience, so it is more important than ever that staff members have avenues to discuss their issues and manage their stress. It is virtually impossible to remove stress under these conditions, so the key is to offer formal and informal methods of mitigation. For example, celebrate small daily successes, such as the number of patients discharged to home or the number of tests performed without issue. Perhaps focus on a patient who has recovered from COVID-19 to demonstrate the positive influence of the lab. I have found that good leaders assume responsibility for the physical and emotional health of their team, and clear and open communication is essential to this task. Likewise, given the need for clinical interdependency, it may be helpful to hold daily or shift-based huddles to provide your team with situational awareness, both of laboratory operations and the organization overall. Ultimately, please keep in mind your own physical and emotional health. Practice what you espouse to your staff and seek ways to positively decompress and mitigate your own considerable stress.
In the effort to remain flexible and effective in your staffing model, it may be wise to consider the use of a staffing agency for short- to mid-term needs. There are national agencies that can often provide qualified staff at multiple skill levels (eg, CLS, CLT, phlebotomist) to help meet both surge requirements as well as augment general staff overall. It is particularly valuable to establish these relationships before they become absolutely necessary. If this route is taken, be sure to discuss how the agency solicits and selects its candidates, and what criteria they use to assess competency. Knowing these aspects and having confidence in an agency before it is needed provides you and your institution with an elevated comfort level should the need arise.
For laboratorians, if there is a silver lining to be found in the COVID-19 pandemic, it is in raising the stature (and recognizing the value) of the laboratory to the C-suite, our providers, and the general public. A side effect of this pandemic has been the massive technological advances we see pouring into laboratories of all sizes and service types. Molecular methods traditionally found only at large medical centers and reference labs are now being deployed to community hospitals and free-standing clinics. While a large percentage of COVID-19 or SAR-CoV-2 testing is performed using high-complexity methods on existing analyzers, there are many new manual and point-of-care methods being utilized to improve both antigen and antibody testing.
Anyone who watches the nightly news will hear the clarion call for “more” laboratory testing. While this call to action is positive for our profession, it also requires us to be agile and to ramp up SOPs and training to perform proper testing. Furthermore, if testing is being performed by non-laboratory personnel, lab leadership must maintain strict technical oversight of those processes (in New York and New Jersey, for example, pharmacists can now perform some tests). From specimen collection to result reporting, all testing reflects on the laboratory profession, no matter who performs it. Given the criticality of proper pre-analytic specimen collection to the safety of all lab testing, with the adoption of non-traditional specimen collection methods (eg, drive-through specimen collection or self-collection at home), lab leadership also must play a role in ensuring these collections are properly performed. In doing so, interact with nursing and public health providers and stress both the proper methods as well as the pitfalls of suboptimal specimen collection (eg, potential false-negatives). Finally, always keep post-analytic issues in mind, specifically how result(s) are reported in either the EMR or through manual methods.
Optimizing Other Lab Areas
While it is important to focus on our staffing, testing instrumentation, and consumables in light of COVID-19, we need to consider other aspects of our operations as well. Management of devices and materials such as refrigerators and freezers, transport bags/containers, pneumatic tube carriers, and bulk storage areas are often in the back of our minds, yet these have been thrust to the front of the discussion when it comes to handling and testing COVID-19 patient specimens.
It is probable that most health care organizations are facing basic if not considerable purchasing constraints, so capital requests for additional instruments or devices likely will be looked upon with a critical eye. Therefore, first look at the optimal (yet appropriate) use of existing capabilities. Consider recalculating on-hand par levels for reagents and potentially relocating some products to another area, such as secure storage in logistics/materials management.
Likewise, submit purchase requests for additional transport bags, P-tube carriers, and other specimen containers as soon as possible. Readiness to meet your mission is a powerful metric when seeking support from materials management. Consider inviting your director of materials management into the lab to observe your processes. This will provide a visual representation of your needs and hopefully predispose the lab to material support. Be realistic in your requests; no one wants to end this pandemic with a year’s worth of hard-to-use reagents left on the shelf. Collaborate with your fellow laboratory directors. Organizations such as CLMA can serve as excellent resources for new and novel approaches to lab management.
All heath care professionals have been challenged by this constantly shifting situation, but as a profession, the laboratory’s role has dramatically changed. We have met the challenges of adopting new and rapidly evolving technology and test methodologies and have acknowledged the need to remain technically proficient and emotionally strong. Continual evaluation of our technologies, our P&Ps, and our internal and external relationships will be required to win this battle with COVID-19. Remain open to technological changes and embrace them; assume a larger role in the care continuum if possible and use this crisis as stimulus to get out of the lab and interact more with clinical colleagues and patients. Perhaps this will encourage some to gain a Doctor of Clinical Laboratory Science (DCLS) degree to continue the collaboration amongst disciplines.
Living and working through the COVID-19 pandemic has severely tested our capabilities, but our ability for flexible execution has enabled us to weather the storm thus far. Keeping our eyes on our duties while remaining conscientious and open minded has gotten us to this point. Continuing to do so will bring us out of the darkness cast by this pandemic.
Joseph G. Keary, MS, MBA, is the secretary treasurer of the Clinical Laboratory Management Association (CLMA), having recently retired from Irwin Army Community Hospital in Fort Riley, Kansas, where he served as chief medical technologist in the department of pathology. Joe also is CEO and chief consultant for JGK Leadership Consulting.
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