College of American Pathologists
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Plenty to cheer in first nurses Q-Probes

July 2004
Karen Titus

In a world filled with pessimists and optimists, Bruce A. Jones, MD, slips into both camps with ease. Dr. Jones, co-author of the recent Q-Probes report "Hospital Nursing Satisfaction with Laboratory Services," is likely to look at a half-filled glass and judge it to be equally empty and full. It’s not a bad way for pathologists to regard the information in this Q-Probes, which is the first one to peer into the minds of nurses and ask what they want from labs.

This being a Q-Probes inquiry, the answers are numerical in nature—the slim (16-page) report is packed with table after table that reduce desires and frustrations into percentages, distributions, means, and other mathematical shorthand.

Numbers, of course, are tricky devils. Read one way, they can leave labs feeling briskly confident of their performance and full of warm, fuzzy feelings toward their nursing colleagues. For starters, the mean overall nursing satisfaction score was 3.8 out of a possible 5. Pulling down such a score could leave lab personnel stammering like Sally Field at the Oscars: "You like us, you really like us!"

A closer inspection of the numbers seems to back that up. A king-sized portion of respondents, 90 percent, reported they were either very satisfied or usually satisfied with the accuracy of the test results provided by their labs, while exactly zero percent were rarely satisfied or not satisfied in this category. (The missing 10 percent is accounted for by those who responded positively, albeit with a little less enthusiasm, choosing the "somewhat satisfied" rating.)

In the next highest category, 86.5 percent said they were very/usually satisfied with phlebotomy courtesy toward patients. That doesn’t mean 11.5 percent were rarely or not satisfied; in fact, only two percent chose those ratings.

With these figures in mind, says Dr. Jones, it’s reasonable to make a case that nurses are highly satisfied laboratory customers. In all but one of the 13 categories surveyed, dissatisfaction levels were 10 percent (in one category) or less. Dr. Jones says he purposely chose to start his "Author’s Commentary" at the end of the report with a positive spin, noting the high overall satisfaction score. "I didn’t want to jump in with the negatives right away, because that 3.8 is a fairly significant positive." Moreover, he says, even the most disgruntled nurses (it will come as a surprise to no one that they work in the ERs and ICUs) still recorded average overall satisfaction rates of 3.64.

But enough of the glass—half-full approach. The numbers may be good, but they don’t let labs off the hook. Nor do they tell the whole story.

Nearly all the laboratories, for instance, give their nurses a means for voicing their complaints, which should boost satisfaction. But it doesn’t, reports Dr. Jones, who is senior staff pathologist at Henry Ford Hospital, Detroit. "There’s no correlation between satisfactory performance and the rate of complaints per test being performed."

Likewise, slightly more than a third of the laboratories say they meet with their nursing representatives monthly. "That’s quite frequent, and it’s good," Dr. Jones says. The survey didn’t delve into the matter, so the particulars of each encounter lie doggo, like disclosures at an AA meeting. But whatever’s going on, it isn’t working for the nurses. "Merely meeting with them isn’t enough," says Dr. Jones. Ditto for the customer service training that labs say they give their employees. Though these efforts are well intentioned and should be done, Dr. Jones says, "Most of us appear to be having difficulty translating this training into making anybody happy." The correlation between such training and nurse satisfaction just isn’t there. "Maybe we’re training them to answer the telephone quickly, but then we put one person at a phone to handle a hundred calls an hour. Or maybe they’re not getting reinforcement from the old-timers in the lab. If you’re a new person trained to say all the right things on the phone, but you don’t see anyone else in the lab doing it, you’ll soon regress to that lower level of service."

Perhaps the most cheerless numbers of all concern turnaround time. A full 95 percent of laboratories said they monitor turnaround time. "But it’s the area of least satisfaction," says Dr. Jones—of all the lab interactions measured, stat test TAT had the highest median value (21.2 percent) for percentage of rarely satisfied/not satisfied ratings; 49 percent were very/usually satisfied. "So merely measuring something does not improve it."

Dr. Jones speaks in the unhurried tones of a statistician. His observations are laid out in carefully constructed sentences that often end with the qualifying clause, "at least in a group statistical way." But there’s nothing dull in his analysis of the Q-Probes data, nothing dry in his suggestions for using the data to help labs do better. He’s a first-rate guide through the statistical thicket, as sympathetic as a social worker and as motivating as Bobby Knight, though less annoying than the former and not as scary as the latter. He knows there are times when labs can’t change the status quo, but he’ll knock every last excuse out from underneath those who don’t care to improve their rapport with nurses.

Why should labs even care what nurses think? "Nurses are also our customers," says Dr. Jones. Dealing with specimens and lab information affects nurses’ actions and decisions, he says, and can influence patient stays in ERs, ICUs, and the hospital at large. And yet nurses have, until now, typically been overlooked. Labs tend to react to the demands of credentialing organizations, Dr. Jones says, and those groups have traditionally defined "customers" as clinicians and patients. Nurses have been conspicuously absent. Indeed, this Q-Probes is the first to canvass nurses, though physicians and patients have already weighed in with six earlier Q-Probes. And when it asked whether labs had looked into nursing satisfaction on their own, more than 70 percent said "no." Says Dr. Jones, "This is a fairly new concept, to pay attention to nurses and asking them what they think."

Some laboratorians might argue they don’t need to ask their nurses what they think—they already know, based on experience, that nurses think the lab is too slow.

They’re not necessarily wrong. The lowest level of satisfaction in the Q-Probes survey was the aforementioned stat test TAT.

Also drawing lower marks were laboratory management responsiveness (62.7 percent were very/usually satisfied, and 10 percent were rarely or not satisfied); lab management accessibility (63.9 and 7.5 percent, respectively); and phlebotomy responsiveness (64.7 and 8.7 percent, respectively). It’s nothing personal. Though nurses are generally happy with phlebotomy courtesy, as noted earlier, they would like to see phlebotomists move more quickly-a desire that relates back to TAT, says Dr. Jones. "You can’t do things fast enough." Routine test TAT earned marks of 65.2 percent very/usually satisfied and 8.7 percent rarely/not satisfied.

So far so obvious. Now it starts to get a little discombobulated. Dr. Jones and his Q-Probes colleagues spent considerable time trying to figure out not only when nurses were happiest, but how to achieve that state of bliss. Much to their surprise, the only two things that were associated with more satisfaction were lower numbers of tests and fewer phone calls to the lab.

The predictable explanation is that small labs are more likely to earn high satisfaction rates. Those who do fewer tests, it would appear, have more time to provide better service. Anticipating such a correlation, Dr. Jones asked labs to provide figures on their FTEs and created simple ratios—tests per FTE, phone calls per telephone-answering FTE, and number of complaints per million lab tests—to see if satisfaction was in fact related to workload.

"There’s no difference," he says, still sounding a little surprised. "This is not a workload-per-person type of issue, because the people with high workloads and the people with low workloads per FTE have the same average satisfaction scores."

Poof! There goes the easy excuse for any lab tempted to use it. "Large laboratories will tend to believe that they can’t provide a high level of service because they work too hard, they’re too busy, and they’re just never going to be able to provide the same good service that smaller labs do," Dr. Jones says. But his initial analysis, at least, doesn’t bear that out.

(That’s not to say further analysis won’t unearth a link. Dr. Jones concedes there’s probably something occurring in smaller laboratories that this Q-Probes didn’t measure, an intangible that allows smaller labs to provide better service more often. "But it isn’t necessarily related to laboratorian workload," he emphasizes.)

Another easy answer fell by the wayside when Dr. Jones discovered that monitoring nurses’ complaints didn’t improve their view of the lab. Dr. Jones attributes this to something he’s personally observed, "that a lot of organizations have dysfunctional processes for collecting and processing complaints." And really, when it comes right down to it, who wants to gather bad news more efficiently?

The truth is, however, that poor complaint monitoring makes matters even worse. The process usually starts with a generic, institutional complaint form (which 83 percent of the Q-Probes participants reported using). Nurses with a complaint fill out the form and send it to a central administrative office or to a Q/A office, "where it generally ends up in a pile," says Dr. Jones. The complaints may eventually make their way to the lab, but it’s a little like the Jamestown settlers looking to England for more supplies and receiving barrels of flour and molasses two years later. "One place where I worked, we became very frustrated with this format, because they would collect these and send them in bulk every three or six months," Dr. Jones recalls.

"What happens is (a) you don’t know there was a problem, and (b) you’ve lost the opportunity to investigate, because it’s too old, nobody can remember it, there’s no information, and there may not even be a patient name," says Dr. Jones. Calling the nurse usually draws a bewildered, "I don’t even remember filling out the form" response.

Such pileups also may help explain why nurses were less pleased with lab responsiveness. "They’re waiting for a call or something—a fix—after they send in the form, and they hear nothing back from anybody. They figure we get the complaint the next day, and that we’re not responding because we don’t care," says Dr. Jones. "They think we’re ignoring them, and that just fosters more dissatisfaction." It also means they’re less likely to fill out complaint forms in the future, leading to a crazy teeter-totter effect: As complaints drop, dissatisfaction goes up.

A broken feedback system is no reason to stop seeking feedback. Dr. Jones notes that at an institution where he previously worked, he and his colleagues created an easy-to-use, lab-specific complaint form consisting of categories and check-boxes. The forms were sent directly to the lab’s maître d’Q/A, bypassing the general hospital complaint circuit, and the lab investigated and responded to each one. Dr. Jones, ever the statistician, says he has no idea if that led to elevated nursing satisfaction because he never measured the relationship specifically. But more importantly, "It was a good thing to do," he says. "In the laboratory, people have to take the initiative and say, ’I want this information in real time so I can do something with it.’"

Dr. Jones continues to belt the stuffing out of every excuse labs might lob back in response to low Q-Probes scores. Psychiatric nurses had the highest overall satisfaction rating, 4.21, while ER and ICU nurses fell to the bottom rung, with each group notching the aforementioned 3.64. Labs could easily decide that since ER and ICU nurses demand the highest level of service and the greatest number of stat tests, there’s simply no pleasing them. And in some cases nurses may be deluding themselves about what labs can deliver. They may not realize, for instance, that just because one test can be turned around in 10 minutes, it doesn’t mean that every test is similarly speedy. "But you can’t just sit back and say, ’We’ll never make them happy so let’s not even try.’ You need to sit down with them, you need to understand what their expectation is and how they came to have it," Dr. Jones says.

Giving lab tours to nurses may not be a bad way to start opening their eyes. "Lab managers who’ve done this tell me the nurses invariably comment that they didn’t understand how big or how busy the laboratory was," Dr. Jones says. "They didn’t understand that some specimens require processing steps, like centrifugation."

This approach also helps bury the so-called black box—the idea that the lab is staffed by nameless, faceless individuals who exist only as a voice on the other end of the telephone or at the end of a pneumatic tube system, deep in the hospital’s basement. Nurses who find it easy to complain about these invisible colleagues will find it’s a little harder to sound off against flesh-and-blood colleagues. "They’re more likely to pick up the phone and talk to somebody they’ve met and know and have seen and say, ’I have an issue here, how can we resolve it?’"

Most issues can be resolved, he insists, especially if labs bear in mind that the bulk of complaints are a step or two removed from most lab work. "Average turnaround time, average level of service, doesn’t generate complaints. It’s the outliers. People remember the situation that caused them aggravation, even if it only occurs one out of a hundred times."

That should make it easier for labs to fix matters. "When we sit down to talk about solving problems, I want to see the spread of our performance," Dr. Jones says. If TATs range from 10 minutes to two hours, with an average time of 45 minutes, it’s likely that no one is complaining about the 45-minute TAT; the problem is with the 1.5 to two-hour TATs. "My first focus would be finding out the cause of these longer turnaround times and trying to reduce them. Even if I don’t affect any of the other tests, I would eliminate a large percentage of the specimens and situations my customer is complaining about."

Ever hopeful, Dr. Jones rests his case on one final Q-Probes category: accuracy of test results. This is what labs live for, and yet in ranking the categories, nurses felt this was less important than stat test TAT.

No, nurses are not crazy. Remember, says Dr. Jones, 90 percent of them reported being very/usually satisfied with test accuracy, the highest of any category. "I think this means we have successfully made accuracy of test results a nonissue for nurses—it’s an assumed quality characteristic." It’s less important to them because it’s no longer a problem—a sign, if ever there was one, that labs are doing a good job.

Maybe the glass is half-full after all.

The other co-author of the Q-Probes report is Stephen G. Ruby, MD, MBA, chairman and medical director of pathology, Palos Community Hospital, Palos Heights, Ill. Drs. Jones and Ruby are members of the CAP Quality Practices Committee. Karen Titus is CAP TODAY contributing editor and co-managing editor.