[Histonet] Basis for Quality Work in a Histotech

Mon Dec 17 11:52:23 CST 2012

Here is our slide labeling procedure. It is simple, but we insist it be followed. This will  be modified once barcoding is instituted to use scanning ID of slides vs block. 
We also instituted block ID beads at the embedding center. That has helped tremendously to identify people that may need embedding retraining. 

One other thing I should mention. People in the lab should be told to trust their inner voice. We had several labeling errors that on investigation were suspected or ignored by a tech in the chain or events. In  one case the sectioning tech pulled the wrong block from the file, labeled the slides with that block number and sent it to the IHC group. An IHC tech took the slide and noticed the number was wrong but ASSUMED the sectioning tech had made an error, so "corrected" the number to match the request on her log. The mistake was only caught by the pathologist who noticed the IHC slide did not match the H&E slide from the proper block. 

I tell  my techs: Trust your instincts. If something seems wrong - for whatever reason - STOP!!! Investigate the issue. You will save time, effort, and maybe lives.

I also tell my techs not no pathologist will remember how fast you were, just how many mistakes you made. 

Tim Morken

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Slide Labeling Procedure at the Microtome

Slide labeling at the cutting station is the most important part of the process used to identify slides. A mistake at this point will cause a mix-up in slides or cases and could lead to improper diagnosis and treatment for patients.

Because this is such an important step the following procedure must be followed exactly. Deviation may cause mislabeling. Deviation from the procedure may be cause for reprimand and termination.

Important points:
1.	Label slides for one block at a time.
2.	Do not pre-label slides before cutting sections from a block, or for any other blocks.
3.	Work with one block at a time as much as possible. If the block must be re-soaked before completing the slide count then the block must be isolated from the other blocks to prevent a mix-up.
4.	The stainer tech will compare stained slides to the blocks to ensure they are correct.

Sectioning Procedure
1)	Pick up the next page of the processing log and the blocks that are on that page.
2)	Verify that the blocks picked up are on the processing log. 
a.	Put the blocks in order according to the processing log.
b.	Put a check mark “” next to the block line on the log to indicate the block is present in the group.
c.	Note any problems with the blocks
1.	Put an “X”  mark next to any problem blocks and note the problem.
a.	Add-ons
b.	Missing
c.	Reprocessing needed
d.	Re-embedding and reason
e.	other
3)	Face-trim the blocks and put them on ice (if necessary) in order as shown on the processing log.
4)	Pick up the first block on the log. 
a.	Do not pre-label slides for this or any other block
5)	Place the block in the microtome and cut sections according to 
a.	requests on the processing log and established sectioning requirements 
b.	 “Tissue Sectioning Standards” of the Sectioning section of the Histology Laboratory manual
6)	Pick up the proper number of sections on the appropriate slides.
7)	Label the slides 
a.	Write the Accession number and Part letter/number of the block on the microtome.
b.	Label slides with your initials (legibly)
c.	Label initial slide in the group with the cassette color and page number (this slide is first in the rack and faces forward for the Stainer person to see)
d.	NOTE:  If the block must be re-soaked to complete the slide count, then isolate the block on the ice tray by putting it at the back of the tray facing backwards. This will indicate that some slides have been cut previously.
8)	Place the slides for H&E in the H&E staining rack 
a.	Write the color and page number of the processing log on the first slide of the rack.
b.	Place slides in the rack beginning at the front of the rack and working backward. 
c.	Place designated “unstained” slides in separate rack(s) for use later (IPOX, Specials, etc).
d.	Discard any unused slides with sections on them.
9)	Take the block from the microtome and put it in the cardboard filing box.
10)	Clean the surface of the water with a Kimwipe or paper towel. Be sure there are no tissue fragments floating on the water bath.
11)	Cross off that case on the processing log with a diagonal line through the entire case.
12)	When the H&E slide rack is filled take it to the 60C oven
a.	Hand-write a label with the cassette color and page# as well as the time the slides will come out of the oven (10 min from current time).
b.	Place the label on the front end of the slide rack (end with first slide).
c.	Put the slides in the oven with the label facing forward.
13)	When all the blocks have been cut, write your initials (legibly) on the bottom of the log and note the date/time.
a.	Compare Blocks and slides
i.	Give blocks to the Stainer area tech
ii.	When staining is completed the Stainer Tech compares the stained slides against the blocks and the process log.
iii.	If stained slides and blocks match, write “Blocks/Slides match”, your initials and time at the bottom of the process log. 
iv.	If slide(s) and block(s) do not match, determine the problem and correct it.
v.	Note the problem and correction on the process log along with your initials and time.
b.	Deliver the slides back to the Stainer Tech.
14)	Place the cut blocks on the filing table.
15)	Fill out a workload tally sheet for the day.

-----Original Message-----
From: Lynette Pavelich [mailto:LPaveli1 <@t> hurleymc.com] 
Sent: Monday, December 17, 2012 9:12 AM
To: Sheila Haas; Morken, Timothy; histonet <@t> lists.utsouthwestern.edu
Subject: RE: [Histonet] Basis for Quality Work in a Histotech

Would also love to hear! $$ for bar coding too far away!

Lynette

Lynette Pavelich, HT(ASCP)
Histology Supervisor
Hurley Medical Center
One Hurley Plaza
Flint, MI 48503

ph: 810.262.9948
mobile: 810.444.7966

________________________________________
From: histonet-bounces <@t> lists.utsouthwestern.edu [histonet-bounces <@t> lists.utsouthwestern.edu] on behalf of Sheila Haas [micropathlabs <@t> yahoo.com]
Sent: Monday, December 17, 2012 11:57 AM
To: Morken, Timothy; histonet <@t> lists.utsouthwestern.edu
Subject: Re: [Histonet] Basis for Quality Work in a Histotech

Tim,
I'd be interested in more information in your labeling at the microtome that has all but eliminated errors. Would you share?

Thank you,

Sheila Haas
Laboratory Manager
MicroPath Laboratories, Inc.

________________________________
 From: "Morken, Timothy" <Timothy.Morken <@t> ucsfmedctr.org>
To: "histonet <@t> lists.utsouthwestern.edu" <histonet <@t> lists.utsouthwestern.edu>
Sent: Monday, December 17, 2012 11:30 AM
Subject: RE: [Histonet] Basis for Quality Work in a Histotech

Travis,

Histology has a very complex workflow AND requires "artisan" level workmanship to deliver a product. Those two together nearly guarantee mistakes, mostly minor, but sometimes literally life-threatening to patients. The goal is to instill a sense of Best Quality in the techs. A large part of achieving that attitude is to ensure the pathologists and administrators are behind the techs 100% and ALLOW the techs to do Best Quality - ie, accept that Best Quality will sometimes mean slower turnaround time. Does that aspect mean more people are needed? That's your call, but can be determined by workload accounting.

The attitude should be that the SYSTEM makes the mistake, not the individual. It is not likely a person makes a mistake on purpose, but instead is it some aspect of the system that allows them to make a mistake (though "shortcuts" can be thought of as intentionally risking making mistakes "on purpose," the "purpose" being to save time or effort).

Workflows can be "engineered" to ensure some mistakes don't happen. Protocols must be followed to the letter by EVERYONE. No workarounds allowed (a workaround is an indication that there is something wrong in the system - the employee feels the need to take shortcuts. Why?  BTW, Bill Gates said the most important word in his vocabulary is "why." Why is something done the way it is? Why does a mistake happen at a certain point? ). In failure analysis a problem is approached by asking 5 levels of WHY? After asking WHY 5 times back down the workflow chain you usually find the root cause of a problem. If not, you keep asking why until the root cause is found.

For instance, we worked out a slide labeling protocol at the microtome that, if followed, will ensure the tech does not make labeling errors. All participated in working this out and so have bought into the system. All new employees are trained in that system. That will eventually be followed by barcoding, but that is a year away at least. But our protocol has nearly eliminated labeling errors (we still get a few sneaking in here and there but as we catch them we try to figure out how to engineer them away).

We also finally instituted the printing of cassettes directly from our LIS rather than using a stand-alone printer or hand-writing. That has almost totally eliminated cassette labeling errors - we used to have hundreds per month, mainly by residents putting in cassettes that they did not enter in our LIS, or making simple typo errors on a stand-alone cassette labeler, or hand-written cassettes.

All these methods need to be investigated.

Rewards are also very helpful. We give out "Bear hugs" that are $5 gift certificates to the campus store, cafeteria, various food vendors in the institution, etc. it's a small reward, but people actually appreciate it. We also have "Star Awards" of $50 gift cards for those times when someone does something more beyond the usual. The receiver chooses the card they want from about 2 dozen available (coffee shops, VISA, various stores, etc).

Good luck with it!

Tim Morken
Supervisor, Electron Microscopy/Neuromuscular Special Studies Department of Pathology UC San Francisco Medical Center

-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu [mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of Rene J Buesa
Sent: Saturday, December 15, 2012 8:38 AM
To: Travis Troyer; histonet <@t> lists.utsouthwestern.edu
Subject: Re: [Histonet] Basis for Quality Work in a Histotech

First I want you to excuse me, but I do not think that you are really qualified to supervise 2 histotechs if you need to ask for such quality guidance.
You end by bemoaning about "budget crunch" and because of that it seems to me that your 2 histotechs are not receiving a "decent" salary and, as everybody knows, you are getting what you are paying for.
With 10 years of experience you should know that the first step for quality of sections is quality of fixation and quality of processing. You have first to manage that aspect.
Quality of sections comes after wards and there is no "standard" for mistakes and for what you are describing it seems that mistakes are frequent. By the way, if the pathologists are not pleased, they will not it take on the histotechs, but on you as a supervisor unable to provide them the quality they require.
There is no such thing as "instant reward" for a good quality job; the histotech should not be treated as "dogs receiving a cookie after a trick performed" but there are 2 tools: you need to keep track of the mistakes → counsel the HT after a mistake → retrain them → keep a track of mistakes and there are verbal and written counselings and an annual evaluation, I am sure you know that.
The ideal limit of mistakes is "0" but there is some acceptable mistakes limits, as long as they are few and far between. The pathologists are the ones who can tell you what they are willing to accept as mistakes limits. Ask them.
It seems that if your 2 HTs do not improve, you should start looking for replacements, but they should be better paid, and if the mistakes continue at a high rate, you should put your 10 years experience to work and start doing some bench work René J.

From: Travis Troyer <ttroyer <@t> petersonlab.com>
To: histonet <@t> lists.utsouthwestern.edu
Sent: Friday, December 14, 2012 5:34 PM
Subject: [Histonet] Basis for Quality Work in a Histotech

This is a question for all of the lab supervisors.  I am the supervisor of two histotechs.  I am not doing techwork now, but have 10 years of experience.  The pathologists are getting more and more upset at the lack of quality in the work and the mistakes that are happening.  I was wondering if anyone had some ideas on what sort of a goal to set up and how to reward/punish for variations from that goal.  For example,  if the goal is three mistakes for the month, what is the best way to reward them for making that goal and what would be best if they had more mistakes in a given time frame.  We are all feeling the budget crunch and the pathologists are trying to figure out a good solution.

Thanks,
Travis Troyer
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