Challenges of Laboratory Medicine in Paradise

Written By: Calvin Ball, MS, MLS(ASCP)CM, CLS

Bermuda is Another World

Bermuda is another world, 700 hundred miles at sea
And the way the people greet you, is like a friendly melody
To touch your flowers in the morning to listen to the honey bees,
To hear a bird who sings a song, just to say that he is free

Bermuda is another world, turn around I’ll tell you why
Just to watch the morning sunrise, from the sea up to the sky
To look out across the harbour, and see a multi coloured sail
To water ski upon the water, that always leaves a snowy trail

Bermuda is another world, turn around and you’ll be gone
But they’ll always be a memory, that will linger on and on
And someday I’ll hear you say, just as I have said today
Bermuda is another world

Written by Hubert Smith, 1969

Hubert Smith wrote the song “Bermuda is Another World” to pay homage to the uniqueness and beauty of the island. Bermuda seems like another world located approximately 665 miles east-southeast of Cape Hatteras, North Carolina. Mark Twain once famously commented, “You go to heaven if you want to — I’d rather stay right here in Bermuda.” Bermuda is a British protectorate that is a 21 sq. mile subtropical island with a population of approximately 65,000 people. The Government of Bermuda identifies its main industries as tourism, insurance, and reinsurance. Having a large population for its size (Population Density = 3084 persons per sq. mile), their healthcare needs are mainly provided by the King Edward VII Memorial Hospital.

King Edward VII Memorial Hospital (KEMH) is a 294-bed acute care facility that provides continuing and alternate levels of care as well as hospice service. It is overseen by the Bermuda Hospital Board (BHB), which is a quango that is mandated to provide mental health (carried out at the Mid-Atlantic Wellness Institute) and acute care services to the residents of Bermuda, ex-patriots, and approximately 200,000 tourists that visit the island each year. The hospitals rely on its laboratory, Department of Pathology, to provide high-quality results. The laboratory conducts a wide range of testing that enables local clinicians to properly diagnose and treat patients. Laboratory testing sections include Blood Transfusion, Chemistry, Hematology, Microbiology, Histology and Cytology, and Mortuary Services. Tests are carried out for the hospital’s in-patients and out-patients as well as for several private physician and allied health practices on the island.

The laboratory produces approximately 3.2 million test results per year. At the heart of producing these results, the laboratory relies heavily on the principles of Quality Management. This is evidenced by KEMH being a finalist for the Quality Service Provider of the Year 2018 [Large Business] Wow Award; quality is an organizational effort.

The main laboratory is located on the first floor of the five-story General Wing of the hospital. An entry-way to the waiting room features posters of blood donation statistics for local companies competing in the hospital’s annual Corporate Blood Donation Drive, disease facts, and information about laboratory services. This layout was designed to inform and educate staff and visitors on various laboratory topics. Danee Swan, Pathology Quality Manager, describes the effect of this introduction to the laboratory’s quality journey as, “An opportunity to inform and educate visitors of the ongoing issues that the laboratory is involved in, which leads to patient engagement.” She recalled one patient who had engaged with a poster on lupus and commented to her that it was very informative. Engaging visitors with laboratory events, quality initiatives, and information epitomizes the laboratory’s Quality Management focus. However, its location in the middle of the Atlantic Ocean on a 21 square mile island provides unique challenges when it comes to staff recruitment, accreditation, inventory management, instrument maintenance, and staff engagement.

57895~26033236724482937398..jpgBermuda’s South Shore. (Calvin Ball)

Staff Recruitment

With no medical laboratory science schools on the island, the laboratory must rely on a combination of native-born Bermudians (who have to go abroad to obtain training) and qualified medical laboratory scientists (MLS) from overseas. At the time of this interview KEMH’s Laboratory Manager, Kathy Stephens said MLS overseas staff were primarily from the Philippines, the Caribbean, and the United Kingdom. Despite the United States being Bermuda’s closest neighbor, Ms. Stephens, remarks that in her 29 years in the laboratory, she can only remember one American MLS on the laboratory team. KEMH is not a teaching hospital and requires potential MLS applicants to have been trained in a well-rounded curriculum. To ensure that all staff members are competent in the clinical laboratory, the hospital requires the ASCP, ASCPi, or HCPC, and English certifications.

Once hired, the MLS starting pay range is $44.91 – $48.31 (BMD) per hour. Also, laboratorians must be registered with the Council for Allied Health Professionals. One way of trying to increase their talent pool and to address the universal problem of an aging MLS workforce is by performing outreach to local secondary schools (high schools) to expose students to the MLS field and giving them a first-hand look at the laboratory. The department has invited students to open-house days during lab week for several years and is regularly represented in job fairs and career days at local schools.

Accreditation

KEMH and the Mid-Atlantic Wellness Institute are accredited by Accreditation Canada. However, Kathy Stephens and her team realized 15 years ago that it would be beneficial to also have a lab-centric accreditation. “Years ago, Accreditation Canada came and spent one day in the lab. As a group, we felt they weren’t really inspecting us. They weren’t really looking at our work, our quality,” stated Ms. Stephens. The laboratory embarked on a journey to identify an accrediting agency that fit the laboratory’s needs. They performed a study to evaluate several accrediting agencies and decided to seek Joint Commission International (JCI) accreditation as it is considered the gold standard in global healthcare. “We worked for 3 years to get ready for JCI accreditation and we made it on our first try,” said Ms. Stephens.

Once accredited, the laboratory began an inspection cycle of every 3 years. The JCI inspectors are professional inspectors that adhere to the Commission’s mission of meeting the highest international benchmarks for accrediting bodies. Laboratories in large jurisdictions like the U.S. anticipate inspections during a predetermined inspection window and are usually inspected for 2 – 3 days. The challenge with undergoing JCI inspections is that the inspectors spend almost a week performing the inspection, a deep dive into every aspect of the laboratory. One advantage of being inspected in Bermuda is that the law requires BHB to obtain work permits for those carrying out on-site inspections, which means managers know when they are going to be inspected. The strenuousness of such a high-caliber inspection is mitigated by the KEMH laboratory’s commitment to adhering to the highest quality standards. Ms. Swan performs audits and unannounced inspections every 3 months. She emphasizes, “I keep on top of everything in order to avoid any surprises and to avoid saying ‘Oh my gosh! How did we get to this point?’ “

Inventory Management

Having the right supplies in sufficient amounts is crucial to laboratory operations and ensuring quality results. Just-in-Time inventory management in a laboratory includes setting par levels of inventory and supplies to reduce costs due to waste but maintain adequate supply levels for laboratory operations. Managing supplies is a challenge in many laboratories without the added factor of location. The KEMH laboratory’s inventory management weighs the value of continuous operations without interruptions due to lack of supplies.

The KEMH laboratory’s inventory management is very delicate and can be adversely impacted by shipping issues due to weather and extraordinary events. One such event was 9/11. “I remember 9/11 I was the hematology supervisor and we were waiting for our lysis [reagent] shipment to arrive, then 9/11 happened and nobody was flying. Everything was backed up, [when flying was possible] we had people hand-carrying hematology lysis reagent on the airplane with written notes,” states Ms. Stephens. Since then, she’s become more sensitive to the need to have adequate supplies should something unforeseen happen. She says that physical space also dictates stock levels she is able to maintain.

What happens when a reagent runs out? Ms. Swan states, “We can only borrow chemistry reagents.” She is referencing the laboratories within doctors’ offices. She continues that if they can’t borrow reagents, then they aliquot samples and freeze them or send them for testing to their reference laboratory in California, USA depending on the backlog.

Instrument Maintenance

It is inevitable that an instrument will go down (require maintenance) at some point in its useful life. Going down when your nearest field service engineer (FSR) is hundreds of miles away and must obtain a work permit to perform on-site troubleshooting is a challenge in and of itself. When asked about this scenario, Ms. Stephens did not skip a beat with her response, “Well, our senior techs are very good.” Also, Ms. Swan interjected that they do as much troubleshooting as they can, and they utilize the instrument manufacturer hotlines.

To mitigate the impact of an instrument requiring service and not available for testing, the KEMH laboratory has an “instrument mirror” policy; they have two of each instrument to ensure continuity of testing.

Another interesting twist to the challenge of the timely availability of an FSR when an instrument needs repair is that Bermuda law allows doctors to operate laboratories within their medical offices/facilities and many times these doctors have the same instruments as the KEMH laboratory. Even though having several “competitors” can impact the bottom line, one advantage is that the FSR makes the rounds to the hospital just to check on the instruments when on the island for repairs for a different client.

Staff Engagement

A common challenge in laboratories is keeping staff engaged in every aspect of Quality Management. Both Ms. Stephens and Ms. Swan describes the KEMH laboratory staff as very proactive and ready to help solve any problem that arises in the lab. In fact, one of their laboratorians, Delmonte Swan, was recently nominated for and is a finalist for the Wow Awards’ Unsung Hero Award. His ability to jump in and assist wherever he can has left a significant imprint on everyone who works with him.

Having an engaged staff is essential to optimizing quality management within the laboratory, but like many laboratories, KEMH managers expressed a desire to see their staff feel more connected to their patients. Patient empathy in any laboratory is a challenge. Many laboratorians do not routinely interact with patients and the sense of urgency for specimen results is not always present. The uniqueness of Bermuda’s location with its high population density, means that there is a higher probability that the patient is a relative and Ms. Stephens and Ms. Swan regularly reminds them about the significant impact specimen testing has on patient lives.

lab2017-169064964262211582052.jpgDelmonte Swan, Senior Medical Technologist (Courtesy KEMH Public Relations Department)

Staff recruitment, accreditation, inventory management, instrument maintenance, and staff engagement are essential to having a robust quality management system and can present challenges in any laboratory environment. These essentials are the basic building blocks of a laboratory’s commitment to providing quality services and results. KEMH’s location amplifies the challenges they face when addressing issues involving these essentials. The KEMH laboratory has shown a tremendous ability to adapt when issues arise. That is the price to practice laboratory medicine in paradise, another world.

 


For general laboratory inquiries or laboratory job openings, please contact Ms. Kathy Stephens via email at Kathy.Stephens@bhb.bm.

I would like to thank Kathy Stephens and Danee Swan for opening their lab to me and contributing immensely to this article. I’d also like to thank Cathy Stovell, KEMH Senior Public Relations Specialist, for being a conduit for information and resources, which helped to make this article possible.

Feature photo of a map of Bermuda and it’s location in relation to the North American seaboard by Shutterstock.com.