Wednesday, April 26, 2017

I will remember you (Musings on TM colleagues past)

Updated27 April 2017

April's blog focuses on a friend and colleague who recently died. How to write about Kathy Chambers after she so suddenly and unexpectedly died? Celebrate her life with a series of anecdotes on how she affected Canada's transfusion and quality community and beyond and especially those she closely worked with. 

Kathy's was the first blog in the CSTM's 'I will remember you' series (Further Reading). This blog allows me to be more personal and intimate.

For those who didn't know Kathy, I hope the blog has interest and value as a narrative on the complex interpersonal and mentoring relationships that exist in the transfusion workplace, indeed, any workplace. As you read it I encourage you to think of your own colleagues and how you interact.

The blog's title derives from one of Canadian Sarah McLachlan's songs.

ANECDOTE 1
Upon first meeting Kathy when she worked as a senior in the transfusion service of UAH, Edmonton I was struck by how she was so no-BS and down-to-earth, true to her Saskatchewan roots. She told it how it was, without the soft edges of political correctness. 

My gawd, I thought, this is the hard-nosed technologist I must collaborate with to develop the students' blood bank rotation experience? She was confident and a bit intimidating. If intimidating to me, an experienced transfusion professional, how would she appear to the 'kids' (as I call them to this day). 

Well, I needn't have worried. Kathy turned out to be the proverbial 'egg', hard on the outside and soft on the inside. She truly wanted the vulnerable neophytes (students) to have a good experience, to learn and grow during their clinical rotation. Kathy's confident exterior was intimidating, but she was warm and caring too, a trait that became increasingly clear the more I got to know her. 

Someone you could treasure as a lifelong friend no matter where life's divergent paths take you. 

ANECDOTE 2
At the CSTM 2000 conference in Quebec City, 10 years after she'd left Edmonton, Kathy introduced me to the then BC PBCO medical director and put me forth as the webmaster/content coordinator of its TraQ website. The offer came out-of-the-blue, totally unexpected, and was very kind given that we hadn't kept in close touch over the years. 

That conference generated many laughs. Kathy had such joie de vivre, always smiling and sharing an unspoken joke. 

TraQ was a dream job because I'd recently left a tenured position in MLS at the University of Alberta. After 22 years it was time for a new adventure and to give some of the 'kids' I'd taught a chance to transmogrify the job into the 21st C.

On subsequent trips to Vancouver for TraQ, and later on a CBS educational website project, Kathy always picked me up at the Vancouver airport (a chore in itself, given the traffic) and I stayed at her home and got to know her up close and personal.

One tidbit I recall is how we'd sit on her back deck each morning over coffee and she'd laughingly point out the neighbours who were suspected drug dealers.

To my surprise, I learned that Kathy gave me significant credit for something I took as normal. During her time in Edmonton she'd undertaken an ART (Advanced Registered Technologist), no longer offered by the now CSMLS. The ART was a way for Canadian medical technologists without BSc degrees to qualify for supervisory and managerial positions in clinical laboratories. 

Part of the ART requirement, besides a research project and oral examination, was a literature review. Kathy's lit review needed quite a bit of work and, as an experienced instructor, I gently suggested how she might improve it. Goodness knows who had taught her in the past because she in in-explicitly credited me for being a kind mentor and never forgot it. 

I suspect it formed the basis of her many acts of kindness to me over almost 40 years.

Fits with my experience that what we remember in life is mainly a series of small events (sometimes even seconds long) that strongly affect us positively or negatively and that we recall for the rest of our lives. 

I'm so glad that Kathy saw a small act in a positive light because her resulting kindness made my post-Med Lab Science career.

ANECDOTE 3
In 2000, Kathy and I were approached by Heather Hume, who had a vision to create a CBS educational website, which we did (2000-2003). Still think the site was a vein-to-vein masterpiece but impossible to maintain without considerable resources. Today, it's morphed to CBS's Professional Education site.

We had so much fun creating the original website. And I learned a lot from Kathy. Her breath of experience was incredible. 

Towards the end of the project, Kathy and I had a parting of the ways, so to speak. The details are not important but, in retrospect, the fault was all mine. Indeed, Kathy went out of her way to rectify the situation and soothe my feelings but I was the stupid, hurt-feelings, hard-headed one. Keep this in mind for what comes next.

ANECDOTE 4
In 2007 I formed a consortium that was eventually hired by Alberta Health & Wellness to develop a Provincial Blood Contingency Plan to deal with severe blood shortages from pandemics and other causes (July 3 - Nov. 30, 2007). Folks I asked to form the Consortium included Penny Chan, Maureen Patterson, Dianne Powell, and Maureen [Webb] Ffoulkes-Jones, and yes, Kathy Chambers. 

As it turned out, Kathy Chambers became the 'de facto' lead under difficult circumstances and led the project to its successful conclusion. Quite an accomplishment and one that showed she had the 'right stuff', which I never doubted for a moment. 

Those of us involved refer to it as the 'project from hell' and Kathy was its saviour.  We can laugh about it now but not then.

ANECDOTE 5
When CSTM asked me to do a series of 'I will remember you' blogs, the first person I thought of was Kathy Chambers. She agreed without hesitating and, as was typical of her, quickly delivered the 'goodies' needed for the blog. 

Kathy was so talented and efficient throughout her entire career. How the heck could she have such focus? Amazing woman! A force of nature, a 'oner'. Like many in Canada and beyond, I'm fortunate to have known and learned from her. 

My best memories are of the many laughs we shared. Cannot see Kathy's face without a smile. I hope readers will recognize themselves and colleagues such as Kathy who have affected their lives for the better. 

FOR FUN
Naturally, I've chosen Sarah McLachlan's song for this blog:
I will remember you, will you remember me? 
Don't let your life pass you by 
Weep not for the memories.

FURTHER READING

Sunday, March 26, 2017

Sweet dreams are made of this (Musings on conferences and why we attend them)

Stay tuned. Revisions sure to occur

March's blog was stimulated by Twitter, specifically a tweet by UK's Sylvia Benjamin (Further Reading) about the value and limitations of lectures (conference presentation) based on a podcast by physicians Rob Orman and Amal Mattu both with 1000s of followers (Further Reading). 

The blog's title comes from a song by Annie Lennox, one I've used before.

Executive version
This blog will highlight Orman and Mattu's excellent podcast and where I differ with them. Pretty nervy but it's no fun to always agree.

I'll be somewhat provocative and facetious about the real reasons many folks attend conferences and why conference presentations often suck. 

Also included will be strategies for how to make conference presentations better. I offer suggestions because, when Powerpoint (PPT) came out in 1990, I was mid-career in MLS and loved PPT (my handwriting is awful). Accordingly, I pretty much made all the mistakes that now jokingly constitute, 'death by PPT.'

Why continue reading the blog? Maybe for insights into giving presentations and listening to them? Or just to see how provocative I can be? Your choice.

INTRODUCTION
The Orman-Mattu podcast has much useful information for presenters and educators but, after a lifetime of attending lectures at scientific and medical conferences and even giving some, I disagree with two of their premises. 

First, they discuss talks at conferences as if their main goal was to train and educate, then strike this aim down because presentation lectures often fail. Perhaps their premise is a logical fallacy that comes close to a straw man argument?

Second, the podsters claim that lectures are an inefficient way to transmit information and knowledge. That their only uses are to inspire or convince/convert.  About inspire, I confess that many conference keynote speakers are inspiring people who give inspiring talks. Yet even with them I seldom can recall what they said of lasting value. 

But lectures can do much more than inspire / convert. They serve other key functions, which include being efficient and effective ways to 
  • Transmit practical information not found in textbooks or published papers;
  • Emphasize and summarize what the crucial information is on a given topic;
  • Model how practitioners approach and think about problems;
  • Explain the evolving nature of technical and clinical practice and incorporate historical developments to show the big picture;
  • Model soft skills such as professional work attitudes, how practitioners approach feedback on performance, interpersonal and professional relationships and ethical dilemmas. 

In fairness, it may be that Orman-Mattu were giving an executive version of what lectures can do well. 

The presumptive purpose of delivering lectures at conferences is to train and educate, i.e., communicate something worth communicating. And often that fails on many levels. I'm reminded of this clip from Cool Hand Luke:



But is training and education really the main purpose of conferences? Allow me to be a bit facetious.

REAL PURPOSES OF CONFERENCE TALKS

The accepted purposes of presentations (lectures) at medical conferences by researchers, physicians, nurses, medical technologists are to educate others and disseminate knowledge but the real purposes often include these. My Top Ten:
Perhaps, 'alternative facts'?

1. Present research findings, maybe new research or perhaps old research whose data's been massaged to get more published papers (main way academics are judged, despite lip service to teaching and service to the profession);

2. Justify the expense of attending;

3. Have something to put on academic annual reports;

4. Further one's career, essential to young researchers to obtain grant money to keep their positions;

5. Travel to new cities, even better if they're international and somewhat exotic;

6. Fluff egos: "Yes! I'm a 'thought leader' in my field. I can dine off this research talk at hospitality suites and Big Pharma din-dins for the entire conference."

7. Schmooze and spend quality time catching up with colleagues, often in the exhibitor area at vendors with the best free food and booze;  

8. Escape temporarily from family obligations, which can be especially onerous for females with a busy career, a home to run, and children to care for;

9. For pathologists and others who find social interaction and chit chat awkward, presentations give something to talk about, take the pressure off socializing;

10. For some folks, often married ones, conferences provide an annual opportunity to meet up with lovers (who may or may not be colleagues). Over time I've known quite a few people who regularly did this. They never discussed it with those who knew them, but the reality was an open secret among their colleagues. Just the way things are, never to be mentioned.

PRESENTATION  DISTRACTORS
What can go wrong with presentations and why do they so often suck? 

1.Busy Slides
Think of the slides that many, if not most, physicians often use at conferences. I'm not picking on docs, it's just that they do most presenting at conferences. 

Invariably, they begin by apologizing for a busy first slide using a tiny font size that is unreadable at 10 feet. With slide after similar unintelligible slide, audience eyes gaze over and judgmental folks who know a smidgen about education / communication tend to think, rather uncharitably
  • 'What arrogance! Or is it laziness? Is he really that clued out? And, jaysus! Why didn't I sit at the back for an anonymous exit?'
2. Entire Sentences
Then there's the not-that-rare presenter whose slides consist of sentences presented in bullet format. As if that's not enough, he (yes, it's often a 'he') reads them word for word. Zzzzz....

Once saw presentations like this from a well known, prestigious researcher who held a high position in a blood system. Confess that I felt sorry for the guy because his level of shyness and fear of presenting must be extreme.

Still, it's torture to endure such talks. One of my favorite Dilberts is the guy who wants to be throttled rather than....(2010-02-28)

3. Ringing Bells
You expect  'ringing bells' aka verbal tics in nervous neophytes. Examples: um, you know, er, like, an almost silent 'okay' at the end of sentences, or ending sentences as if they were questions. Other verbal tics in those who should know better because they are experienced speakers include 'actually' and 'absolutely'. 

Trouble is, once you hear a presenter say a few, all you focus on is the repetitive ringing bells.

4. Pissing Contests
Another distractor may occur at the end of  presentations, where someone in the audience aggressively challenges the speaker over research methodology or conclusions, especially if the speaker did not mention them in the talk as limitations. Ex:
  • It's just an observational study, so weak and unreliable;
  • What new findings does your study show;
  • You didn't take into account these confounding variables;
  • Your small sample size lacks statistical power; 
  • The study has little external validity because....
Nothing the matter with peer feedback and constructive criticism except if challengers clearly have an axe to grind or want to get into a pissing contest to show how clever they are. Also, if they attack someone who is less well known than them, all pretense of collegiality ends and the feedback approaches abuse.

We like to think of transfusion medicine as one big happy family but I've seen such combative nonsense and it's not pretty. 

5. Attention Spans
I'll end this section with noting research about attention spans. An often repeated fact is the average attention span of students is 10-15 minutes, but there's no good evidence to support it. 

Research shows that college-aged students (the group most educational research is done on) listening to lectures have attention lapses during the initial minutes, again at 10-18 minutes, and then as frequently as every 3-4 minutes toward the end. 

I used to joke with my students after ~ 15 minutes that I knew they were fantasizing about sex. The mention of sex immediately drew their attention back to me. Indeed, nodding-off heads and glazed eyes would become alert and they'd invariably laugh. If lucky, I'd have them for the next 5 minutes.

Who knows how attention span research applies to adults. Indeed, older adults because we are an aging profession. And while not necessarily sex-obsessed, today's conference attendees cope with many distractions. They may think of the work piling up in their workplace, of the talk they'll give tomorrow, of aging parents or children and spouses at home, etc.

6. Attention-Getting Strategies
1. One way to maximize attention is to introduce your presentation up front and summarize what it will be about, why it's important, and what you hope listeners will get from it. This is akin to being 'above the fold' in newspaper parlance, i.e., stories that editors think will interest readers and sell papers.

2. Also, consider saying as an addendum to the intro, that if the presentation isn't what an audience member anticipated, it's okay to leave. Add something like,  'Seriously, I can take it and would hate to think of you feeling trapped. If it were me, I'd appreciate the same opportunity.' Believe me, you'll have the attention of everyone in the room.

3. Another effective way to get and keep people's attention is well known by reporters, sometimes called the 'Identifiable Victim Effect' or 'one person's story' effect.  The strategy is to focus on one or two individuals because an individual's story is always more compelling than statistics involving masses of anonymous people. 
  • An example from the 1970s Vietnam war is Phan Th Kim PhĂșc.
  • Perhaps the best recent example of this effect is with refugees drowning in the Mediterranean. The numbers who drowned are now into the 1000s. But nothing got the world's attention more than Aylan Kurdi.
Similarly successful authors tell the story of a few people or one family to illustrate larger learning points with more effect. Think of virtually any book you may read.

So how can conference presenters of scientific and medical studies / topics use the 'one person's story' effect to good advantage? Some examples:

1) Research: Audits of how well nurses follow hospital SOPs and policies when administering blood

Begin the talk with a summary of the story of two U.S. ICU nurses who were perhaps fired for not following their hospital's blood administration policies (Why were RNs fired, Further Reading)

2) Topic: Best practice for bedside identity checks prior to transfusion
Begin the talk with a summary of the story of the UK nurse who lost her license and was charged with manslaughter over an identity error that led to a patient's death. (Nurse spared jail over transfusion error, Further Reading)

3) Topic: Challenge of providing clinical training to students in an age of decreasing resources
or: Current issues in handling medical errors in a quality system

Begin the talk with a summary of a real case like TraQ's Case A-8: Severe Hemolytic Transfusion Reaction Involving a Student (Further Reading) or one you know of personally.

Such real-life stories have the added advantage of telling the audience why your research or topic is relevant.

WHO ATTENDS AND PRESENTS AT CONFERENCES?
My experience as a lifelong transfusion professional is that conferences invariably are top heavy with physicians and PhD researchers. Guess that's to be expected given that conference goals are to disseminate and advance research. Not that nurses and medical technologists do not engage in research, just much less often, given how hard it is to obtain funding these days and that research is not usually a core part of their job descriptions.

Also, for a long time it's become difficult for medical technologists to get funding to attend conferences, perhaps transfusion nurses too. 

Granted, today most transfusion conferences include a few front-line medical technologists who work in the trenches, often presenting at workshops. Similarly, there may be the odd talk (or workshop) by transfusion nurses.

HOW TO PRESENT
The most important thing about any talk is its content and why it's worth disseminating to peers. On that point, conferences don't have nearly the reach of press releases and journal publications. If the research seems to a genuine breakthrough (or is made to sound like it is), local science media can be counted on to gladly gobble up the release almost verbatim because writers are always desperate for something to write about.

Podcasters Orman and Mattu spend time on explaining how to deliver a lecture (present at a conference), including offering only a few take-home messages and reinforcing them, plus using pictures / graphics more and text less. 

They also note the problem with handouts (often PPT slides with room for handwritten notes) that invariably get taken home, filed, and never read again. So true. 

A known problem with the ubiquitous PPT handouts is that audience members will read them and not listen to you. The same applies to bulleted slides, even if there's only a few bullets/slide. 

Of course, presenters love PPT because it serves as a handy crib sheet for the talk. To put up a slide with only a picture would require more effort and memorization. Granted, 'grand poohbahs' usually have given the same or a similar talk dozens of times, so are well rehearsed.

Face it. Most transfusion professionals are not 'rock star' presenters who can mesmerize an audience for 15 minutes or longer, especially when more than 50% of listeners have dined out and partied to the wee hours the night before courtesy of a diagnostic sales rep. 

Since most presenters will continue to use PPT software or similar for conference talks, it's at least prudent to know how to use it. Search 'death by Powerpoint' (~1.7 million Google hits, 26 Mar. 2017) and you'll see how many folks tell us how to avoid it.

But this Dilbert Powerpoint collection conveys the pitfalls more effectively. 

One person whose advice for presentations with PPT slides that I find useful is Garr Reynolds (Tips, Further Reading). An example (Source: Slide Share, Further Reading): 




Also Reynolds doesn't ignore the basics, such as what's the purpose of the talk and especially the 'So what?' message you should look for, including in scientific papers. 

FOR FUN
For all transfusion professionals it's an honour to be asked to speak at conferences and increasingly a privilege to attend. Hence, Sweet dreams are made of this. Beyond the title, the song is a favorite of mine. 

An upcoming 'sweet dream' to keep in mind is the CSTM joint conference with the ISBT International Congress in Toronto, Canada , June 2 – June 6, 2018.
FURTHER READING

This blog's origin: Sylvia Benjamin tweet on a podcast  by Rob Orman with Amal Mattu 

Are medical conferences useful? (12 Aug. 2012)

Blog: The way we were (Musings on the benefits of attending conferences) -11 May 2013 

Garr Reynolds Presentation tips

Garr Reynolds Slide Share

UK: Nurse spared jail over transfusion error

USA: Why were RNs fired? 

TraQ: Case A-8: Severe Hemolytic Transfusion Reaction Involving a Student


Saturday, February 25, 2017

Take chance on me (Musings on transfusion professionals collaborating)


Stay tuned: Revisions will occur
February's blog was stimulated by the planned transition of an informal mailing list of Canada's Transfusion Safety Officers (TSOs) to the CSTM website. I've been the list manager and moderator since the list ('transfusion')  was created in 2000. The blog is shorter than usual, which is likely a good thing.

As part of the move, we did a survey of 'transfusion' subscribers, many of whom do not have the job title of TSO, but perform many of the same functions. Historically, mainly for financial reasons, most subscribers are Canadian but we've had a few foreign subscribers, including ones from Ireland, Switzerland, UK, and USA.

What is this blog about and why might you want to read it? Many other transfusion-related communication mechanisms (workshops,conferences) exist but today it's often electronic communication, such as websites with discussion forums. In transfusion medicine, PathLabTalk comes to mind, whose BloodBankTalk participants are mainly USA and UK medical laboratory technologists / medical lab scientists. 

Similarly, professional associations like AABB and BBTS offer discussion forums and my experience is that most posts are by technologists.

In contrast, Canada's TSO list includes medical laboratory technologists and transfusion nurses, including blood conservation nurses, and even a few physicians.

That's a huge advantage because transfusion service laboratories and nurses who administer blood transfusion really do need to learn more about each other and appreciate the role each plays.

The blog's title derives from a 1978 ditty by Sweden's ABBA.

HISTORICAL PERSPECTIVE
For decades I've been privy to the views that med lab techs/scientists have on nurses, based on anecdotal experience in hospital transfusion services.

Common themes (misconceptions?) are that RNs do NOT
  • Understand quality control procedures and lack competence to do Point of Care Testing (POCT)
  • Truly dig the importance of patient identity and understand what can go wrong. Hence they're not that concerned if patient identities on specimen labels do not EXACTLY match those on blood transfusion requisitions, because, hey, they took that sample and know it's the patient.  Hence they think the lab is being anal-retentive on what they see as minor. 
It's possible that nurses have views of their colleagues in transfusion laboratories that are not always complimentary and may be based on sterotypes. I'd love to hear some. 

PARTICIPATION
Transfusion nurses have come relatively late to transfusion organizations. But physicians have belonged for ages, indeed from the get-go. They tend to dominate proceedings as evidenced by talks at annual meetings.

Yet few physicians participate in transfusion lists and forums, or on Twitter. Why not? My guess is that some think of social media such as forums, lists, and Twitter as beneath them. Perhaps some can't be bothered to interact with the hoi polloi, meaning lab techs and nurses or is that too harsh? 


Or, unlike the laboratory and nursing trench workers of the transfusion community, most physicians are too busy (can't bother?) to talk to anyone but other physicians, and only at medical rounds, conferences, etc.? Please advise. 

Three Transfusion Pros Walked Into A Bar
To illustrate my point about stereotypes among transfusion professionals, I created a joke. Yes, it's satire with a smidgen of truth.
A female doctor, medical lab technologist, and a nurse walked into the bar. Oh, great said the bartender, we have a contest tonight and you are just the ones to play it. Out came 2 glasses and the bartender said, 'Guess which one is British and which is Canadian.'
The doctor considered herself a beer aficionado and passed on asking the age and history of the brews. Feeling more knowledgeable than her colleagues, and somewhat infallible, as she often did at work, she immediately stated, based on her gut feeling: Pale lager is Canadian, dark is British.
Canada

Britain
The nurse took and recorded the vital signs, including colour and temperature. She recalled Canadian beer was more likely to be pale yellow and served cooler and that Britain had dark ales. Her guess was the same as the doctor's: Pale lager is Canadian, dark is British.
The lab tech asked if a historical record existed of the samples in the glasses and which bottles they came from, and then demanded it. When told that would be cheating, the technologist replied, 'Sorry, we in the lab don't guess about identity.'
Correct identity thanks to the lab technologist (You knew this was coming):
Canada
Britain

BOTTOM LINE
If only med lab techs/scientists, nurses, and physicians could get to know each other better, transfusion medicine would be a better world. I've been lucky in Alberta, Canada, thanks to the Med Lab Sci program at University of Alberta, to have taught several students who went on to become hematopathologists. Their lab background is a huge plus. 

And I know from the TSO 'transfusion' list that technologists and nurses have benefited from learning the issues and challenges each has.

For interest: In 1994 when the Internet became available at my workplace, I created a mailing list 'MEDLAB-L' for medical laboratory professionals of all disciplines. I could have gone with a transfusion list but am so glad to have opted to be inclusive. Over the years lab professionals (med lab technologists / scientists, PhD level scientists, and physicians) in all clinical labs have benefited from learning about each others' issues.

FOR FUN
The song I chose is a 1978 ditty by Sweden's iconic ABBA. It's meant to say to nurses and med lab techs and physicians to talk to each other on social media, break down stereotypes, trust each other, because we're all in this together.
As always, comments are most welcome.

Saturday, January 28, 2017

Four strong winds (Musings on trends identified by Malcolm Needs' 3rd CSTM blog)

Updated: 29 Jan. 2017
This month I'm going to feed off CSTM blogs on the career of the recently retired UK's Malcolm Needs (Further Reading). 

Typically, in the CSTM 'I will remember you' series of blogs, I offer my musings on what the featured author writes. But for January I've developed comments originally written for Malcolm's third CSTM blog (not yet published) into a stand-alone TM blog. So in a way this blog will foreshadow Malcolm's upcoming blog on regrets, concerns, and challenges, and serve as an advertising 'teaser' for it.

The blog's title comes from a 1963 song by the iconic Canadian duo, Ian and Sylvia. The blog is organized as a take-off on the song's title.

Strong Wind #1: AUTOMATION 
In his upcoming third blog, Malcolm mentions automation in the context of how it has changed the skill mix of staff employed in transfusion hospital laboratories. I've written about automation often including in 2010:
  • Goldfinger's filings, a customer's toolkit: Musings on business intelligence (Further Reading)
In the July 23, 2010 filing of its FORM 10-K Immucor (Form 10-K reports, which public companies file with the U.S. Securities and Exchange Commission, offer comprehensive business overviews of a registrant's business, such as history, competitors, risk factors, legal proceedings.) , one maker of blood bank automation (Immucor) writes:
'Our long-term growth drivers revolve around our automation strategy. We believe innovative instrumentation is the key to improving blood bank operations and patient safety, as well as increasing our market share around the world.'[Note they put improvements and patient safety up front, but increasing market share is their prime concern.]
'We believe our customers...benefit from automation. Automation can allow customers to reduce headcount as well as overtime in the blood bank, which can be a benefit given the current shortage of qualified blood bank technologists.' [Reduce headcount is a nice euphemism for get rid of staff and their costly benefits. Diagnostic companies also tout automation as freeing lab technologists/biomedical scientists to do more interesting tasks. And of course, if you can remove the human, you remove most of the error, or so it is said.]
  • 'We believe that instrument placements are the most effective way to gain market share ... Because our business operates on a “razor/razorblade” model....' [A razor/ blade model means give them the instruments relatively cheaply, because we can soak them with reagents costs, which continue forever.]
'In the new field of molecular immunohematology, we are currently developing the next generation automated instrument for the DNA typing of blood for the purpose of transfusion, which we believe will be the future of blood bank operations.' [And, by gawd, if a demand doesn't exist, we'll create one. See Strong Wind #4 below
Aside on automation: As a long-time transfusion science instructor (1974-99), graduates often told me they chose to work in hospital transfusion service labs because of the hands-on testing, correlating test results with patient diagnosis and history, and problem solving. They didn't choose clinical chemistry, in particular, because that clinical lab was heavily automated. Loading patient specimens on instruments and relying on software to flag abnormal results struck them as not nearly as engaging as transfusion science, or clinical microbiology, for that matter. 

Other grads obviously loved the highly automated clinical labs, and not just because job opportunities were more abundant. Of course, those who went to work for the blood supplier - on the 'dark side' as I affectionately call donor testing, where I enjoyed working in prehistoric days - inadvertently were sucked into the world of automated, mass testing of donor samples. 

Indeed, transfusion service labs whose test volumes warrant it, have moved into automated testing big time, as shown in the 'Goldfinger's filings' blog.

Strong Wind #2: LEAN
In his third blog, Malcolm also mentions LEAN. LEAN is a biggie in NA too, touted as an industry 'saviour', developed in Japan by the American Deming. LEAN expanded into health care ages ago. LEAN is promoted as allowing clinical laboratories and component production facilities to do more with less. 

For example, Canadian Blood Services (CSB) cooperates with Toyota and makes videos about  it. CBS higher level staff sport Master Black Belts in Lean Six Sigma. Jargon (~bafflegab) abounds as LEAN, Kaizen, and Six Sigma run together in a blur. 

Moreover, LEAN consultants make a great living by marketing it to health providers and training staff in-house. 

In 2008 I wrote a blog on automation and LEAN: 'Morning becomes Electra' (Further Reading). Refer to my views on whether automation and LEAN are progress, given that progress generally means improvement or growth, whether for individuals, organizations, societies, or humanity. 

Bottom line: Add automation and robotics to LEAN hospitals and soon we'll have gotten rid of all the non-value-added waste in the health system, as well as most of the health professionals. But is it progress?

Strong Wind #3: STANDARDIZATION
In his upcoming blog 3 Malcolm mentions that, in an effort to streamline how laboratories work, and to standardise (Brit spelling - grin) the work, a 'one size fits all' campaign was instituted in all NHSBT reference laboratories. 

From talking to colleagues in the field, I sense that standardized operating procedures (SOPS) are now 'SOPs on steroids'. Some hospital transfusion service lab SOPs are now so complicated that even long-time transfusion specialists must consult them often as they perform routine procedures they've done 100s of times. Do 'busy' SOPs increase patient safety? To me it's likely staff lose focus on patients due to the extreme emphasis on paperwork. 

Whenever a national blood supplier in any country tries to standardize work across laboratories or regions, my initial reaction is Beware! In his blog Malcolm explains the ways in which standardization doesn't always fit. My guess is that frontline staff aren't consulted enough initially and the head office folks writing the SOPs don't have the experience to realize it's a no-go from the get-go. 

Later the organization may ask for feedback on the SOPs that have been rolled out but seldom acts on it. Staff may even stop offering feedback because they've learned it's useless. 

I saw staff giving up firsthand in my brief stint as 'assman' at CBS (1999/2000). Staff tolerated nonsensical inaction from head office, because their feedback was met with a brick wall of silence and un-returned e-mails. Perhaps more senior people on-site knew little, too, because they were never told. Frankly, I shook my head in bewilderment at how dedicated, talented staff had come to accept the unacceptable. But, being naive, I went up the chain at head office until I found someone with real authority, who, when told what was occurring, fixed it immediately. 

About nation-wide SOPs:
  • Sometimes it seems as if they've been written by folks who have never performed the procedure, at least not currently;
  • Or maybe the writers know one lab's methods and don't understand that it won't fit others, a version of the clichĂ©, 'a little knowledge is a dangerous thing';
  • Or perhaps standardization is a significant someone's current hobby horse;
  • Or, and here's the crux of the matter, standardization will save money in writing and revising. Never mind that they won't work operationally for every laboratory.
What's going on with SOPs in hospital transfusion service labs is a mystery. But I suspect it relates to government regulation and inspections by Health Canada (HC). 

HC regulators presumably gather input from all the stakeholders before new standards / regulations are instituted. But how much medical lab technologists / scientists play a role is debatable. 

My sense is that HC inspectors of transfusion labs have little, if any, first-hand knowledge of working transfusion medicine. Their concern focuses on documentation that processes have been validated and paperwork exists, regardless if it adds to patient safety, or even if they don't truly understand what it means. 

Strong Wind #4: MOLECULAR RBC GENOTYPING
Also in his third blog, Malcolm welcomes blood group genotyping as long overdue in immunohematology labs. 

As with any new technology, many constraints to widespread adoption exist, including staff expertise and cost. In the USA an added roadblock has been convincing government to pay for special DNA blood grouping when some of it is hard to justify with evidence. Naturally, patients with the money can get it. 

Again, see my 2010 blog, 'Snip, snip, the party's over?' for an overview of the issues (Further Reading). I see genotyping as a great innovation, but decry the increasing move to expand its uses beyond what can be justified clinically as a return on investment (ROI) in the technology. 

Moreover, I understand why, given that some folks have built their careers on it, and also dig the seductive lure of 'personalized medicine' (typical, over-the-top Rah!Rah! snake oil).  

For interest, see the UK's 'Red Book' (incredible resource) on 'Clinical applications of blood group molecular typing'.

LEARNING POINTS
In his upcoming third blog, Malcolm identifies concerns and challenges and shows hope for the future of TM labs. The issues he identifies are significant forces. Automation, LEAN, standardization, and molecular blood grouping are 'four strong winds' currently shaping transfusion medicine laboratories worldwide. At their heart, I see these 'winds' as deriving from 
  • Vested commercial interests;
  • Cost constraints and the need to do more with less;
  • Government regulation gone amok.
FOR FUN
Given Malcolm's four topics, I decided the 1963 song by Canadian icons Ian and Sylvia was too good to resist. Of interest, in 2005 this song was voted the top Canadian song of all time, quite an honour given that Canadians have written many great songs. 

The song is a reflection on a failed romance, but the phrase, 'if the good times are all gone' resonates with me. Of course, even the earth's seas and mountains change over time, nothing is forever. Also, as an Alberta resident for ~40 years, I can attest there is plenty to do here all year round. 

Not sure, however, just who all these TM changes/trends benefit. As always, I hope the blog is 'food for thought' for readers. Watch for Malcolm's multiple blogs at CSTM. His second will be published this weekend (Jan. 28-29) and third in Feb. 2017.
  • Four strong winds (Ian and Sylvia 1986 reunion concert)
    • At end see Murray McLauchlan, Judy Collins, Gordon Lightfoot, Emmylou Harris (left to right) join them on stage.
Four strong winds that blow lonely, seven seas that run high,
All those things that don't change, come what may.
If the good times are all gone, and I'm bound for moving on,
I'll look for you if I'm ever back this way.

Comments are most welcome.
FURTHER READING

Thursday, December 29, 2016

Don't worry, be happy (Musings on decreased government funding as a TM disruptive force)

Updated: 2 Jan. 2017 

Last December I got a bit mushy and wrote
  • Islands in the Stream (Musings on how love of transfusion medicine unites us) [Further Reading]
This year I'm not as sentimental and am okay with being a grinch who stole Christmas. Besides Dr. Seuss's tale has a happy ending. Not saying it applies to this blog, though it may. You decide.

Continuing the series on disruptive forces that affect, or will affect, the practice of transfusion medicine (TM) is hard. Why? Mainly because of all TM health professionals, to date the ones who have been most affected by disruptive forces are medical laboratory technologists / biomedical scientists (whatever they're called in your country). I suspect that an in-depth discussion of laboratory realities would cause many nursing and physician eyes to glaze over.

Including the three main TM professionals is part of the challenge of writing TM blogs. For the most part I try to write about big picture 'poop' that affects all so lab techs, nurses, docs can relate.

So what is December's blog about? It's about the disruptive force of DECREASED GOVERNMENT FUNDING of health care in those nations where universal health care exists, and to a lesser extent in the USA.

USA readers may think the blog is not as relevant because you don't have government-funded universal health care like the rest of the developed world (Further Reading). But from what I've read on medical laboratory and clinical laboratory educator lists, similar things happen in the US, perhaps for different reasons. For example, consolidation is rampant in the blood industry. (Further Reading)

The blog was stimulated by a seemingly odd source:

  • How physicians can keep up with the knowledge explosion in medicine (Further Reading) 
One suggested solution was to create the equivalent of 'paralegals' for medicine. Yes, my mind works in strange ways. More later.

The blog title derives from an 1988 ditty, 
which I've used before, by 10-time Grammy award winner, Bobby McFerrin . 

In an effort to keep the blog short and sweet, well at least shorter, I'll muse on Canada and leave it to you to judge if similar events apply to your country. References for many of the points will not be provided because they are available by doing simple Google searches. For example, in writing a literature review, you do not need to reference facts taken as a given and available in many resources, e.g., Donald Trump will become the 45th US President.

December's blog was also partly motivated by the economy currently tanking in my Canadian province of Alberta because prior governments made us depend on the price of oil to provide government services, including health care. Unfortunately, our economy regularly tanks. Suffering from boom and bust cycles is normal if you depend on others for prosperity, others like Saudi Arabia and the nations that make up OPEC (Further Reading).

The blog reflects on the disruptive force and effects of governments deciding to save money on the backs of health care professionals and the health system, including patients. First I outline the immediate effects in general of decreased funding, then present long term consequences for transfusion medicine.

DECREASED GOVT FUNDING - IMMEDIATE EFFECTS

CLINICAL LABORATORIES
Decreased health care funding began in a big way in Canada in the 1990s. Driven by right wing ideology, provincial governments (responsible for health care in Canada under our constitution) decided to save money in many ways, including by cutting funding to health care, particularly clinical laboratories. 


The result was a concurrent move to regionalize and centralize laboratory testing because it facilitated saving money by eliminating laboratory administrative staff and 'trench workers' alike (See Dianne Powell, Further Reading).

Management gurus tapped into the big government money available to consultants by propounding
 catch-phrases such as 'right sizing' and 'working smarter, not harder'. All in the belief that 'BS baffles brains', which it apparently does when it comes to governments to whom bafflegab is second nature.

'Working smarter, not harder' particularly rankles because it led to managers of transfusion labs trying to do more with less  - in effect, being guinea pigs to government experiments - and considered failures if they couldn't.

Staffing
For example, if five labs became one lab, the first to be axed could be four lab supervisors, now that only one was needed. Similarly, the five trench workers who covered the midnight shift as the sole technologist on duty could become one worker. You get the idea. What happened in Canada due to this disruptive force was many lab technologists, mainly middle managers and trench workers, lost their jobs.

Education programs
Concurrently, med lab technology/science programs closed across Canada, since far fewer graduates were needed. 


In Canada in the 1990s only two programs survived in the 4 western provinces (constituting ~31% of Canada's population) and both were in Edmonton, Alberta, perhaps due to the programs' strength, since Alberta was the province hurt worst by funding cutbacks. I taught in one (MLS, University of Alberta) and was a clinical instructor for the other (NAIT).

Medical lab technologists/clinical lab scientists
Under NAFTA, those with university degrees were lucky to get clinical laboratory jobs in the USA, where shortages had become extreme. Others had to give up the career they loved and had worked at for up to decades when laboratory jobs disappeared.

Clinical placements
Another factor was that government cutbacks resulted in clinical labs becoming under-staffed. Staff could barely keep up with doing core work (patient testing), let alone train students. As a result no one wanted to, or even could, train students, even though it was in their best in interest for succession planning.

Automation
Semi-automated and fully automated lab instruments found great favour and prospered in the era of decreased government funding of clinical laboratories. Instrument manufacturers promised their impressive looking instruments would decrease staff numbers, a tempting advantage since staff had costly benefits such as supplementary health insurance and pensions.

Companies also tried to take the edge off axing technologists by claiming now they could concentrate on more interesting skills and let the instrument do the 'grunt work' (my phrase). Cue a kumbaya moment. Except those without a job wouldn't be singing.

But, oh how pathologists' eyes would light up at the thought of becoming less of a cost centre in the hospital hierarchy. Of course, the more bells and whistles the gizmos had, the bigger the eyes.

No one seemed to care that

  • Government money was sucked outside Canada to multinational for-profits, rather than to staff who worked in Canadian communities, paid taxes and raised their families here. 
  • Lab automation operates on a razor-blade business model
  • Despite promises of smooth integration with lab information systems, automated instruments often had a hidden cost - the need to buy middleware so they could 'talk' to the LIS. And then the fun begins.
NURSING
Perhaps nurses can add to this discussion, at least I hope so. In Canada, decreased government funding of health care led to unemployed graduate nurses being recruited to the USA, Australia, NZ, pretty much everywhere outside Canada. More than 20 years later, Canadian hospitals still suffer because there are not enough nurses to staff operating rooms, emergency departments, etc.

Indeed, the nursing shortage is growing because of an aging workforce (Further Reading). Impending baby-boomer retirement affects all health professions.

MEDICINE
In Canada, decreased government funding did not affect physicians as much as med lab techs and nurses, mainly because physician numbers are much lower. However, in Alberta in the 1990s lab physicians lost jobs and, as might be expected, were compensated much more than other health professionals.  See 'History of 1990s Laboratory Restructuring in Alberta':

DECREASED GOVT FUNDING - LONG-TERM EFFECTS
In a way the long-term consequences of decreased government funding are the same for lab technologists, nurses, and physicians. Here I'll focus on transfusion medicine tidbits.

LABORATORIES
How have TM labs coped (saved money), and with what effect on medical laboratory technologists/scientists, post-government funding cuts?

Regionalization and centralized testing laboratories and increased automation all led to decreased staffing needs. But more than that, automated instruments led to a decreased need for well trained transfusion specialists.

Less educated and specialized staff
Hospital transfusion service labs are more than happy to decrease costs by hiring lab assistants (some with formal educational qualifications but also those trained on the job). Generalist technologists who work in other labs such as chemistry and hematology also play a key role, especially in labs beyond the centralized transfusion service lab and in rural areas.

The result has been fewer and fewer transfusion specialists with more and more staff relying on the few specialists to problem solve and keep transfusion service laboratories functioning safely. When TM specialists retire, who can fill their key role?

Dummy-proofing
For decades, some TM educators have referred to hiring less well educated staff as the 'dumbing down' of the profession. That sounds harsh but does not mean that lab assistants or generalists are dumb because they clearly are not and deserve respect. Rather it means that with the advent of automation and 'mistake-proofing' tools, many staff no longer need to be as educated and trained as before. For example:

Tools
Mistake-proofing is designing processes and devices to help prevent errors and make them obvious at a glance. Synonyms include error-proofing, fail-safing, and the politically incorrect idiot-proofing. Mistake-proof devices are common in daily life. Ex:

  • Beeping alerts when keys are left in cars or headlights are left on
  • Computer dialogue box that asks, "Do you want to save the changes you made...."
Mistake-proofing tools are also commonly used in transfusion processes and include:
  • Checklists for specific processes;
    • Inspection checklists for receiving blood into inventory;
    • Pretransfusion nursing checklists;
  • Colour-coding of ABO antisera;
  • Cross-checking work done by others;
  • Barcodes on donor bag labels;
  • RFID for release of transfusion units from refrigerators and more (Further Reading)
Bottom line - Labs: To make a transfusion lab run safely, some staff  must be well educated transfusion specialists.  How many depends on the locale, test volume, patient mix, etc. My experience is there are too few specialists and they're aging, about to retire in large numbers.

NURSING
How have hospitals and blood suppliers coped (saved money), and with what effect on nurses, post-government funding cuts?

Hospitals
In hospital wards across Canada there are fewer and fewer RNs, also fewer LPNs. Instead we have a new category of health worker, called by various names, including heath care aides and nursing attendants.

In Canadian hospitals, such workers usually have formal qualifications taking about a year to complete, including an internship. They often are the main care givers, especially to the elderly in long-term care.

Besides being short-staffed, the big nursing change within hospitals, discussed in the first 'disruptive force' blog, is the advent of transfusion nurse specialists/safety officers and blood conservation nurses. But they arose from the tainted blood tragedy and government regulation, not government cost-saving measures.

Blood suppliers
In Canada, as a cost saving measure, CBS decided to axe the number of expensive nurses it employs by hiring cheaper on-the-job trained 'donor care associates'.

* Health Canada approves new blood donor screening model (10 Feb. 2013)

This correlates to how USA blood donor centers operate, where  phlebotomists are trained on-the-job to draw donor blood and perform other functions. Having a Certificate of Phlebotomy helps since employers would rather get trained staff to decrease their costs.

Once I joked that CBS may do the same with its transport staff.



Bottom line - Nursing: I've no idea how well 'donor care associates' work at CBS and what effect, if any, their employment has had on nurses, other than fewer jobs available. On hospital wards, nurses suffer from short-staffing and a different mix of staffing, which is stressful.

PHYSICIANS
How have TM labs 
coped (saved money), and with what effect on medical staff, post-government funding cuts? With regionalization and centralized testing labs, fewer transfusion service medical directors exist because one physician fulfills the role for an entire health region. 

And, although all staff have responsibility, transfusion service medical directors are ultimately responsible for keeping patients safe, which becomes more challenging with staff shortages and a different mix of staff.  

In the health care system in general, several strategies have been floated to decrease physician costs, and some have been tried. 


For example, in Alberta a system of primary care networks exists (Further Reading). They work well (I've accessed one myself) and consist of physicians and other health professions, including nurse practitioners, dietitians, respiratory therapists, exercise specialists, etc.

The cost saving derives from the benefits of preventative medicine and using less expensive health professionals as appropriate. Now that Canada has assisted dying legislation, the Alberta government expanded the list of medical professionals authorized to assist patients with their deaths to include nurse practitioners. (Further Reading) 

The news item that caught my eye dealing with physicians:

  • How physicians can keep up with the knowledge explosion in medicine (Further Reading)
The article proposed interesting solutions:
  • Create 'paralegals' for medicine (para-medicals)
    • Meaning let nurses and junior doctors do more
  • Build a learning medical information ecosystem
  • Wow, what a bafflegab mouthful! At first it seemed to mean teamwork between health professionals (always a great idea), but then the authors pivoted to information technology. 
Always the technological solution, eh? Makes me laugh because I know physicians who have difficulty using their office computer system to renew a prescription easily. And some of these docs are not that old.
  • Mutter, mutter...Why won't it let me select renew? Aaargh! (Then writes it in pen on the computer print-out)
And how many physicians resist Twitter as a huge waste of time and don't see it as a valuable tool? Yet they attend medical rounds for the sandwiches (and to be seen) and chitchat or snooze or check e-mails throughout? Or perhaps, just to show how clever they are, ask the presenter an obscure question?  Perhaps I'm being too cynical but that's how it seems sometimes.

Bottom line - Physicians: On a personal level, transfusion physicians have been more successful than lab technologists and nurses in fighting job loss caused by government cutbacks. Or maybe it just seems that way because their numbers are fewer. Of course, medical directors of transfusion service labs feel the full staffing effects of having fewer specialist lab technologists/scientists.

I cannot but smile imagining physicians being told they must concede a significant percentage of what they always considered their health care role to others. But don't worry about it, docs, it's to your advantage. Others will now do the boring 'grunt work'. And you'll be able to concentrate on the interesting, complex stuff you were educated for. Don't worry, be happy.


SO-WHAT? 

LOW MORALE AND MORE
With cost cutbacks, low morale affects all health professions to varying degrees. My experience is morale falls mainly due to uncertainty, lack of control, and feeling devalued

When government cutbacks occur, health systems are stressed to the max and are forced to change. You might think of it as tough love. The change includes finding innovative ways to keep functioning safely. What often results is a series of experiments, experiments in which both staff and patients are the guinea pigs. 

Often outside consultants are brought in to push and implement what is often the hobbyhorse that's become their cash cow. Sorry, couldn't resist the mixed metaphor. They implemented 'the solution' elsewhere and now they're the experts, commanding big money. It's led to the joke
  • 'We're consultants and we're here to help you.' [Sure you are.]
➽In this system-wide experimental laboratory where cost saving rules, the biggest impact on staff is uncertainty and loss of morale. Change is always hard but even 'keeners' can soon become unhappy when they learn that they have no control over events, including job loss. Competent, skilled staff are let go because their positions are eliminated. In a unionized environment sometimes the 'best and brightest' lose jobs due to lack of seniority.

Moreover, staff who survive the cuts often feel guilty. The 'Why me, not them' syndrome. Suddenly folks you've worked with for years are gone, perhaps needing to change careers they love, and you're left for no apparent good reason. Some may even need a job to care for their families away more than you do but....

In such an environment staff invariably begin to feel devalued. Unfortunately, this is one of the most long-lasting invidious effects of cost restraint in which it matters not how capable someone is, how dedicated or how loyal. Staff begin to feel like checkers being moved around a board, where any checker will do. 

Effects such as low morale take a long time and much effort to reverse. It seems that some feelings are branded into people's souls, and not in a good way. 

The other long-lasting invidious effects are mistrust and cynicism about the intentions of governments, that with a limited money pot, make choices that cripple a health system and leave it with a lasting hangover. This happened in Alberta, Canada in the 1990s.

Similarly, where massive funding cutbacks lead to significant job loss, internal disruption and re-organization, distrust and cynicism invariably extend to the administrators who lead the health system, whether those at hospitals or the blood supplier. 

The health care system becomes similar to a dysfunctional family with some of its characteristics
'One or both parents exert a strong authoritarian control over the children. Often these families rigidly adhere to a particular belief (religious, political, financial, personal). Compliance with role expectations and with rules is expected without any flexibility.'
In the case of health care, the de rigueur belief system includes cliches such as 'do more with less', 'work smarter, not harder', the lean business model and its many variants rule. Oh, and by the way, no dissent allowed

One final tidbit: The long-term effect of decreased government funding leading to less educated and trained staff is disconcerting because 
  • A little knowledge is a dangerous thing. 
The most dangerous folks in any profession are those who do not know what they don't know. And that plays out daily on hospital wards and in transfusion services labs, where we can only hope there are enough well educated specialists to catch errors leading to patient harm. 

SUMMARY
In this blog I muse about the short- and long-term effects of the disruptive force of decreased government funding for health care and transfusion medicine in particular.It's happening everywhere.Will governments have a

It's doubtful. Today governments still do not consult frontline workers enough, or at all, about coming cutbacks and give them an opportunity to participate fully in a transparent change process.

Changing government policy is difficult and analogous to Newton's First Law of Motion:
A body at rest will remain at rest unless an outside force acts on it, and a body in motion at a constant velocity will remain in motion in a straight line unless acted upon by an outside force.
A sufficient outside force hasn't acted because professionals in the health system tend to accept whatever poop falls on their heads and do everything to make it work. Don't rock the boat, yes, this worries us, but let's wait and see. Somehow we'll muddle through, even if it creates much stress to us.

That's the thing. Physicians, nurses, lab technologists/scientists in transfusion service labs make the system work, regardless of the personal cost to their health and well being. And those in charge, physician-administrators
 (see below), bureaucrats, politicians alike, seem happy to let them. 

FOR FUN
This song has been used before because it fits some of the blogs and, face it, I obviously like it.

For interest, in 1988 McFerrin's song was used by 'Bush 41'  - a one term President - as his official campaign song without McFerrin's permission. McFerrin protested, stated he'd vote against GHW Bush, and dropped the song from his performances. Ouch!

Anyway, given recent political events in the USA, you can likely guess my take on Donald Trump. Similarly for the long-term effects of government cutbacks, I could slit my throat (figure of speech) or sing this song and I choose the latter.

Here's a little song I wrote
You might want to sing it note-for-note
Don't worry, be happy
In every life we have some trouble
But when you worry, you make it double
Don't worry, be happy Don't worry, be happy now


As always comments are most welcome.

FURTHER READING

CSTM blog: I will remember you: Dianne Powell on lab restructuring

Dec. 2015 blog: Islands in the Stream (Musings on how love of transfusion medicine unites us)

How physicians can keep up with the knowledge explosion in medicine (19 Dec. 2016)


The rise of the hospital administrator [Reality is that hospital administrators railed at in the article are often physicians who've become 'suits'.]

Alberta's Primary Care Networks | Edmonton Southside PCN

Alberta government expands medical professionals authorized to assist patients with their deaths, by including nurse practitioners (12 Dec. 2016)

Truth about the nursing job market

USA blood industry consolidation

Blood industry shrinks as transfusions decline (2014)
Blood centers should position themselves to be agents (not victims) of change (2014)

U.S. health care from a global perspective

U.S. spends more on health care than other high-income nations but has lower life expectancy, worse health
Middleware revolution bridging automation gaps

UK health agency plans RFID trial to staunch transfusion errors (2006)

The case for RFID in blood banking (USA perspective, 2016)

Saudi's destructive oil freeze (March 2016)