'Get back' Jo Jo (Musings on cognitive dissonance)

This blog is about competing blood safety standards and a current conflict that caused me to muse on cognitive dissonance. The title comes from a catchy 1969 Beatles song with silly lyrics.

Cognitive dissonance (CD) is a fascinating thing. I've experienced it several times over the years, ie., the uncomfortable mental conflict that arises when holding incongruous beliefs simultaneously. An example is the conflict that many nicotine addicts feel knowing that smoking is bad for them, yet at the same time managing to convince themselves that it is not that bad, even believing it is "good" for them in some ways (e.g., helps to cope with stress, fit in with peers, etc.)

Currently I'm experiencing CD that started with the

• AABB Letter to The Joint Commission Regarding Proposed Blood Transfusion Service and Donor Center Standards

The letter requests a meeting to discuss AABB's concern about TJC's creation of a separate set of blood standards for hospitals. Excerpts:

"AABB was both surprised and dismayed to see that The Joint Commission has determined not to incorporate AABB standards into its most recent proposed standards, but rather to draft a separate set of blood standards applicable to hospitals accredited under The Joint Commission's laboratory accreditation program."

"We do strongly believe that the proliferation of overlapping, but potentially divergent, standards for transfusion services and blood banks is a disservice to hospitals and will actually decrease patient safety as hospitals work to adhere to two separate sets of standards. Further, the time and resources that will be required to ensure that the proposed standards do accurately reflect AABB standards, now, and in the future, are significant."

As mentioned in the letter, AABB standards have existed since 1958 and are widely adopted within the USA and worldwide. I do not know why TJC decided to set up another set of blood standards that do not incorporate AABB standards. The US blood bank community already has an array of compulsory government regulators and voluntary accrediting bodies, including FDA / CBER, AABB, CAP, FACT, and TJC.

That said, regarding the new TJC regulations and their impact on hospital laboratories, AABB-accredited or not, I have no idea about the range of opinions that may exist within the USA. Nor will I wade into the morass of competing blood standards and regulations in the US.

COGNITIVE DISSONANCE
Instead, this blog muses on the cognitive dissonance that unexpectedly occurred after reading the AABB's TJC letter.

For those who do not know, TJC operates accreditation programs for a fee to subscriber hospitals and other health care organizations (> 17,000). Most state governments recognize TJC accreditation as a condition of licensure and Medicaid (health program for low income individuals / families) reimbursement. Like all voluntary accrediting organizations, AABB also charges users for its inspection and accreditation services.

The two competing thoughts:

• Thought "A": AABB standards are exemplary and, of course, AABB is right in saying, "What the hey! Slow down and reconsider these new TJC standards. This is nuts and could harm patients!" They said it more respectfully, of course, but that's the core message.
• Thought "B": Yes, all that's true, but AABB has a big investment in its standards and a vested interest in preventing anything that threatens to undermine their primacy. Many of its activities revolve around standards, especially the standards and associated accreditation activities, as well as AABB Consulting

Indeed, standards are arguably the AABB's prime line of business, more important than its role as a professional association. The AABB standards are its main brand. Think of AABB and what do you think of? Standards. If American, think of blood safety standards and what comes to mind? The AABB. Even its mission statement incorporates the term standards:

• AABB advances the practice and standards of transfusion medicine and cellular therapies to optimize patient and donor care and safety.

In a nutshell:

• Thought A: AABB is clearly right and has the moral high ground because it's fighting for patient safety.
• Thought B: AABB is motivated by self-interest and fighting for survival of its main business line.

What to do with the cognitive dissonance that arises? CD theory proposes many ways to reduce CD. Dilbert has several CD-related beauties:

• CD cartoons
• My favorite

The coping mechanisms in the Dilbert cartoons are discussed in

• Fighting cognitive dissonance & the lies we tell ourselves

So, let's see. I could reduce dissonance by thinking as follows (a few examples, some tongue in cheek):

• "AABB may be motivated by self interest, but it does such good work, I don't care."
• "TJC is out of line, dead wrong." (I don't know TJC's rationales and would like to hear its viewpoint first.)
• "AABB does good work. But what it proposes is in its self interest and has to be taken with a huge grain of salt."
• "TJC is a good organization. It must know what it's doing. I just don't know what the justification is yet."
• "AABB has jumped at the chance to accredit everything going. It wants to dominate the TM standards world, evidenced by removal of 'American' and 'blood banks' from the name. They are power hungry and will fight to the last standard standing."

For now, the questions remain. Which position is closest to the truth? Who cares? Should we all care?

CANADA

Interestingly, for years the Canadian Society for Transfusion Medicine has produced

• CSTM blood safety standards

In 2004 the Canadian Standards Association came out with a new set of blood standards, revised in 2010:

• CSA Standards for Blood and Blood Components Z902-10

This resulted in the need for CSTM to revise its standards to incorporate CSA standards. So with TJC and AABB, some aspects seems like deja vu all over again (to quote Yogi Berra).

At the time I wrote about the impact on hospital transfusion services:

• CSA Standards Z902-04: implications and issues

Excerpts:

• "While regulations and standards share many similarities, they differ in one fundamental respect: regulations apply standards through the force of law and provide penalties for noncompliance. Standards, in and of themselves, are never legislative tools. To have the force of law, standards must be incorporated into the regulations.
• Health Canada is currently developing new regulations specific to blood and blood components intended for transfusion under the Food and Drugs Act. Health Canada will use CSA Standards as one of several tools employed to develop new federal regulations for blood and blood components. Based on the Standards, a goal of the proposed regulations is to outline clear and intelligible requirements, allowing for timely updating as new technologies / products / issues emerge, and achieving greater harmonization in Canada related to blood collection, handling and post-market surveillance.
• A review of Z902-04 is currently underway [ by Health Canada] to determine which parts can be referenced in the new regulations. Some sections of the standards fall outside of Health Canada’s jurisdiction and will not be referenced in the new regulations."

Tidbits:

• Since the 2004 article was written, CSA Z902-04 has come and gone, replaced by CSA Z902-10, and still no regulations for hospital transfusion services have materialized from Health Canada.
• CSTM is a relatively small organization yet has had to invest much time and energy to revise CSTM Standards for Hospital Transfusion Services to comply with CSA Z902-10.

Where does all this leave organizations that had been using CSTM Standards? Where does it leave the CSTM Standards?

BOTTOM LINE

In the USA, AABB is 'dismayed' that TJC chose not to incorporate AABB standards into its most recent proposed standards and strongly believes that proliferation of overlapping, potentially divergent, blood standards is a disservice to hospitals and will decrease patient safety.

• Is AABB clearly right? Does it have the moral high ground because it's fighting for patient safety?
• Or is AABB motivated by self-interest and fighting for survival of its main business line?
• Are both statements true?
• Does any of this matter?

Readers can decide for themselves. Perhaps the issues will become clearer as events unfold.

But it's obvious that anyone with AABB accreditation (nearly 2000 institutions, the vast majority in the USA, and no doubt including all of the large transfusion service laboratories) - and any institution thinking of becoming accredited - would be unhappy to say the least. If unchanged, TJC's action will cost AABB-accredited institutions time and energy that could be better spent elsewhere.

In the meantime, the song that comes to mind is this irreverent Beatle ditty, sung here by Paul McCartney in live performance:

• Get back

Maybe The Joint Commission ('Jo Jo') should get back to where it once belonged?

And for a fun change of pace, since summer has come to an end, at least in my corner of the globe, from André Rieu's 2004 concert in Cortona, Tuscany, a lovely version of

• The Rose (Carmen Monarca, Carla Malfioletti, and Suzan Erens)

As always, the views are mine alone. Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice. 

Take this job and shove it (Musings on process efficiencies in the blood system)

This blog was motivated by annual reports for Canada and Ireland's national blood suppliers included in TraQ's September newsletter:

• CBS 2009-2010 Annual Report
• IBTS 2009 Annual Report

Both reports emphasize the need for ongoing cost efficiencies. As well, TraQ's August newsletter featured cost savings in the UK NHSBT due to reorganization that decreased the number of testing and processing centres.

The blog's tongue-in-cheek title derives from the old Johhny Paycheck hit:

• Take this job and shove it

Before beginning, allow me to digress briefly and explain how the blog's monthly topics come about:

1. It's usually a last minute thing, during which inspiration comes (or not).

2. Besides current relevance, my main concern is to appeal to as many TM professionals as possible. This means that at least one aspect of each blog should be meaningful to all who work in TM, regardless of profession, e.g., serologic issues, no matter how fascinating to me as a lab technologist, are out.

3. Taking a contrarian view that goes against current established dogma is in. Everyone should have their beliefs challenged now and then.

4. Perspectives cannot be so controversial as to alienate cherished friends and colleagues. It's a tricky judgement call (see addendum below).

That said, this blog's topic focuses on how CBS (Canada's national blood supplier) treats cost savings in its latest annual report, specifically how it stresses process efficiencies that result in a decrease in "the number of labour hours" (i.e., staff reductions). I could have written about other aspects of the report such as the self-congratulatory tone typically pervasive in such documents, but what fun would that be? <8-)

How does the CBS report relate to you, given that you are probably (i) not Canadian and (ii) not a CBS employee? Some possibilities:

• It may amuse you to see how saving people's lives via transfusion has become so business-oriented.
• If you are employed as a TM professional in any capacity, learning how one employer views process efficiencies, and what achieving them usually means, may apply to your situation now or in the future.
• There are interesting data on staffing and other costs that you can compare with costs in your own country.

MUSINGS ON BLOOD SUPPLIER COST EFFICIENCIES

The quotations come from CBS's 2009/2010 annual report

First, some musings on language. This year's report is called the "Annual Checkup" and extends the medical analogy with headings such as "healthy results"; "vital signs"; and "We're making surgical decisions" in its introduction. Most Canadians, if they read the report at all, are unlikely to make it past the 'cutesy' introduction apparently targetted to the public, not TM professionals.

Thereafter, the report takes on a distinctly business perspective and is replete with business jargon. Examples (my comments in brackets):

• This financial report includes forward-looking statements. (Statements based on assumptions and projections that may not occur, made in the interest of transparency and butt-protecting so that investors do not unduly rely on expectations of a company's success)
• CBS "operates four lines of business"....(An internal business unit, i.e., their main business activities)
• There are threee "major drivers that impact our budgetary environment" (Cost driver = term associated with activity-based accounting: any factor that causes a change in the cost of an activity) (Gotta' love the bureaucratese: budgetary environment = budget).
• The organization’s liquidity is largely affected by the timing of funds received. (Liquidity = ability and ease of an asset to be converted into cash quickly.)
• Regarding purchase of plasma protein products from Canadian and international suppliers, which result in cost fluctuations due to changing exchange rates: "To manage costs more effectively we continue to hedge a portion of our currency requirements." (Hedge = An investment position taken to protect investors from the risk of an unfavorable price change.)

All of these terms stimulate musings on CBS as a business attempting to achieve ever more cost efficiencies. Since Canadians fund CBS through provincial and territorial governments, in a way Canadians are all shareholders, albeit indirect, non-voting ones and shareholders have the chance to question financial reports.

As background, the CBS report includes these tidbits on staff costs (paraphrased):

• Staff costs make up ~59% of total 'transfusable products' expenses (components collected, tested, prepared by CBS)
• Staff costs increased 0.9% (compared to 4.9% in the prior year)
• Further efficiencies will come from more process efficiencies, i.e., the number of labour hours required to collect, test, manufacture and ship products will decrease.

As a shareholder, it would be interesting to see the average percentage increase in staffing costs for the 75% of CBS's unionized staff (clerical, laboratory, facility maintenance, IT, transportation, nursing), compared to non-unionized staff (managerial, medical, legal, and executive). Of course, since both staff groups are diverse, it may make more sense to provide a detailed analysis of staffing cost increases.

For example, on average costs for "group A" increased by x%, for "group B" by x%, etc. Even though there are significant differences between staff in any one category, thinking as a shareholder, such a breakdown could be informative.

Since its creation in 1998, transparency has been a key CBS goal. The report states that

• Staff costs constitute a significant expense and is influenced by product demand and collective agreement obligations and goes on to note:
• "While it is difficult to influence our labour rates (nearly 75% of our workforce is unionized) and demand for our products, we do have the ability to improve our process efficiency."

But what about the 25% of staff who are non-unionized? Since the report brings up the unionized workforce in the context of cost efficiencies - by CBS's own logic - the 25% of its non-unionized staff could be a open to cost scrutiny, yet no mention is made of it in the report. Although there are fewer of them, one quarter is not insignificant. (I know, I could have used significant but not insignificant is used as a litote.)

Addendum (28 Sept. 2010): I've had feedback on the blog since it was written and would like to clarify that the blog's discussion questions the reasoning behind the following statement from the CBS report and is not meant as a comment on anyone's compensation: "While it is difficult to influence our labour rates (nearly 75% of our workforce is unionized) and demand for our products, we do have the ability to improve our process efficiency." I have also altered some examples that may have suggested otherwise. Thanks to those who took the time to write.

As an aside, the Internet has all kinds of unexpected information. Just like contracts for unionized staff that outline salaries and negotiated increases (available on union/association websites), many of the salaries of non-unionized CBS national staff are publicly available on provincial government websites if you know where to look.

The first time I saw my fees as a contracted supplier of services on a health region's website, I flipped, thinking (incorrectly) that the information was private. The applicable freedom of information and protection of privacy act states,

• A disclosure of personal information is not an unreasonable invasion of a third party's personal privacy if the information is about the third party's position, functions or remuneration as an officer, employee or member of a public body or as a member of a minister's staff.

Process efficiencies also include such strategies as CBS's proposed Donor Care Associate role:

• "... multi-skilled workers will work in blood donor clinics to assess donor eligibility. Nurses will continue to be present in all our clinics, in leadership roles better aligned with their skills."

This approach (known as de-skilling) aims to replace health professionals (nurses) with less well skilled workers who can be paid less. It fits with strategies such as outsourcing as an attempt to pay less for workers, but only those on the front-lines in the trenches.

INFLUENCING DEMAND

Just as cost efficiencies should apply to all staff and even executives should be fair game for cost-cutting, so should demand for products. Influencing product demand is no simple task (another litote) and time intensive, but CBS has a mandate to help educate health professionals "to ensure our blood products are used wisely".

CBS educational efforts are extensive and include

• Presentations at local and national symposia and conferences
• Funding educational events
• Liaison with local transfusion service staff
• Development of an educational transfusion website 
• A joint initiative with CIHR to fund research on blood utilization and conservation.

Although mentioned in the report, why did the report not more directly link existing and future educational efforts to potential cost efficiencies, instead of the almost sole emphasis given to process efficiencies (de facto synonymous with reductions of staff in the trenches)?

The report makes it seem that product demand is 'what it is' and cannot be affected.

• Is it because process efficiencies that reduce staffing needs are quicker and easier to achieve than physician education on blood utilization (no doubt true)?
• Does it reflect a mind-set and corporate culture that equates savings with reductions in staff costs because staffing typically accounts for so much of the budget?
• Is it because Lean and the concept of staff optimization (cousin of right-sizing, ubiquitous in the 90s, generally resulting in staff reductions) is the new religion?

Such thinking, once entrenched, often discourages creative problem solving that goes against or falls outside current dogma. Who wants to question those in power, often a career limiting move?

Regardless of the cause, more emphasis in the report on educational efforts to reduce demand and promote better blood utilization seem appropriate, given that

• Blood components and plasma derivatives are regularly transfused inappropriately (a huge waste that potentially threatens patient safety)
• Plasma protein products such as IVIG and albumin (as a 'business line') account for the largest percentage of CBS's expenses (48.2% compared to 45.6% for fresh blood components) and costs increased by 14.7% in 2009-2010.

Highlighting the fact that reducing product demand is achievable and will result in cost savings would also validate the too often unsung efforts of CBS staff who go the extra mile to educate colleagues on effective blood usage and best practices.

Just for fun, enjoy Dolly Parton's mega-hit, Nine to Five

As always, I alone am responsible for the blog's content. Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice. 

Goldfinger's filings, a customer's toolkit (Musings on business intelligence)

Updated: 28 Jan. 2017 (Fixed broken links)

This blog's thesis is only slightly tongue in cheek but its title definitively is. The title derives from the ubiquitous toolkits currently found everywhere in transfusion practice, and the 1964 James Bond movie, Goldfinger in which the eponymous character is obsessed with gold, much like private companies are focussed on profits, albeit not usually with the same gleeful fervour as a sinister villain.

As an aside, Goldfinger has special memories for me because I saw the film in Tel Aviv, Israel in 1965. We had to buy tickets ahead of time (none sold at the door) and catch much of the dialogue by reading the French sub-titles (goodness knows why) due to the uproarious cheering of the audience at every Sean Connery feat. We were told that television was only on for a few hours each day and movies were incredibly popular.

By happenstance I came across the SEC Form 10-K Annual report for Immucor, a blood industry supplier of automated instruments and reagents. The 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.

Now before your eyes glaze over, if you work in the blood system in any capacity, I highly recommend that you take a peek at these fascinating reports. In a way, it's akin to industrial espionage, i.e., gaining access to information about a company’s plans, products, clients, and trade secrets in order to gain insights and predict their actions, including marketing strategies and sales pitches.

Normally it's competitors who engage in industrial espionage, but if you buy a company's products and services, you can potentially use the information to your advantage. Spying is illegal if the information is private but, since the SEC records are public, it's all above board and fair game.

Donning our sleuth caps, let's examine just a few aspects of the business intelligence that's publicly available in Immucor's July 2010 SEC filing and how it can be used to advantage by potential clients.

The specific information is most relevant to those in the lab but the lessons can be applied to dealing with any sales representative and related marketing, advertising, and selling strategies targetted to your profession.

Immucor's SEC 10-K report merely serves as an example. To all my sales rep friends and colleagues, as they say in the Godfather films, "It's not personal. It's strictly business."

Reality is that companies spend considerable time and effort getting to know potential customers and understand their likes, dislikes, wants and needs. Think of those free wine and cheese parties, dinners, and tour-the-bay cruises you've attended at conferences. They weren't just to create goodwill. Similarly, customers can benefit from knowing how companies think and what tools they will probably use to get you to buy.

Here's a mini-toolkit to get you started. Quoted text is from Immucor's SEC Form 10-K report (23 July 2010).

1. AUTOMATION

"Our strategy is to drive automation in the blood bank."

MUSINGS

Obviously, automation must be strongly promoted, since it is in Immucor's interest to sell its instruments and automated ("capture") reagents. As mentioned in an earlier blog, the latter have one of the highest gross profit margins in the industry, 80.2% in Immucor's 3rd quarter for 2010.

From a client's perspective, profits in the range of 80% may seem excessive. But profits are the primary purpose of private enterprises. From the company's perspective, the higher the profit the more they will be able to

• pay shareholders
• raise additional financing
• survive in hard times
• invest in R&D that can develop new products and lead to continued or increased profits.

However, to drive automation and increase profit, automation must be seen not as a way to increase profits, but as a way for clients to save money while improving safety.

Hence the comapany's sales pitch:

"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.

We also believe that automation can improve patient safety, can increase operational efficiency and, for customers such as integrated delivery networks with multiple blood banks, can permit the standardization of best practices.

For Immucor, automation allows us to gain market share and secure a long-term, contractual relationship with our customers."

MUSINGS

On the safety issue, while it may be true (or not), is there published evidence to support a decrease in life-threatening errors and resultant increase in patient safety after Immucor's automated instruments have been introduced in the transfusion service?

Don't ya' love "reduce headcount," an euphemism for eliminate staff, and interesting that it merits first place ahead of "improve patient safety."

About the "current shortage of qualified blood bank technologists", this largely happened because restructuring and regionalization with associated automation led to fewer jobs, which in turn led to closures of medical technology schools. Concurrently, at least in Canada, nurse and physician education programs were also decimated.

In Canada, in response to increased demand, more technologists (nurses and doctors) are now being trained, but a significant number of jobs for technology graduates continue to be part-time.

In a way, automation contributed to a shortage of "qualified blood bank technologists" and now automation is being promoted as a solution to the shortage. Say what?

Fact is that automation allows for less trained staff to perform routine work in the transfusion service and leads to fewer blood bank specialists. Isn't it having it both ways to say that automation now solves the problem that it intrinsically helped create?

In the past, I recall that Immucor promoted its automated instruments to transfusion services as a way to save ~1.5 staff members and to allow remaining staff to concentrate on more 'important stuff' for thinking technologists (i.e., humans) such as identifying antibodies.

In today's economic climate, I imagine that cost saving is still the main mantra of the sales reps, with patient safety tossed in as a 'feel good' justification for eliminating jobs.

With automation, it's worth considering what is actually happening, i.e, a transfer of money from people (staff) residing in a community (people who pay taxes, buy houses, shop and support local businesses, and contribute to community life) to generating profits for a large corporation situated elsewhere. Does this benefit society in the long run? Complicated question but I sometimes wonder.

Obviously those considering automation need to extensively analyse multiple factors between competitors such as

• initial capital costs
• ongoing maintenance and reagent costs
• sensitivity and specificity (as applicable)
• ease of use
• ease of transition and implementation (impact on other processes & procedures)
• redesign of physical layout, etc.
• training requirements, and more

Potential clients should also consider Immucor's huge gross profit margins when negotiating reagent contracts. And it's worth remembering that those long-term contracts for reagents are where the money is. From the NEC submission:

"As of May 31, 2010, we had an instrument backlog of approximately 179 Echos and 43 Galileo/NEOs. This backlog represents instrument orders that have been received but the instruments have either not been installed or the customer validation process has not been completed.

As such, the instruments are not generating recurring reagent revenue at their expected annualized run rates. ....we had not recognized approximately $16.7 million in deferred revenue from instrument sales contracts that had reagent price protection and from extended warranty sales."

Note that Immucor considers extended sales contracts to have built-in reagent price protection. Did they mean protection for themselves or clients or both?.

#2. NEW PRODUCTS

Successful companies must continually innovate to create new products and generate new profits.

" For the fiscal years ended May 31, 2010...we spent approximately $15.4 million...for research and development. Research and development expenses have increased over the past three years due to the acquisition of BioArray...and the subsequent development work on our molecular immunohematology offering."

"In August 2008, we invested in what we believe will be the future of the blood bank – molecular immunohematology....With the goal of improving transfusion medicine, we believe that molecular immunohematology will revolutionize blood bank operations.

In many countries, blood pre-transfusion testing is limited to the prevention of transfusion reactions and not for the prevention of alloimmunization, which occurs when antigens foreign to the patient are inadvertently introduced into the patient’s blood system through transfusions. If alloimmunization occurs, the patient develops new antibodies in response to the foreign antigens, thereby complicating future transfusions.

By using multiplex, cost-effective molecular testing, our molecular technology allows testing to prevent alloimmunization for better patient care."

MUSINGS

In a consumer society, if a real need does not exist, companies try to create one.

So, can we now expect an onslaught of propaganda and industry-funded research to convince us that preventing alloimmunization is where it's at and what we should strive for?

My gut reaction is fuggedaboutit! But the writing is already on the wall:

• Hillyer CD, Shaz BH, Winkler AM, Reid M. Integrating molecular technologies for red blood cell typing and compatibility testing into blood centers and transfusion services. Transfus Med Rev. 2008 Apr;22(2):117-32.

#3. RISKS

Under "Risks", Immucor lists FDA "administrative action", governmental investigations and litigation, fluctuations in foreign currency, and more. Three that stood out:

(i) "A catastrophic event at our Norcross, Georgia facility would prevent us from producing many of our reagent products.

Substantially all our reagent products are produced in our Norcross facility.... and we currently have no plans to develop a third-party reagent manufacturing capability.

Therefore, if a catastrophic event occurred at the Norcross facility, such as a fire or tornado, many of those products could not be produced until the manufacturing portion of the facility was restored and cleared by the FDA.

We maintain a disaster plan to minimize the effects of such a catastrophe, and we have obtained insurance to protect against certain business interruption losses.

However, there can be no assurance that such coverage will be adequate or that such coverage will continue to remain available on acceptable terms, if at all."

MUSINGS: Despite a disaster plan to minimize effects (on clients and the bottom line?) the company's main worry seems to be that its insurance may not cover its losses.

Clients need to include a scenario with a possibly very long delay in obtaining reagents in their disaster plans. Think not only of time to restore production but also time to obtain FDA clearance on a restored facility.

(ii) "Gross margin volatility may negatively impact our profitability."

"Our gross margin may be volatile from period to period due to various factors, including instrument sales, reagent product mix and manufacturing costs....

The higher margins on the Capture reagents used on our instruments may not be enough to offset the lower margins on the instruments themselves...."

MUSINGS: Once again, the importance of Capture reagents to profits is emphasized. Immucor's gross profit margins for these reagents are among the highest in the business. When faced with, "Have I got a deal for you", best to think twice.

(iii) "If customers delay integrating our instruments into their operations, the growth of our business could be negatively impacted."

From time to time in the past, some of our customers have experienced significant delays between the purchase of an instrument and the time at which it has been successfully integrated into the customer’s existing operations and is generating reagent revenue at its expected annualized run rate. 
 
These delays may be due to a number of factors, including staffing and training issues and difficulties interfacing our instruments with the customer’s computer systems.

Because our business operates on a “razor/razorblade” model, such integration delays result in delayed purchases of the reagents used with the instrument.

A number of steps have mitigated these integration delays: improved performance of our field service staff, better instrument instructions, increased use of internet-based remote diagnostic tools, and more efficient scheduling of instrument installations....."

MUSINGS

Potential clients should note the reasons for delayed implementation and acknowledgement of the “razor/razorblade” business model.

A “razor/razorblade” model is the well established business tactic of selling dependent goods for different prices. The one-time product is sold at a discount, while the second dependent one for which repeated purchases are required, is sold at a considerably higher relative price. Think of the practically free razor but expensive replacement razor blades or the low priced video game console and its dependent high priced games.

4. COMPETITORS

"In the U.S. and Canada, Ortho-Clinical Diagnostics (“Ortho”), a Johnson & Johnson company, is our main competitor. In Western Europe, our principal competitors are Bio-Rad Laboratories, Inc. (“Bio-Rad”) and Ortho. Both Ortho and Bio-Rad sell instrumentation as well as reagents. Our principal competitor in Japan is Ortho."

MUSINGS

There is not much competition in transfusion service / immunohematolgy automation, nor for reagents for non-automated testing. Immucor, along with its main US competitor, Ortho-Clinical Diagnostics, is being investigated by the US Department of Justice concerning possible criminal violations of the antitrust laws.

Perhaps not unsurprisingly, both are the subjects of several private civil suits by customers (hospitals) seeking class certification and alleging price fixing.

Anytime you have a market oligopoly, a virtual duopoly, allegations of collusion and price fixing are bound to occur, but they are almost impossible to prove. 

FURTHER BUSINESS INTELLIGENCE
For interest, a few more blood industry companies with SEC Form 10-K reports:

• Johnson & Johnson (1 Mar. 2010) (parent company of Ortho-Clinical Diagnostics)
• Tidbit in report (OCD has many more products besides reagents and automated instruments for pretransfusion blood testing)
• "The Ortho-Clinical Diagnostics franchise achieved sales of $2.0 billion in 2009, a 6.6% increase over the prior year primarily attributable to the recent launch of the VITROS 3600 and 5600 analyzers."
• Bio-Rad Laboratories (26 Feb. 2010)
• Beckman Coulter (22 Feb. 2010)
• Haemonetics (1 June 2010) - One tidbit (and are we surprised?):
• "Our devices use single-use, proprietary consumables, and these consumable sales represent 87% of our total revenues."

BOTTOM LINE
You can discover many useful tidbits in SEC Form 10-K filings. These tidbits can be used to help customers decide on suppliers and to leverage information when negotiating contracts. I hope that this Goldfinger toolkit has given a few ideas.

For fun, here's the theme song from the Bond movie of the same name:

• Goldfinger (by the wonderful Shirley Bassey)

As always, the ideas are mine alone. Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice. 

United we stand? (Musings on competition for blood donors)

This blog examines a recent news item on the effects of a poor economy and increased competition for donors among blood suppliers in the USA and muses on economic basics, as applied to blood suppliers. The blog ends with a silly skit suggesting what competition for donors might look like in Canada, where Héma-Québec reigns supreme in La Belle Province and CBS has a monopoly in the Rest of Canada. The title derives from an old hit song by the British pop group, Brotherhood of Man.

BLOG'S GENESIS
Unlike fractionated blood products, where commercial drug companies "duke it out" across the globe, competition in providing blood and blood components is something foreign to Canada and many other countries. Hence, this item from the USA recently caught my eye:

• Erie Community Blood Bank battles economy and competition

Apparently, in Pennsylvania competition for donors has become fierce: the Pittsburgh-based Central Blood Bank (a division of the Institute for Transfusion Medicine) has increased the number of blood drives in Erie County, although it doesn't supply blood to hospitals there.

"The turf battle came to a head July 1 when Community Blood Bank held an impromptu blood drive outside the Sheraton Erie Bayfront Hotel, while the Central Blood Bank was holding an indoor one. Employees from each blood bank exchanged heated words, but the two organizations haven't talked since then...."

A Community Blood Bank spokesperson is reported as saying,

• "It's a shame. We used to work together on projects. Not anymore."
• The Central Blood Bank declined to return the reporter's phone calls requesting comment.

So, competition for blood donors seems to have taken a nasty turn in the USA. The news item goes on to report that, with the current struggling US economy, the Community Blood Bank will lose money in 2009-10. It has not laid off employees but has increased its blood prices.
Pointedly, Community Blood Bank's website specifies that it "only draws from the areas in which it supplies."Writing a blog on the blood system as a business in which blood suppliers compete was further promoted when the latest Journal of Blood Services Management issue came out, prefaced by a letter explaining that it cannot meet its planned quarterly schedule. In reviewing the types of articles wanted, competition was listed as a suitable topic. For more on JBSM, see last July's blog, "Transfusion lite" - Back in the USSR?

For interest, you can now read the first JBSM issue free online.
ECONOMICS PRIMER
What follows is a simplistic take on complex economic issues. I'm totally unqualified on the subject, being a mere, somewhat cynical observer of private sector machinations to generate profits. But, hey, why let ignorance stop one from voicing opinions.
Canadian Blood Services (CBS) and America's Blood Centers (Héma-Québec, but not CBS, belongs) are non-profit organizations (NPOs). By definition, NPOs use profits, if there are any, to pursue goals, rather than distributing them to owners or shareholders.
To survive, NPOs and other businesses must be profitable in most years or at least break even. That means that revenues must exceed expenses. Successful companies increase revenues or decrease expenses or do both.

DECREASE EXPENSES
Decreasing expenses involves strategies such as
1. Decreasing overall staff (a significant cost) via automation, centralization, regionalization, e.g., CBS's move to only 3 blood testing centres for all of Canada and one National Contact Centre for booking donor appointments

2. Decreasing staffing costs, achieved by hiring less qualified staff who can be paid less, e.g., CBS's move to use "donor care associates" in donor screening (as opposed to RNs)
3. Hiring more part-time and casual staff whose health care, pension, and other benefits do not need to be contributed to by the employer (statistics are hard to obtain and are not usually publicly accessible)
4. Forming consortia (or merging with others) to facilitate volume purchases by the group, e.g., Group Services for America's Blood Centers
INCREASE REVENUES
Companies can increase revenues via increased sales volume or increased prices. In Canada (and other countries with mainly government-funded national blood suppliers), increasing revenues is not an option except by negotiating with relevant governments and who knows what goes on in those dark and dirty meetings, certainly not I.
In general, strategies used by companies to increase revenues may include the following. Some of these may apply to US blood suppliers.

• Create a demand for products, if none exists, or an increase demand (e.g., commercial umbilical cord blood banks such as Alpha Cord and Pacific Cord .The latter offers 'concierge service'!)

Get ahead of the curve by moving into emerging, 'latest/greatest' in-demand products, and charging more for them (so called value-based pricing) e.g.,human cells, tissues, and cellular- and tissue-based products

Produce a better product than competitors, preferably at a competitive price, or argue for your product's value-added benefits (e.g., leukoreduced red cells, double red cell collections, improved customer service)

Increase distribution area so that the number of potential clients increases (rapid, reliable long distance transportation)

Increase clients with loss leaders ("Like our cheap RBC? Now have we got a deal for you...."), and later promote products with high profit margins (e.g., inexpensive or free instrumentation with costly, ongoing reagents)

Entice more clients with a positive corporate image, e.g., promote impressions of quality products and services via public relations campaigns and community involvement

Develop an effective and easily recognizable brand identity for the organization, e.g., CBS's logo and tag line, It's in you to give

From the website: "Canadian Blood Services has updated all key brand positioning elements and personality traits. The result is a focus on positioning Canadian Blood Services as the trusted place where Canadians can share their health and vitality to help others regain theirs."

SILLY SUMMER SKIT
Since it's summer, and the city where I reside had its "silly summer parade" on Canada Day (July1), here's a skit that I hope makes you laugh. It's totally tongue in cheek and written with affection for the characters involved. My apologies to all concerned for taking such liberties.
Just as the Pittsburgh's Central Blood Bank made an apparent raid into the territory of the Community Blood Bank, I could not help but wonder, WHAT IF Héma-Québec made a similar raid from Hull, Quebec across the river into Ottawa, Ontario, the site of CBS's head office? (Rough translation follows the skit.)
START OF SILLY SKIT

• Graham (shocked): "Francine, quelle surprise! Mais, que fais-tu ici?
• Francine (playful): "Bonjour, Graham. Ça Va?"
• ===================================
• Graham (puzzled but now more formal): "Mais, pourquoi, Francine? Vous êtes sur 'my turf'!"
• Francine (smiling): "Oui, mais nous sommes toutes les canadiennes, n'est-ce pas?"
• ===================================
• Graham (ashen-faced): "Merde, Francine! J'accuse! N'avez vous aucune pitié?"
• Francine (chuckling with a wicked gleam in her eyes): "Graham, c'est un signe des temps. Vive le Héma-Québec! ...(long pause...) Vive le Héma-Québec libre!"
• ===================================
• Graham (sweating profusely): Mindy, aidez-moi, s'il vous plait! Notre amie, elle est....'bonkers'! Il doit être son expérience avec ces Européens fou au ISBT!"
• Mindy (ruefully shaking her head and with a mischievous glint in her eyes): "Désolé, mais vous êtes vous-même, mon ami! Voulez-vous le numéro de téléphone de Heather?"

SILLY SKIT (ROUGH TRANSLATION)

• Graham (shocked): "Francine, what a surprise! But what are you doing here?
• Francine (playful): "Good day, Graham. How goes it?"
• ===================================
• Graham (puzzled): "But why, Francine? You are on my turf!"
• Francine (smiling): "Yes, but we are all Canadians, no?"
• ===================================
• Graham (ashen-faced): "Sh_t, Francine! I accuse! Have you no pity?"
• Francine (chuckling with a wicked gleam in her eyes): "Graham, it's a sign of the times. Long live Héma-Québec! ...(long pause...) Long live a free Héma-Québec!" (see historical relevance in Canada)
• ===================================
• Graham (sweating profusely): "Mindy, please help me! Our friend, she is....bonkers! It must be her experience with those crazy Europeans at ISBT!"
• Mindy (casually shaking her head and with a mischievous glint in her eyes): "Sorry, but you are on your own, my friend. Do you want Heather's phone number?"

.............END OF SILLY SKIT.........
Doesn't a donor competition scenario, in Canada or anywhere, seem nuts? Everyone knows the maxim, united we stand, divided we fall, but is a Pennsylvania blood center ignoring it? Here's a sugar-sweet song version of the axiom:

• United we stand (Gotta love the 70's outfits)

MORE FUN
Another scenario comes to mind. WHAT IF the Brits made a raid across the Atlantic to poach American blood donors. As you ponder, consider lyrics for an updated version of this catchy Johnny Horton mega-hit, The Battle of New Orleans (funky version from Ed Sullivan show)
For a serious glimpse into CBS's view of its business management strategies:

1. The transformation of CBS. Strategy management to create results .....[Source: Sophie de Villers, Balanced Scorecard Forum in Dubai, UAE , March 2010]
2. Embedding a results-based management culture / Moving modern management forward (Speaking notes) ....[Source: Ian Mumford, Performance and Planning Exchange Conference, May 2003]

As always, the views are mine alone. Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice. 

I will remember you (Musings on mentorship)

In an article in the June 2010 issue Transfusion* Nancy Heddle wrote:

"Appropriate training and mentorship will serve as the foundation for the next generations of clinical trial specialists."

* Heddle NM. The randomized controlled trial: in celebration of Transfusion's 50th. Transfusion 2010 Jun;50(6):1173-8 (Published online Jan 15 2010)

This got me thinking about mentorship in transfusion medicine (TM) and how well this tradition is continuing. The blog's title comes from a love song by Canada's Sarah McLachlan, a song that can be applied to diverse relationships.Mentorship can be defined many ways, but I mean it simply as many informal ways, large and small, that professionals guide less experienced colleagues to help them enhance their knowledge, skills, and careers, while simultaneously gaining much in return.

ANECDOTES
First, some personal anecdotes. Over the years I've been fortunate to have several mentors, most of whom probably do not realize that I consider them mentors. As you read, consider reflecting on those who have mentored you.

One mentor was the lab manager at my first job working as a lab technologist. The manager encouraged me to read and eventually I devoured the three 'bibles' of the time, known simply as Race & Sanger, Issitt, and Mollison. The gems, both theory and practice, inside those textbooks gave me a solid foundation in TM, an advantage that helped my career progress.

During these early years the odd misstep was also tolerated, as when I decided to change a method in the reference lab (there were no written SOPs at the time), an alteration that I thought was brilliant but, in my ignorance, did not realize could have adversely affected test results. I received a well deserved and controlled verbal 'spanking' along with rationales for why my innovation was bad, but was not fired or otherwise disciplined. Instead I continued as a valued employee who had the ear of the manager and input into lab policies and operations. Despite being pre-quality systems, a culture of blame did not exist, a lesson that has stayed with me to this day.

A second mentor was a transfusion service physician with whom I worked closely for several years after becoming an educator and clinical instructor. Our relationship helped build confidence, especially being accepted as a colleague without any hint of a pecking order. Sharing many a laugh over student responses in oral exams (one example: anti-A₁ lectin = Delicious biflorus) significantly contributed to a sense of collegiality.

Working together on a research project and various interactions involving students enhanced my respect for the physician, who had incredible knowledge of immunohematology practices and the techie side of the lab. The confidence gained during this time to deal with physicians on a footing of mutual respect was essential to my career over the ensuing years.

Other mentors included a technologist who encouraged me to get involved with my professional society, which opened up many networking doors and led to lifelong friendships; and a colleague who taught by example valuable teaching skills, particularly the critical importance of respect and empathy for one's students as individuals.

MENTORSHIP in TM
There are many mentorship papers in the literature. [Note that you can filter results to reviews and free full text - see right side of screen.]

In preparing this blog, I also searched the Internet for mention of mentors in a TM setting. Some examples:

1. ASH has a mentor award.
General criteria to receive the award:

"...awardees will have had a sustained career commitment to mentoring, a significant positive impact on their mentees' careers, and through their mentees have advanced research and patient care in the field of hematology."

2. Several TM physicians discuss mentors and their influence. Random examples:

Ira Shulman's profile for BloodMed.Com

Paul Ness in an interview in HemOnc Today

The value of mentors in medical education is discussed by Natalie J. Belle (known as njbmd on the Student Doctor Network) in her blog entry on pathology (unfortunately, no longer online).

Of interest: "My pathologist mentor for Transfusion Medicine had a profound influence on the manner in which I practice medicine today. He was an excellent professor with a wonderful staff who was quite willing to show an eager medical student all aspects of Transfusion Medicine."

• "...willing staff and eager students..." Hmmm...

WHAT MAKES A GOOD MENTOR / MENTEE?
Two articles in particular caught my eye, one on each side of the mentorship relationship:

1. Davis OC, Nakamura J. A proposed model for an optimal mentoring environment for medical residents: a literature review. Acad Med. 2010 Jun;85(6):1060-6.

In brief, to develop a model of optimal mentoring for medical residents, the authors searched the literature. They found six attributes of a good mentor that were consistent across the 20 papers that met their inclusion criteria and that can serve as interactional foundations that underlie an optimal mentoring relationship:

• emotional safety
• support
• protégé-centeredness
• informality
• responsiveness
• respect

Among other things, this study suggests that, when guiding students and new staff, by modeling appropriate behaviors, we should convey that

• not knowing everything is normal and "okay";
• their needs are more important than ours;
• they are colleagues (not nuisances); and
• we respect them by responding to challenges, even those that differ from current dogmas.

2. On the other side, proteges also have responsibilities as explained in this paper:

• Melanson MA. Qualities of the ideal protégé. US Army Med Dep J. 2009 Oct-Dec:44-6.

According to the author, who discusses formal mentorship in the USA military, but whose ideas apply more broadly, the 10 most important qualities of ideal proteges (mentees / learners) include

1. Love of learning
2. Self -starter
3. Confidence
4. Prudent risk taking
5. Flexibility to rebound after mistakes
6. Enthusiasm
7. Open minded to advice and constructive criticism
8. Commitment to relationship with mentor
9. Loyalty (keeping confidences)
10. Gratefulness, to include becoming a mentor to others

As a former educator, I believe that these qualities constitute what could be considered the ideal student. The only thing I would add is a willingness to challenge established practices and policies rationally (asking why and requesting evidence), as opposed to accepting everything passively or offering knee-jerk opposition to authority (seen in some students, and a normal part of growing up).
A teacher's reply may often be the equivalent of

• historical precedence (no good reason - it's always been done this way)
• practicality (e.g., allows for reduced staffing on weekends)
• favorite 'hobby horse' of local pooh-bah (colleagues are afraid to challenge pooh-bah's beliefs, especially those of a grand pooh-bah)

WITHER THE MENTORS?
So, do TM professionals entering the field today, whether physician, medical technologist, scientist, or nurse, get the mentorship they need to develop as the 'next generation'? I'll speak to the technologist side of the question as this is what I know best.
Mentorship in the clinical lab seems on the wane. With ongoing cutbacks and finding ways to do more with the same or less, technologists have little or no time to train new staff fully, let alone mentor them.
Yes, training and competency assessment occur, as they must, but with few resources everything often devolves to the basic minimum. Is this situation specific to technologists or does it apply to other professionals on the TM team? Feedback is appreciated.
As well, with fewer technologists as TM specialists, training may not include problem solving skills, since cross-trained staff are directed to pass problems to supervisors. The option to by-pass problem solving by on-the-bench technologists may accommodate current realities, but the question arises,

• "What if there is eventually no one suitably trained to investigate anomalies and problems?"

With the anticipated retirement of baby boomers, this issue becomes more relevant. 

BOTTOM LINE
New recruits to TM need mentors. Indeed, without mentors there soon may be no recruits. The challenge is how to foster mentorship with diminished resources.
If potential recruits see TM as a fulfilling career (financially, intellectually, emotionally) AND if TM professionals view mentoring as an opportunity to make a real difference, mentoring will happen no matter what the challenges.
I have always been surprised, delighted, and humbled when colleagues acknowledge me as a mentor. There is absolutely nothing - NOTHING - that compares to the satisfaction of knowing that you played a role, no matter how small, in students choosing TM as a career, or that respected colleagues consider you to be a mentor.
Sarah McLachlan's I remember you offers a fitting sentiment for all mentors and mentees:

I will remember you
Will you remember me?
Don’t let your life pass you by...

JUST FOR FUN
Enjoy Islands in the Stream, a delightful duet by Dolly Parton and Kenny Rogers. 

Comments are most welcome BUT, due to excessive spam,  please e-mail me personally or use the address in the newsletter notice...and we have some (see below). Thanks to those who posted - great food for thought.

Smile on your brother: Musings on labour woes in the blood system

The idea for this month's blog came from the latest labour relations difficulties facing North America's blood suppliers. The title derives from the lyrics of a 1960s song recorded by many, Get Together.

USA - American Red Cross [ARC]

• Staff cuts at ARC harm blood supply, coalition says
• Connecticut: Red Cross workers: Phlebotomist firings due to contract tiff (includes comments from fired worker)
• Southern California: Nurses may strike over wages, benefits, practices
• Background (labor's perspective): Labor relations at the ARC and its impact on employee and donor safety (23 page report by Philip Dine)

Canada

• Canadian Blood Services (CBS): Nurses vow to fight CBS pilot to phase out RNs from donor screening
• CBS: "Moving forward to pilot multi-skilled workforce"
• Hema-Quebec [H-Q]: H-Q deplores union's attitude and invites the public to give blood

This blog uses the above labour conflicts to offer musings on the role of trust among TM health professionals. Because the underlying issue in any management / employee negotiation relates to trust, I will not discuss the specifics of the news reports. Besides, without in-depth knowledge of what is actually happening, analysis would be folly.
Many good friends are either staunchly pro- or anti-union health professionals. I know from experience that discussing union issues, like religion and politics, is sure to lead to passionate disagreements fueled by anecdotes and emotion, not objective, evidence-based logic, and may result in hard feelings. I'm hoping not to wander into that morass as the blog's narrative unfolds.
UNIONS
As background, to my knowledge, Canada's blood system, both blood suppliers and hospital-based transfusion services, are mostly unionized. Unionized workers usually include laboratory technologists, lab assistants, and nurses, and a diverse group of other staff, e.g., clerical, IT, lab scientists, maintenance, etc.
Some employees, e.g., TS laboratory managers and blood centre management positions, may be "out of scope" (not included in union contracts).
Practical implications of being out-of-scope include the

• ability to negotiate salaries and benefits directly with employers (and to keep them private from co-workers);
• subtle promotion of a them-versus-us mentality;
• ability of employers to fire you without the hassle of a union grievance.

As well, for non-union health professionals at senior levels, including dismissal terms in personal contracts, and threats of legal action for wrongful dismissal, may result in generous, golden handshakes for staff such as TS and blood centre medical directors.
Many of the news items referenced in this blog involve contract negotiations. From my experience observing Canada's blood system, frequently workers do not trust employers / management to do the right thing for employees, patients, and the public at large. The worker view is often that management has a hidden agenda, typically to save money, even at the expense of safety.
Conversely, it's not that rare for employers / management to regard unions negatively, and by extension to view their members as overpaid and more or less lazy, with unions leading to unwarranted, costly job perks and promotion of the most senior rather than the most competent staff. Management seldom voices such opinions publicly and would deny them if asked, but these viewpoints exist nonetheless.
Indeed, these perspectives reflect public opinion, with proponents on both side of the union issue.
The unproductive, adversarial mentality in labour negotiations seems relatively common everywhere despite major progress in labour relations worldwide during the 20^th C.
The sad fact is, that with contract negotiations, a lack of mutual trust is common. When discussions reach an impasse, each side often sees the other as self-serving and sometimes in even more negative terms.
Tidbit: In 2007, the percentage of employees that were members of a trade union (Source: OECD - Union density 1960 - 2007) included:

• Australia: 10% (2006)
• Canada: 29.4%
• Norway: 53.7%
• Sweden: 70.8%
• UK: 28%
• USA: 11.6%

These statistics likely do not include the employees such as physicians and university professors who are not members of a union, per se, but do belong to professional associations that act as unions by negotiating contracts and benefits.
A ROSE BY ANY OTHER NAME
When is a union not a union? When it calls itself a professional association. When working at the University of Alberta I was in the Association of Academic Staff, which negotiated salaries and benefits for professors. The Association's activities approximate that of a trade union.
In Canada, health care is a provincial jurisdiction and provincial medical associations negotiate physician fees that are binding for insured services.

• See Paying for Physician Services in Canada (1996)

Despite their loftier broader goals and objectives, Canadian provincial medical associations perform some of the same functions as unions. Yet unions may be disdained by some professionals partly because of their origin as trade unions, with "trades" somehow being more lowly than professions.
For interest, Norwegian and Swedish physicians have no problem in identifying their medical associations as unions. Many of their physicians are state employees, as are physicians in many other European countries.

• Swedish Medical Association
• Norwegian Medical Association

To my knowledge, Canada's transfusion medicine physicians (hematologists, hematopathologists, pathologists) who work for transfusion services and blood suppliers are usually salaried employees, although they often have multiple appointments that earn additional salary. In essence, they too belong to professional associations that function partly as trade unions.
TRUST
People who work as part of any health care team must trust each other's competence, trust that each will to do the best job possible, maintain a high level of quality care, and put the patient first. There are checks and balances in the TM system, e.g., audits of blood transfusion requests, error management programs, etc., but the system would not function without trust in a colleague's motivation and competence. The first instinct of health professionals is to trust each other to maintain high practice standards, unless shown otherwise. For example:

• When talking to a nurse on the ward who reports a possible transfusion reaction or to a physician in the ER who requests unmatched RBC, do lab technologists routinely think, "That lazy bum is so self-serving"?
• When discussing follow-up treatment of patients suffering from transfusion complications with nurses, or holding a staff meeting with laboratory staff to plan implementation of an new LIS, do TS medical directors routinely think, "These nurses / techs deserve less pay and fewer benefits"?
• When management staff from national blood suppliers consult with blood centre medical directors across the country, does "head office" routinely think, "These MDs don't have patient safety at heart. Their attitude is deplorable."?

Do management staff who are not members of a health profession (whether representing health regions, hospitals, blood suppliers, or governments) often think such thoughts about members of the TM team?
I think not. The many technologists, nurses, and physicians that I have known over a lifetime in Canada's blood system are dedicated to patient safety and trust each other to provide the highest quality care possible.
How is it that trust seems to evaporate with labour negotiations?
CASE STUDY
In the mid-90s in Alberta, health care restructuring caused major job losses in the laboratory sector. One result was the creation of Calgary Laboratory Services* (CLS), a private lab that assumed 100% of clinical lab services in Calgary, one of the province's two major cities.
* CLS is now a wholly owned subsidiary of Alberta Health Services (organization responsible for providing publicly funded hospital and other health care in Alberta)
The case study below describes how a union (HSAA) and private-sector lab (CLS) cooperated under extremely traumatic circumstances. It paints a rosy picture of what's possible. I have no idea how closely it conforms to reality but there may be some lessons here.

• Beyond Collision: High Integrity Labour Relations. Calgary Laboratory Services -- HSAA Case Study1 (2004, by Darcy Shenfield and Allen Ponak)

All this lack of trust and conflict reminds me of a song from the 1960s:

• Get together (performed by the Youngbloods)

As the song's lyrics go,

C'mon people now, Smile on your brother Ev'rybody get together, Try and love one another right now

Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice. Let me know if you think I'm off the mark.