Blood Assurance Team Leader Development Program

Transcription

1 Blood Assurance Team Leader Development Program April 04, 2018

2 Initial Survey Initial Survey 1) What is the proper procedure for requesting one of your employees to be retrained? o Notify training, training notifies manager, training prescribes a solution Notify training, training tells you what they did oonotify employee and keep management out it. o Notify manager, manager notifies training, training prescribes a solution 2) Where is the MSDS located? o Master Control o Get from Maintenance o Get from Manager 3) When an employee or a manager comes to you about a problem, how much of that information should be shared with the other employees? Nothing, keep it all to yourself. The employees will figure it out eventually o Everything you know o o Only pertinent information relevant to them or the job they need to accomplish 4) True or False: QC can be copied from the day before. True oo False 5) What does MSDS stand for and what is the purpose? oo Material Safety Data Sheets; provides basic information to treat potential exposure oo More Stupid Documented Standards; just another bunch of information people are required to know how to find when asked. oo Managed Safety Data Sheets; they let poison control know how to handle possible exposure or ingestion to help when we call them. oo Material Safety Data Sheets; provides detailed information on health effects, hazard, protection and procedures on how to handle exposure to chemicals.

3 Initial Survey 6) Error correction on QC should be: No error correction needed, QC reveiwer will find the mistakes and fix them. oo Draw a single line through error with correction. In the blank space provide initials and date error was corrected. oo Single line through error, with correction. In the blank space, provide a reason for correction along with initials and date. 7) If/when the Genesis daily QC measures out of range, how many times must the scale be retested? oo 4 8) When should you check lot numbers before writing in QC? o Daily o Monthly Quarterly o Annually 9) True or False: You have to complete QC before the bus leaves for a drive. o True o o False 10) When should new QC documents be printed? The first day of the month, before collection starts The first day of the month, before you go home o The first week of the month o o Any time during the month before sent in for review

4 Initial Survey 11) True or False: You can document QC data on QC review sheet prior to writing in QC book. o True o o False 12) When should the Daily Operations checklist be performed? Before drawing donors o Before leaving facility o While collecting donations o Eh, just check it off. Its no big deal. 13) Whose initials can YOU put on the QC form before, during, or after its completion? o Anybody s o Yours only o o The person who completed it o As long as it s signed it doesn t matter 14) Who can perform QC? o Team Leader oo Both A and B DCS who has been trained o CCS under TL supervision 15) Room temperature should be recorded every hours, during collection oo 5

5 Initial Survey 16) What should be documented on the Daily Operations sheet (opposite from checklist) o Basics; no problems. o A little more detail if a problem arose. o Everything, if any problems occured details should be written down to have documentation. oo Make stuff up, not like they truly read the document. 17) If you have 2 Alyx machines on the bus, how many Alyx Monthly QC and Maintenance Checklists are needed? oo 4 18) True or False: If an employee is not trained on Alyx, he/she can still QC the machine. True oo False 19) As the TL, you do a daily check on your QC book and see a write over. How do you fix the problem?

6 Good Delegation: TL Examples Good Delegation: TL Examples Good Delegation: DCS Examples 1

7 Good Delegation: DCS Examples 2

8 Poor Delegation - TL Examples Poor Delegation - TL Examples Poor Delegation - DCS Examples 3

9 Poor Delegation - DCS Examples 4

10 Guide for Discussion Guide for Discussion This document is to be used for notes. This does not replace SOPs, Job Aids, or QC documents. Make sure when filling out any paperwork, whether it is QC or a DRF that you write clearly in the space provided and fit the size of writing to that space. Print all required pages to be filled out; do not only print one of two pages. Incident Report: QA-F-110 This is for donors/visitors who had an accident on Blood Assurance property or at a Blood Assurance operated blood drive. Should be filled out as soon as the donor/visitor accident is discovered. This form is used in the instance of a hematoma or arterial stick. 5

11 Incident Report: HR-F-170 Incident Report: HR-F-170 This form is to be filled out if an employee has an accident/incident (not including body fluid exposure). This form should be completed immediately following the incident. Incident Report: QA-F-008 This form is for employees who have a body fluid exposure. 6

12 Out of Service: DS-F-106 Out of Service: DS-F-106 This form will be used when a machine is taken out of service. If you perform daily QC and your machine doesn t pass within the stated guidelines, this should be used to distinguish it from properly working devices. Once this document is placed on the machine, at the earliest convenience notify the equipment manager. Current equipment manager Contact Number 7

13 Short Draw: DS-F-137 Short Draw: DS-F-137 The short draw form is to be used to remove a short draw from your record. As noted on the bottom, this form is not to be used in the case of the donor moving or donor requesting the removal of needle due to pain. All donors should be observed during collection to prevent these errors from occurring. However, if a donor has a reaction and cannot complete their donation due to this, the short may be removed since this is a factor that is out of DCS s control. A short may also be removed if due to machine malfunction. All fields should be completed entirely. Give a good description for the short in the appropriate column to show validity of request. Supervisory Review of Records: DS-QC-011 This states that DS managers are responsible for reviewing QC testing results the 1st week of the following month. It also states that the supervisors should be notified of any results out of range. 8

14 Mobile Site Assessment Checklist DS-F-075 DAILY Mobile Site Assessment Checklist DS-F-075 All sites should be assessed for adequate space, proper privacy, safety, and temperature within draw range. 9

15 Daily Operations Schedule: DS-F-134 Daily Operations Schedule: DS-F-134 The front of this page should be completed daily before and after the drive to make sure everything needed is available. On the back of the page, the business name(s) and recruiter will be written in the spaces provided. Any problems with the drive will be written in the comments section. If there are problems with the flow of donors, for any reason, write problems in comments section. 10

16 QC Review Sheet QA-F-049 QC Review Sheet QA-F-049 If QA calls about documentation on the Daily QC sheet, make sure to complete documentation on YOUR QC sheet kept in your binder. Must be completed before any blood collection occurs All QC records must be documented where indicated on this sheet. Genesis - Acceptable ranges Genesis Under the # Scale, in the same box, the genesis number should be written. In the following rows/columns, the daily genesis recording should be written. If the genesis fails daily QC, retest the donor scale 3 times and document the results in the comment section, bottom of page, or on the back of all actions taken to rectify the problem. If after 3 recordings the scale is not back to normal then attach an OUT of SERVICE tag and notify the equipment manager listed on the previous page. HemoCue - Donor Checker # is the last 3-4 numbers of the serial number on the back of the HemoCue machine. Cuvette Batch Lot # is for the lot number on the current cuvettes. When turning on the HemoCue device, the machine performs self QC. Once you are given - - -, this indicates that QC was passed. If you receive an error code then the QC failed. Document the error code that was shown in the comments section of QC. 11

17 QC Review Sheet QA-F-049 If QC fails, turn the device off for 30 seconds. Once you turn the device back on and QC passes, document on the bottom of the QC page the machine number, date, and the machine passed. If the machine fails for a second time, remove it from service and return to the equipment manager. Document on the QC sheet the machine number, date, and that the machine was removed from service. Make sure to document whether the machine passes or fails QC. Test Tubes - Fill this section out according to the current active test tube lot numbers found on the sticker portion attached to the tube. Expiration date should be documented as mm/yy. While it is perfectly acceptable to have 2 active lot numbers, it is not a practice recommended unless unavoidable. During the day if your facility changes lot numbers, this is documented on the bottom of the page with a notation that the lot number has changed followed by initials and the date written. Write the correct information in the given space. Arm Scrub Lot # s - This should be filled out daily with the current arm scrub lot numbers and expiration date, found on the paper portion of the scrub container. Pay close attention to the duoswab expiration dates, these are not used often and can easily become out of date without notice. Alyx Will be covered by Automation Trainer during Alyx training. Any untrained employee should not be performing this task. 12

18 QC Review Sheet QA-F-049 Aurora Will be covered by Automation Trainer during Aurora training. Any untrained employee should not be performing this task. Non-Contact Forehead Infrared Thermometer - Document the devices serial number under the section labelled thermometer #. The thermometer passes QC when the following criteria are met: when the device is turned on the last temperature will appear briefly and the device will then show three dotted lines along with the forehead symbol and flashing F symbol. The pass/fail will be documented beside the previously written serial number. Room Temperature - Acceptable ranges C Room temperatures should be taken every 4 hours of collection. If you have a collection time of 8 hours, there should be 2 temperatures on the document, 12 hours should have 3 documented temperatures. IF the 4 hour temperature is forgotten, for whatever reason, this should be documented stating Failed to read temperature for documentation, no platelets were collected followed by initials and date. If found in the same day, document a temperature as soon as the mistake is found. 13

19 QC Review Sheet QA-F-049 DO NOT LEAVE THE SPACE BLANK. If this error is found the next day, document that the 4 hour temperature had been failed to be recorded. To keep the failure at a minimum, set an alarm for 4 hours when you get to the drive and record the initial temperature. If temperature is out of range, ONLY doubles can be drawn and should be placed in a validated container or temperature monitored refrigerator. If triples are supposed to be collected, document they were stopped and doubles only began, if the temperature is below 20 C or exceeds 24 C Acceptable ranges 1-6 C Refrigerator - Chart and thermometer MUST match within 2 When the refrigerator is in service the chart must be read, closest to the needle, followed by the digital monitor, and then moving to the inside with thermometers on both top and bottom shelves. Recording charts should be changed on the Monday of each week. If the mobile has been inactive, the chart should be replaced on the first working day. Initials of the employee changing the chart and the date changed should be added to the new chart being placed on the recorder and on the chart being removed. On the new chart being placed in the recorder also add the facility number. To remove the chart, press the number 3 in the top left corner of the recorder. Once the needle moves out of the way, unscrew the Hub-Nut in the center to remove chart. Serial numbers should be added to the top portion of the page since they do not frequently change. The serial number can be found in the yellow section of the thermometers and should be recorded as seen from manufacturer. 14

20 QC Review Sheet QA-F-049 If the refrigerator is not in service, this should be documented beside the date. If the temperature moves out of range during collection, blood must be removed from the refrigerator and documented on the chart that blood was removed and placed in a blood cooler during that time. Supply Room Temperature Acceptable range C Should match within 2 Temperature on the digital and chart recorder should be documented in the same way as the refrigerator. Should be recorded for any extra storage room for your facility. Make sure that the person performing QC documents the Facility ID, Date, Initials, and the weight ID #. This document needs to be completed before a copy is made and sent into QA at the end of the day. At least one copy must be placed in the QC book daily. The last temperature of the day needs to be recorded on the sheet. Should be sent to QA in the white interoffice envelope with the end of the day reports. If a device does not pass QC (based on the corresponding SOP regulations) the device should be removed from service, tagged and notify the equipment manager for further instructions. Make sure to mark a section as N/A if it does not apply to your facility/mobile (i.e. Helmer, Blast Freezer, Plasma Freezer, Supply Room 1 or 2, etc.) 15

21 Daily Housekeeping for Mobiles and Facilities DS-F-176 Daily Housekeeping for Mobiles and Facilities DS-F-176 This document has 2 pages and is important for both pages to be printed. All duties should be performed daily by ALL employees on the mobile at the end of the day. Which means, upon review of the QC book midday, this form should not be filled out at the time. 16

22 HemoCue 301 QC HemoCue 301 QC Donor Checker # is the last 3-4 numbers of the serial number on the back of the HemoCue machine. Cuvette Batch Lot # is for the lot number on the current cuvettes. If the lot number changes during the month or for a specific drive, this should be noted in the comments section. Part of the daily QC is cleaning the HemoCue devices. As needed cleaning is anything extra needed for any reason (i.e. blood not wiped from the side of the cuvette and placed in the HemoCue device causing contamination). When turning on the HemoCue device, the machine performs self QC. Once you are given , this indicates that QC was passed. If you receive an error code then the QC failed. Document the error code that was shown in the comments section of QC. If QC fails, turn the device off for 30 seconds. Once you turn the device back on and QC passes, document on the bottom of the QC page the machine number, date, and the machine passed. If the machine fails for a second time, remove it from service and return to the equipment manager. Document on the QC sheet the machine number, date, and that the machine was removed from service. Make sure to circle whether the machine passes or fails QC. Document if as needed cleaning was required due to a blood spill or any other reason as well. 17

23 Weekly Cleaning Schedule for Mobile/Facility DS-F-177 WEEKLY Weekly Cleaning Schedule for Mobile/Facility DS-F-177 All duties on this form should be completed during the week. It can be divided up between a few days or performed all in one day. This is left up to TL discretion. 18

24 Shipping Temperature DS-F-041 MONTHLY Shipping Temperature DS-F-041 Choose a unit that has been refrigerated for longer than 3 hours. The form should be filled out with facility number and month/year. Attach a small unit number in the appropriate field. The time the unit was collected and the initials of who chose the unit must be documented as well. The form along with the corresponding unit will be placed in a large Ziploc bag and sent to Lab. If unit passes, the form will be returned by QA. If unit fails, the form will be sent to lab management followed by Medical Director. The shipping staff will quarantine all units within that shipment. The Medical Director will determine the disposition of the units which will be documented on the comments section. Form will be sent to QA and returned to initial QC facility to return to QC book. 19

25 Manual Blood Pressure QC DS-F-038 Manual Blood Pressure QC DS-F-038 Verify BP cuff and parts are all intact and in good working condition. Wrap cuff around a cylindrical object like an arm, bottle, etc... The sphygmomanometer should read zero which should be documented on the form. Inflate cuff to, watch to verify cuff hold pressure within. Document pass or fail on the form. If the cuff fails, remove the equipment from service and notify equipment manager. Eyewash Maintenance-Manual DS-F-103 The bottles will come with a number which must be recorded on the form. The bottle of eyewash solution should be examined monthly to ensure the expiration date is still in the future, the seal has not been broken or tampered with, and that the fluid still appears clear. 20

26 Alyx Monthly QC DS-F-027 Alyx Monthly QC DS-F-027 Will be covered during Alyx training with the Automation Training Coordinator Fire Extinguisher Inspection and Maintenance QA-F-013 Complete monthly. Should have one document per machine used. 21

27 Alarm Check DS-F-044 QUARTERLY All documentation in the following fields should be completed within the quarter. This does not have to be performed on the first day of the quarter. Acceptable range Alarm Check DS-F-044 Remove the probe from the rubber stopper, place probe back in bottle, then add the thermometer from the bottom drawer of the refrigerator. Allow the solution temperature to equalize. Record the stabilized temperature of the thermometer, digital display, and the recorder. All temperatures should agree within 2 C. Prepare two cups with 200 ml of water, add salt. Gradually add ice to one cup until the temperature reaches 3-4 C. Remove alarm system probe (rubber coated) from the solution and place in the ice water bath to test the low temperature activation. Add ice to the water bath incorporating gentle agitation motions to the mixture until the alarm sounds. Record the low activation temperature in the designated area. To test the high activation temperature, using the second cup of water, place the probe in the cup and add tap water. While adding, gently agitate until the alarm sounds. Record 22

28 Alarm Check DS-F-044 the temperature in the designated area. Telephone dialer activation, which is for facilities, can be tested by allowing the temperature to be out of range for 10 seconds. This will alert the lab that the refrigerator is out of range and should be checked immediately. The battery alarm system can be tested by unplugging the refrigerator power source. The batter alarm should be activated and the result should be recorded. Plug the refrigerator back in once this test is completed. If the alarm check fails, notify the equipment manager immediately. 23

29 Non-Contact Infrared Thermometer Non-Contact Infrared Thermometer Document the device s serial number under the thermometer # When you turn it on, the last temperature will appear briefly. The device will then show three dotted lines, along with the forehead symbol, and a flashing F. The pass/fail will be documented under the previously written serial number. 24

30 Quarterly Eyewash Maintenance- LAB-F-299 FACILITY ONLY Quarterly Eyewash Maintenance- LAB-F-299 Visual Inspection of the faucet should indicate that both eye nozzles have working covers, they are positioned properly, the center button does turn the eyewash system on, and that the covers can be removed with ease. The faucets should be flushed while performing the QC monthly. Cleaning Log of Donor Room Ceiling Fans DS-F-174 This should not be performed by TL or DCS employee. The performing contractor should write and sign their name in the indicated field. 25

31 Karpman s Drama Triangle Karpman s Drama Triangle Karpman,

32 Karpman s Drama Triangle Persecutor Deals with stupid people a lot. Life s hard, it s harder when you re dumb. I m going to put a stop to this Rescuer Here I come to save the day! Here s what you should do It s a sick, parasitic relationship. Victim Every injustice happens to him/her. It s impossible You don t even know what I ve been through. All roads lead to 27

33 To Be The Victim To Be The Victim The victim is always morally right. He s never responsible. Never accountable. The victim is forever entitled to sympathy. 28

34 Ill Communication Ill Communication Productive Communication includes the following four traits: 1) 2) 3) 4) Some benefits of Productive Communication include: 1) 2) Rewrite the following statements to be less toxic, and more productive. You don t listen to instructions. 29

35 Ill Communication That donor just pulled me aside to complain about you. These bio-buckets need to be emptied. Your bathroom breaks are taking too long. 30

36 Ill Communication You smell bad. You aren t following SOP correctly. 31

37 Bosses vs Leaders Common differences between the two: Bosses vs Leaders NBC Universal LucasFilm 32

38 Bosses vs Leaders Your title gives you claim but (people) don t follow titles, they follow courage. -William Wallace Boss Le ad e r Depends on Inspires Says, Places Blame Commands Says, Employees how it s done people credit Depends on Generates Says, Places Blame Commands Says, Employees how it s done people credit 33

39 Motivation Tactics Punishment: One-day suspension Formal reprimand Coordinated by management Not best for long-term solutions Negative Reinforcement Removal of least-favorite task E.g. not having to interview Not emptying bio-bucket Positive Reinforcement Introduction of a reward E.g. donuts Take first lunch Stick to a specific task Motivation Tactics What s the best way to find out which method works best for one of your employees? 34

40 Necessary Disciplinary Documents Necessary Disciplinary Documents The Disciplinary Action Report, HR-F-070, is presented here. This document is required to be completed by you, the team leader, and signed by your employee. This document, HR-F-105, is required when creating a Performance Improvement Plan. You and your employee are required to complete and sign this document. 35

41 Create Your Own Culture Create Your Own Culture List five concepts/adjectives that you want to be in place for your bus or mobile 1) 2) 3) 4) 5) What will you use to brand your center? A coat of arms? A mascot? A logo? Other? 36

42 Post Training Survey Post Training Survey 1) Was the environment comfortable to ask questions as they arose? Not Comfortable Neutral Very Comfortable 2) How could the environment be changed to be more effective, for future training classes? 3) Was the information presented in an understandable manner? Not Understandable Neutral Very Understandable 4) How confident do you feel about implementing the information you learned from training in your new role? Not Confident Neutral Very Confident 5) How likely are you to get support from management to use these techniques? Not likely Neutral Very Likely 6) Was the delivery of information smooth? Not Smooth Neutral Very Smooth

43 Post Training Survey 7) Was the delivery of information digestible? Not Digestible Neutral Very Digestible 8) Was the information relevant to your job? Not Relevant Neutral Very Relevant 9) From workiking knowledge of the company, what do you feel should be included in future TL training classes? 10) What is one takeway from this training? 11) What would you have wanted to be covered, that wasn t?

44 Post Training Survey 12) Do you feel your questions were successfully resolved? Yes oo No 13) If no, why? 14) Any follow up questions?