Why can’t I just fire someone who makes a mistake?

There are practical considerations. First, we would quickly run out of people in the laboratory. Good people make mistakes. The key is to determine whether the mistake was a slip or lapse (most common), or an egregious, willful error (rare)—or perhaps something in between.

As David Marx has pointed out in explaining the concept of just culture, most errors are not deliberate. Asking yourself whether a similarly trained person could make the same mistake is important. If the answer is yes, then it is up to leaders to improve the system and prevent recurrences.

Why is it so difficult to implement a just culture in the lab?

The United States often is a litigious society. We are admonished in daily ads that there is always a guilty party. Find the guilty party and make them pay! This may fuel emotional satisfaction on some level. However, it takes enlightenment and constant reinforcement from leadership to establish and maintain a just culture. It’s easier—but unwise—to blame problems on a bad apple.

What’s all this jargon about systems thinking?

Anyone who spends enough time trying to improve their laboratories eventually has an epiphany. The early writers like W. Edwards Deming, Peter Senge, and Avedis Donabedian had profound and timeless wisdom about quality and safety. The real question is whether or not we are willing to listen and learn.

A high-quality system that is safe, effective, patient-centered, timely, efficient and equitable is every bit as elegant as the coagulation cascade. The key is to work with fallible human beings to convince them that this is so.

Why do some labs seem to make a lot of progress, while other labs flounder?

As Michael Astion, MD, points out in a recent CLN article, the magic lies in having the courage to fail: in other words, to do rather than merely know. As Yoda said, “do or do not, there is no try.” That is entirely counterintuitive to us as scientists. We need to learn to revel in failure, because that is the only way we will learn what does and doesn’t work. Ultimately, managing change is 10% book knowledge, but 70% experiential. You are not alone if you find this absolutely fear-inducing.

What do I need to know right away if I am thrust into a leadership role?

It is important for everyone who works in a modern clinical laboratory to have a basic understanding of lean and six sigma. Know what DMAIC (define/measure/analyze/improve/control) and six sigma mean. Know when you need a quality improvement project, which should have a clearly defined and time-limited goal. Know when you have a “Nike—just do it” situation. Know how to perform a root cause analysis and become comfortable asking the “5 whys.”

Become comfortable making others uncomfortable by asking pesky quality questions. Know the effect of errors on patient care and your lab. Listen to the voice of the customer, including your bench technologists and phlebotomists. They have skin in the game.

Understand how your processes and people are connected. Understand that you cannot wish your way to better quality and safety by writing procedures ad infinitum. If the lab keeps making the same mistakes, it is up to leadership to find out why.

Isn’t this all up to management to figure out anyway?

The College of American Pathologists, the Joint Commission, the Food and Drug Administration, the Centers for Medicare and Medicaid Services, and an army of regulatory and accrediting bodies don’t see it that way. They are pretty clear that this is up to laboratory leadership, especially the designated CLIA medical director, to guide.

Management can help, but ultimately, medical directors are responsible.

What do I do if a group of us have suggestions for improvement, but we can’t get others to engage?

Put an imaginary string on the table and make it straight. Now put your finger at one end of the string and push it. You go nowhere fast. Now put the same string on the table, straighten it, but pull the string instead of pushing it, gently at first, but more quickly later on. That is the way quality improvement projects go. Reframe your suggestions using what’s called appreciative inquiry that begins with a focus on what’s going right.

You can also up a straw dog and ask others, “what would you say to someone who said….?” Be deliberate and persistent. Channel Peter Falk’s detective Columbo: “Just one more question….”

There is a lot of pain and very little gain in improving the system. What’s in it for me?

Good question. Quality improvement projects take a lot of backbone and persistence. Frankly, you may never see the full fruits of your labor in your career. You could be doing something else that pays more or gets you more peer-reviewed publications and citations. Ultimately, this is legacy work.

The effort is a little bit like working as a macadamia nut farmer. Macadamia nut farms don’t bear nuts for 5 years, sometimes longer. You either have the heart and persistence of a macadamia nut farmer or you don’t. Personally, I really like macadamia nuts and want to be the best macadamia nut farmer I can be. Forget owning a vineyard.


1. Astion M. Knowing vs. doing in quality improvement. Clinical Laboratory News 2018;44(7)

2. Marx D. Patient safety and the "just culture": A primer for health care executives. New York, NY: Columbia University; 2001.