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Healthcare Customer Satisfaction: More Talk AND More Action

Healthcare Customer Satisfaction: More Talk AND More Action Customer satisfaction (Voice of the customer) is a recurrent th...

Monday, February 4, 2019

GB/T32230: Quality Culture and the Medical Laboratory.

So I was browsing in this month’s Quality Progress (January 2019) and found an interesting article written by Ningning Jing about Quality Culture, a topic about which I have a lot of interest.  What caught my eye was that in 2015 a new guideline was created and subsequently published by China Standard Press entitled Chinese National Standard, GB/T32230-2015—Guidelines for Quality Culture Development in Enterprises.  I was unable to find an ISO equivalent, so I am unsure where or how the Standardization Administration of China (SAC) developed guideline.  As it turns out it is available in English, but it was fairly expensive

The guideline makes for some interesting reading.  It reminded me of how much medical laboratories have changed over the last 15 years, dating in my mind back to the original publication of ISO15189:2003 (Medical laboratories – the particular requirements for quality and competence).   

Laboratory life has changed a lot since those early days.  Despite the awareness of some of the efforts of W Edwards Deming and perhaps of Armand Feigenbaum and Total Quality Management in the 1980s, for the most part, quality in the medical laboratory was largely mechanical and technical.  The concepts of quality were mostly about accuracy and documentation, and very little about timeliness, or appropriateness, or clinical relevancy.  The quality dynamic was the laboratory, the physician customer and the specimen.

Quality principles as expressed in ISO15189:2003 made a material change because it introduced concepts of Quality Managers and patients and the needs and requirements of the staff.   In today’s medical laboratory, quality has expanded to address satisfaction, and interested parties and stakeholders and service excellence.  Modern laboratory quality is an essential component of every aspect of the total experience.

Today many almost every laboratory conference and education program and continuous improvement program for medical laboratorians will focus on some aspect of the essentialness of a Culture for Quality.

What many may not realize is that Quality Culture is not a new concept.  Joe Batten has been writing on the topic going back to 1992.   Back then Batten presented a definition of Culture that I still rely upon today [Culture: The pervasive philosophy, central values, beliefs, attitudes and practices of an organization, and the micro-elements that make things happen.] 

While I still have my old copy of Building a Total Quality Culture, I see it is no longer available even on Amazon, but I see there is a new edition (2014) available.
This new guideline defines quality culture as the “total of quality concepts and values, habits and behavior patterns, basic principles and systems as well as their material performance recognized by the enterprise and its staffs”.  With interest, ISO 9000:2015 provides a similar definition: “a culture that results in the behaviour, attitudes, activities and processes that deliver value through fulfilling the needs and expectations of customers and other relevant interested parties”  When either of these variation definitions is combined with the one used by Batten, back in 1992 you capture a clear picture of Quality Culture. 

The new guideline makes several points: (a)  the culture must be driven and directed from the top; (b) that without leadership, a quality culture is unlikely to happen.  And (c) that leadership by itself is insufficient and if the staff are not engaged then the process with fail.  (I am reminded of Feigenbaum who said that Management is responsible for 80 percent of Quality, with the organization sharing the responsibility of the 20 percent).  (d) the document reminds that Quality Culture is NOT a cookie-cutter operation.  Each organization is unique and their culture must have the freedom to reflect that.  And importantly (e ) building a Quality Culture is NOT a one-and-done activity; culture is a philosophy/attitude that must mature and change with experience.   

Importantly the new guideline urges that to ensure that the organization has implemented a truly effective program, it has to find a way to measure its impact, which begs the question, can one really measure an attitude?  Well the important answer is “yes, you can!” 

In our course on Laboratory Quality Management we talk about Quality Culture, and provide some ideas on how culture measurement can be done and more  to the point, illustrate how it is possible to assist culture realignment when the organization’s changing needs require. 

I have not yet taken the opportunity to read the guideline thoroughly, but so far I am pretty impressed.  I suspect that when the crafters of GB/T32230-2015 were thinking about “enterprises”,  medical laboratories were no where on their list.  But they have done us a valuable service. 
Do I think that the new version of ISO 15189: 202(?) will incorporate some elements of quality culture?  I would be pleasantly surprised if it did. 

But regardless, it is well worth the read.

Monday, December 10, 2018

In-Country Proficiency Testing (EQA)

For those of you who live in the United States or Canada or Europe this will likely be a curiosity rather than the big deal that it actually is.  The North American history of Proficiency Testing started in the 1960-1980s when countries recognized the importance of externally monitoring the quality of medical laboratory test results.  We have in place very sophisticated systems.

The reality was, and still is, that in the vast majority of situations, laboratory test errors go undetected and a wrong result is reported to a physician or patient with frightening frequency. Even doing conventional quality control can’t control this.  The reason they go undetected is because when we go down, humans have enough internal mechanisms that we usually get better on our own regardless of what caused the problem.  Even if we have a diagnostic test that is ordered and performed with the best of intentions but is of wrong value, and is followed up with a medication that we don’t need, we usually have enough internal resources to tolerate all sorts of wrong impressions and inappropriate “medications” that we receive.  There are MANY people walking around with all sorts of missed or incorrect diagnoses. 
But every once in a while, a BAD thing happens, and a person either doesn’t get better, or gets worse and sometimes dies. By then it is too late, and all hell is likely to break loose.

So, our predecessors figured out that by requiring laboratories to test samples where they don’t know the actual result, but an external body does, we may catch more of these errors.  If the laboratory returns the correct accurate result, we inform them they are “proficient” or “competent”.  If they get it wrong, we don’t call them “incompetent” but harsh words hurt, but we say they have “opportunities for improvement”.  

The organizations that send out these quality check samples to laboratories are known either as Proficiency Testing bodies, or more frequently in most places around the world. External Quality Assessment bodies (or EQA).  

Now 30-50 years later, most wealthy countries have developed their own EQA bodies, that focus primarily on the quality concerns of their own countries.  Poorer countries have often struggled to get similar programs up on their own, and end up buying samples from the wealthy countries, which in the majority of situations has been a real failure approach.    

The samples that are sent all too often are inappropriate for the laboratories that receive them and importantly they don’t survive the travel, unless they have been freeze dried for the convenience of the sender (but not for the receiver!).  And more importantly, they were rarely designed with poor countries’ needs in mind.  They are designed for the complex sophisticated laboratories in the countries that created them.

We have struggled with this as a challenge for near 20 years with some success, but also a lot of failure (about 50:50).   We would invite countries to send staff to our EQA laboratory in Vancouver and would teach them a series of simple to learn, easy to implement methods that we developed so they could create their own stable samples at home.  

The methods are usually bullet proof even in climes with elevated temperature, but they depended up the country having some infrastructure to make the program happen.  And sometimes that infrastructure was not there.

So in a new collaborative program with another EQA provider, we are trying a new strategy.  Rather than have people come to us, we are going to them, working in their laboratories working with their staff, and ensuring at some essential parts of the necessary infrastructure, like the informatics system is in place.  So the samples can be made and be distributed in-country, and the information resulting can be simply entered into a computer hooked up to a sophisticated data base and the results can be sent to the key people.

Importantly, this way the country picks the challenges that it wants to send, with the microbiological test challenges it wants to use, rather than depending on samples from companies with a different approach.

So, this week we just did our first in-country training for in-country microbiology EQA in a county in West Africa.  The training program went even better than we anticipated, and plans are being put in place for the infrastructure and follow-up. 
Guaranteed success?  No… but so far things look really good and promising.  We will know a lot more in a few months from now.  But if it works the country will have taken control of the quality of its own laboratories, will have saved mountains of money by not buy samples from other countries, and will have the quality challenges that it needs, not what it receives.

Fingers crossed.

Thursday, November 1, 2018

Customer Service - The Paradigm Shift in Laboratory Quality

Customer Service - The Paradigm Shift in Laboratory Quality
In the 18th Century, Immanuel Kant writing in Critique of Pure Reason (1787) described the change in approach to scientific study as a “revolution of the way of thinking”.  In the 20th century, Thomas Kuhn in his book The Structure of Scientific Revolutions (1962) advanced the phraseology to “paradigm shift”.  By whichever phrase we want to call it, today we are going through an new phase in thought and practice in Laboratory Quality, especially as it refers to customers and service, that is truly a significant shift.

Recently I hosted a conference in Vancouver on the topic of Quality Improvement, Knowing your Customers.  One of our speakers, Colleen Taylor, in a most creative way talked about the dual understanding of the word Patient.  In healthcare we use Patient to refer to one of our customer groups, the person who is the end-user of our products or services.  Equally “patient” describes our all-too-common approach to the end-user: “ You are tired of waiting?  Well we are all very important and very busy, and you just have to be PATIENT.  So just go sit there and we will get to you when we get to you.  Just sit there and be quiet, and you better be darn grateful when we get around to providing you with our time and services.”  

The rest of the world has figured out that that is no longer a winning strategy.  Increasingly customers have figured out there is always choice.  Hospitality, and retail, and banking and schools have figured it out; making an unhappy customer leads to an unhappy customer and a bunch of unhappy friends, and one day you look around and there are fewer and fewer people coming in your door.   And all of a sudden, your business is in trouble.  

Think it can’t happen to medical laboratories?  Point-of-Care Testing did not start in a vacuum.  Pharmacy based testing didn’t just happen.  Theranos, may have turned out to be a failure, but the reality was that Silicon Valley was responding to a perceived need, and there is every reason to believe that the next change will be far 
more successful.  

So at our conference we learned some truly important lessons. 

Hospitality industry can track millions of customer experiences, and can maintain complaints at a level of 3 per 10,000 (sigma 6.17).  They track and correct because they understand that every complaint that goes through the door unresolved gets increasingly expensive.

Tracking customer satisfaction in healthcare facilities can be done competently and comprehensively on a same day basis, and indeed on a same hour basis. 

Healthcare executive administrations are looking for service excellence solutions

International Organization for Standardization (ISO) is developing new standards and tools in service excellence under a new technical committee (ISO TC312 Excellence in Service).  

Some laboratories are developing some novel approaches for improving customer experiences

The approaches of “the customer is always right” and “the customer always comes first” are being replaced by “Your Customer have to come second because your staff have to come first.  Staff who are acknowledged and appreciated for their skills will take care of your customers needs in ways that are in both the short and long term successful”.   

We can shift staff attitudes and culture using thoughtful analysis using techniques like Organizational Culture Assessment Instrument (OCAI) and staff management skills and techniques.  

Small changes can have big impacts. Small changes regularly have huge impact.  

Starting now is ALWAYS better than starting later.

To be clear, other aspects of laboratory quality can not be forgotten about.  Areas like error awareness, error reduction, opportunities for improvement through audit and prevention and correction, continuing education, continual improvement throughout the pre- peri- post- and examination phases will not go away.  But their impact and success will be much enhanced through the dynamic of staff and customer satisfaction. 

For those interested in seeing some of the materials from our conference/workshop you can visit polqm.med.ubc.ca/conference