Tuesday, April 26, 2016

When the VoC is screaming

When the VoC is screaming

Today I received an on-line satisfaction survey from a company that I use regularly.  They are a well-informed “partner” of ours, in the sense that we use their product on a regular basis, and the quality of our program is in part linked to the quality of their product.  That is exactly the type of company to which I will respond.  

These days, every time you go to a store, every time you go to a hotel, every time you travel, you get another survey request, most of which I have found best to ignore, because responding just leads to more surveys.  So I, like I am sure most of you, limit the number of satisfaction surveys that I complete.  I suspect that many of you go one step further and delete them all.

So I open up the survey and the first page has 3 straightforward single answer demographic type questions designed to get some basic information but nothing that could be construed as personal or invasive.  A good start.  The second and third pages are a little longer, but clear in intend with a request for multiple answers, if appropriate.  This is followed by another 4 pages with single questions only.  

And then we hit page 8 and all of a sudden things change.  Now we have 2 grids, each with 5 rows and 6 columns, with a complex set of instructions.  Further both grids are marked as must be completed in order to proceed.  I look to the top of the page to see how far I am into the survey to make a guesstimate on how much more time I am going to have to commit to the survey, but there is not guide provided. 

And my attitude towards this survey starts to change, in a real hurry.  I have three choices.  I can either quit not bother any longer, or I can continue on, row-by-row, or I can send a message.  

And I decide that this is message time.  So I fill in the two grids by random choice just so that I can get to the next page, of which I ultimately discover there are 5 more, all of which get the same sort of treatment.  

On the second to last page I find a text box, in which I comment, “send out crap surveys, get crap information”.  (I found the text box by ultimately getting to the last page and looking for the “Many thanks.  Please leave any additional comments here” box, which did not exist).  Then I hit the “previous” button to find an available text box.

Maybe they read my comment, probably they will not.  What is more likely is that some analyst looks at the collective compiled data, does a bunch of cross-cuts, creates a report which someone reads (or not) and the world goes on.
 The problem with this is that Quality Managed companies actually do need to be able to get information from their customers in order to find out how if they are meeting their needs and requirements.  It is a Crosbyesque as you can get.  

You can get information in a number of ways, one of which is on-line surveys.  There are a lot of other choices, but if done well and carefully, on-line surveys provide a combination of immediacy and directness and distribution that few other choices can provide.  

So if you are going to send out surveys, the least you should do if create them in a manner that optimizes the opportunity for good information and reduces the opportunity for bad information.  

In previous writings [http://www.medicallaboratoryquality.com/2011/06/satisfaction.html ] , I created a number of recommendations to increase your potential for good information, which include:

a.    Focus them to a single issue
b.    Limit the survey to only a few questions , best is to keep it to 5-6 and NEVER more than 10,
c.     Make the questions as uncomplicated as possible.

d.    Pre-test the questions to reduce (you can never avoid) ambiguity and
e.    Make sure that it can always be completed in 3 minutes or less.
f.      Never require an answer. That is a guaranteed invitation to bogus information.
g.    Decide in advance which slice of your audience you are interested in and then only focus your energy on that group. General send-outs are a total waste of time.

Now, some 5 years later, these still seem to be very useful rules to live by, although I would probably now raise the recommendation to limit the questions to 9-10 and never more than 12, provided that you don’t break the 3 minute rule.

In our programs, we continue to rely heavily on our surveys for information from clients, and course participants, and organization members. 

There is no doubt that when performed properly on-line surveys are extremely useful.  When performed improperly they are not only a waste of time and energy, they result in poor information and potential poor decision making.

Saturday, April 2, 2016

Making the Healthcare Mission Real

Making the Mission Real
In a previous post [see:  http://www.medicallaboratoryquality.com/2016/03/cum-minus-facerent-malum.html ] I railed against the tragic levels of customer service in  Canadian Healthcare.  In as much as being a disgruntled healthcare customer (nobody really wants to be in a position of needing healthcare services) as a Quality person I was appalled at how far off track we have come.  

 If there was a single irritant above all the irritants experienced it was the declarative Mission Statement (however named) Embed patient-centered practices in the delivery of all care and services.”  This might have been written in some aspirational moment of hope, but in reality it was both meaningless and, at least from the perspective of this one observer, galling.  In my experience there was no evidence of any effort to support or justify such a declarative statement.
What it made me appreciate all the more is the concept that Mission Statements have to be more than a bunch of nice words, they have to be credible and achievable in a way that the customer and employees can point to an say “Yes, and good-on-ya”  

So it made me think of all those statements that sound good but are of little use.  They remind me of the Crystalian character Fernando, “It is better to look good than to feel good”.  All SHOW and no GO. 

Here are a few:
Quality is Job 1
We meet and beat all requirements and standards of excellence
We provide world-class service.
We are the world leaders in care.
Excellence in all actions all the time.
(and with apologies to Philip Crosby) “Doing it Right the First Time Every Time”

Mission statements are important.  As pointed out in ISO 9000, the organization's mission statement or policy is its “purpose for existing as expressed by top management”.  If it is not real, staff and customers have nothing to hold on to and either ignore or scoff, or as in this situation get angry.  It doesn’t make the organization better; it makes the organization worse because it provides the opportunity for cynicism.  Good words-No substance.

So here is how I see it. 
There are some organizations that need the Fernando Format.  It is not about Quality; it is about profile and promotion; high profile major manufacturers may need at least as much pizazz as punch.  That is about advertising and promotion.   But healthcare organizations do not fall in that category.  Healthcare needs to “put up.  Period.”  Healthcare needs to be good, not just look good. 

So can we agree that unachievable mission statements achieve little other than make the promotion folks feel good.  So put out the message that we want to be there and intend to work damn hard to get there.  And on that point you can hold us accountable.

Our vision is to be recognized by our community and peers in Canada and beyond as a valued contributor to healthcare delivery and  innovation and as a passionate advocate for continued quality improvement for the benefit of patients and their families. 

Too long?  Maybe, but it  delivers  real measurable aspiration. 

I am open to suggestions for improvement.

Monday, March 28, 2016

Cum Minus Facerent Malum

Cum Minus Facerent Malum

It was not our plan, but my wife and I had quite the adventure this weekend.  We set out for a relaxing urban adventure but in the blink of an eye the adventure turned to rushed visits to two Emergency Departments and some emergency surgery.  A few days have passed, but it has given us the opportunity to reflect on what went well and what did not.

First off we do understand that we live in a busy big city and this was a vacation weekend, but taking all that into consideration, this still would not be considered a totally happy experience. 

A little background first.

In Canada, our healthcare story has been quite a ride.  At the beginnings of Canada the crafters of the country’s confederation saw health care as a matter best left to the province.  It was not that big a deal or interest for a national government to get engaged with.  All that changed almost 50 years ago (to the day) in 1966 when the federal government decided that if healthcare was going to be seen as equal sea-to-sea-to-sea, the feds would need to get engaged, and made an absolute commitment to contribute 50 percent of provincial costs.  Public attitudes were mixed, but the politicians of the day knew better and so the path was set.  It was written in stone. 
It took about 10 years to figure out that this was costing a bomb and government of the day decided to erase the stone and renege on payments. The stone was re-written with a new written in stone commitment called the Canada Health Act.   

Ever since the creation of the new Act, the Canadian system has been progressively gutted, less and less federal funds, and the closure of mental health hospitals, and consolidation of health facilities, and continuous reductions of staff.  It has been an experimental Leaning of healthcare on a national scale, without any Keizen.  (If only they had implemented a Poke Yoke – error prevention – program).

All of which brings me to this weekend.  We were sent to one gutted emergency department to find overly busy, swamped folks trying to cope.  The emergency doc, did what he could do and then we were put into a taxi to go to the the other
ER because they were the only ones who had an appropriate surgeon working that day.  

It felt like we were living an episode of M.A.S. H. 

At the other place the mess was infinitely bigger with stressed out staff absent of any vestige of interest or care. After being shuttled around we ended up sitting with a herd of patients in an open corridor without any interest or care or food or medication or even water.  (When I told the staff my wife was in a lot of pain, the nurse on staff to me to get out of her staff room).  This in an institution that proudly pronounces its mission statement “Embed patient-centered practices in the delivery of all care and services.”

After too many hours in the back hall we were finally seen by the appropriate surgeons and had the definitive measures completed. 

So when the smoke cleared, if you use life versus death as the outcome measure, our adventure was a roaring healthcare success; but by any other measure, not so much.  

The number of Opportunities For Improvements were far too many to enumerate, with the exception of the one where the first ER informed the second ER that we were coming but got the name totally wrong, so that when we arrived, no one knew who we were or what was going on.  Of the ones that I will not mention here, two were serious breaches.  Not many, perhaps, but those were the ones that I observed in one afternoon on one day, and I wasn't seeking them out.  

So as much as this sound like a personal grumble, that was not the point.  It is to make the point that for the last 50 years politicians and consultants have made step after step, to get healthcare under control and they have failed miserably.  All the major Leaning initiatives have been failures.  The care has not got better, it has got worse. 

As a Quality oriented healthcare person, this gives me serious pause.  What we are seeing is a lot of Doing and Checking and Acting but either with NO Plan or worse a TOXIC Plan. Deming would be shaking his head.

Nobody can be proud of this mess.

Sunday, March 13, 2016

The Quality Value Proposition

The Quality Value Proposition

I have been reading (always dangerous) recently in the Patient Safety arena about a concept  sometimes called the Quality Value Proposition.  It proposes that one can take the ethereal construct of  Quality and divide it by the tangible construct of Cost, and thereby determine the Value of Quality.  

(In mathematical terms it would be Q/C=V). 

The argument is that if the goal to be achieved is Quality of effective and high value, it is achieved first with the least cost, i.e.achieving more Quality per dollar or best bang for the buck.  Alternatively if costs are not reducible, then the Quality has to be of a higher grade to achieve a better value.


This scores higher than most in the contest for the most inane concept presented anywhere.  That it gets published and repeated talks more to the challenges of some of our great thinkers.  Shame on them.

So let’s take this apart.  

There are multiple views of what is Quality.  I refer you to the Quality classic Zen and the Art of Motorcycle Maintenance by Robert Persig.  If you didn’t read it when you were young in the 70’s you were either too young in the 70s or were just not cool.  

Quality as an intangible, a sense of being more perfect or more satisfying.  A Cadillac versus a Ford, A Harley Davidson versus everything else.  Or you can think of Quality in a Crosbian “meeting customer requirements”  or achieving customer satisfaction.  In any case it is still an intangible, and both a real and ethereal wisp.   You might want to quantify Quality by saying approaching or achieving error free, but it would be still difficult to put a number on it.  (Indeed accreditation bodies may pronounce an organization as having achieved 98% Quality.)  The point is that Quality is an achievable state, but is not a substance to be divided.

Cost I understand.  Cost of Quality – Cost of Poor Quality – Costs of Error reduction.  These are all real numbers and numbers in depth.  You can calculate them almost to the penny, provided that you can put a specific amount to stress and strain, two critical outcomes of error.  

I think that calculating true costs by looking in depth not only at the costs of prevention and appraisal, but also internal and external failures is a valuable exercise.  Something that everyone can do at some point and with certain projects to really appreciate how much money is lost on error. 

But most organizations don’t do that.  What they do is look at prevention costs and appraisal costs and then decide that they are spending too much on Quality Control and Quality Assessment and Continuing Education and then announce with regret that these are unaffordable costs that have to go.

Calculating Quality Value turns into a Lean Reductive strategy.  If I cut out 25 steps and use my reagents twice, then I have saved money and my costs go down, so now I am achieving the same "Quality" but with less expenditure.  This must make my Quality more efficient and therefore of higher value.   (Just in case you are reading this and this this makes sense, I will tell you  this is all about sarcasm.) 

What they don’t realize, because they probably choose to not look, is that when Quality Prevention and Appraisal activities and costs go down, Quality much sooner than soon will start to deteriorate.  More errors will inevitably occur.  

You have not made Quality better…. You have made Quality worse. 

So I understand how people all want to be like Einstein and create a simple formula that explains everything.  But this Quality Value Proposition is not it, and will never be it.  

As the cop on the beat says when there is a big splat in the middle of the road..   "Move on folks, Nothing to see here".  

This is a bad idea that has had more than its share of 15 minutes.   

Time to shut this sucker down.