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Wednesday, February 1, 2017

More Reflections on Philip Crosby’s Reflections on Quality.



The quality improvement process is progressive.  One doesn’t just go from awful to wonderful in a single bound 

Crosby’s book on reflections contains a spectrum of trite such as “Anything that tastes good is bound to be bad for you (110)”, which is the all too common moan of the perpetual dieter, or inane “Once you put on a suit, no one tells you the truth anymore (83)” – I’m sure there is a grumbling story behind this.   

And there there are some very insightful, such as “The quality improvement process is progressive.  One doesn’t just go from awful to wonderful in a single bound.”  (234).  

I am intrigued by this reflection, not because it is so insightful (which it is) but that it comes from the mind of Philip Crosby.  

I never got to meet Crosby, but I have read his books.  He seems in writing to be a pretty black-and-white sort of guy.  “Do it right the first time” or “Anything caused can be prevented” or “The Performance Standard is Zero Defects” and “Zero Defects means doing what we agreed to do when we agreed to do it.  It means clear requirements, training, a positive attitude, and a plan.”   

This is all pretty absolute and without any wiggle room.  And none of that sounds even remotely aspirational.  You either did it Right or you did it Wrong.  

And it is a terrible message.

There have been few messages that have had so much resonance as DIRFT, or has spawned more corollaries.  “Why is there so little time available to do it right the first time, and so much time allocated to repeat it”.  “You can’t do it right the first time, unless you know what right is”  “You can’t do it right the first time, unless you know what it is”, “if you don’t have the time to do it right, when will you have the time to do it over”, and my personal favorite “it takes less time to do a thing right, than it takes to explain why you it wrong”.   

Almost all of these have the ring of bon mots; tone without substance.

In the medical laboratory and I suspect in a lot of other jobs and positions, nobody wants error, and nobody wants to make mistakes, and given a choice we “always” avoid error. But most error is human derived, some systemic, but a huge amount personal, and mostly silent or subtle;  distractions, slips, mis-interpretations, mis-understandings, errant keystrokes.  And while these still lead to errors and consequences, finger wagging about zero defects, does not make things better, it makes thing worse.  

It’s like when you mom or teacher or coach berated you with “you have to try harder”.

The quality challenge is to aspire to no errors, but to be vigilant in looking out, and diligent in catching as soon as possible.  In some situations, we can reduce error through inserting  some effective poke yokes (error blocking) tools and techniques such as required daily and in-run (real-time) quality controls, preventative maintenance, and error-reducing software and providing sufficient time-outs to allow reducing focus and stress.  More diligent attention to internal audits and proficiency testing can definitely help. 

But not always.

So that is why I was so pleased to see that Crosby also had a progressive side which acknowledged that nothing in reality is so cut and dry as zero defects, and that an organization needs to have enough tolerance and patience to accept a planned process of little steps, that allow time to reach a point approaching fewer mistakes and maybe even “zero defects” at least for a little while. 


On a related but different topic, work on our October Quality Conference is coming together nicely.  We have a working group that has come up with a number of very good topics, and some potential speakers.  One topic of special interest is a debate (Is Patient Centered Care in the Medical Laboratory Even Possible?),
We have our location, and assurances from a number of sponsors.  I expect that we will be able to post our first advert on time.  In the meantime,

Save the Date
POLQM October Quality Conference.
October 1-3, 2017
Vancouver BC Canada

Friday, January 13, 2017

LAMP OIL and Quality Indicators



So I got an opportunity to participate in a small but important workshop the other day on developing a large regional laboratory quality strategy and presented on the value and importance of developing Quality Indicators.  This was not a new topic for me, having first put on QI workshops and created a QI worksheet more than a decade ago. 
To put Qis in perspective, Mark Brown, who published Keeping Score: Using the Right Metrics to Drive World Class Performance in 1996 wrote “Many organizations spend thousands of hours collecting and interpreting data.  However many of these hours are nothing more than wasted time because they analyze the wrong measurements, leading to inaccurate decision making.” 
At the same time Philip Crosby wrote in his Reflections “ Quality Measurement is effective only when it is done in a manner that produces information that people can understand and use.

Both were true not only 20 years ago, but sadly, as we visit medical laboratories, it is still true today.  Folks faithfully monitoring “Turn Around Times”  and contamination rates.  They make their graphs, pat themselves on the back on a job well done.  But the results are far from understandable and usable.  Their customers don’t know or indeed care because they aren’t involved at any part of the process.  

And in the meantime, medical laboratories who have never been particularly open to public engagement are quietly losing ground to expanding Point-of-Care suppliers.
Of the five ways that laboratories assess performance (Accreditation, Proficiency Testing, Internal Audits, Quality Indicators, and Customer Service),  Quality Indicators can be the most focused, elegant, track-able, and telling (and available for public awareness and engagement), so it makes sense to focus energy on getting them right.

When I put my workshop materials together way back when, I proposed there were (are still are) seven critical criteria that developed Quality Indicators must meet in order to have any chance of being successful.  Leave one (any one) out, and you can pretty much guarantee failure.

OBJECTIVE:  Know what you want to measure and why, Be precise and specific. 

MEATHOD:  Indicators are by their nature be things, events that can be measured (counted or timed, or weighed).  And more specifically your QIs need to be measured by you.  If you don’t how you are going to capture the information, then don’t start.

LIMITS:  Before you start collecting, know what your level of acceptance is and what is a critical level of error.  Get input from your customers.  And take into account Risk.   Telling even one person they have HIV/AIDS when they do not is a BIG problem.  I understand that others may see this differently, but comparing your results against another organization (bench marking) rarely works, but they aren’t you and you aren’t them and too many variables get in the way.

INTERPRETATION:  When you gather your information, does it tell you, and others, something about your Quality?  If it does not, then it is hard to call it a Quality Indicator.

LIMITATIONS:  No measure is absolute and perfect.  That’s why we have Measurement Uncertainty.  (MU is also not absolute or perfect).  If you don’t appreciate that variables can impact on your indicator, you may go down the wrong rabbit hole.

PRESENTATION:  If you can’t express your results in an easy to comprehend manner then it is going to be tough to have impact to engage the people you need to engage.  Maybe it is a graph, maybe a picture, maybe a sentence – but definitely not a report.  

ACTION PLAN: If everything is pointing in the right direction, do you have a plan about what happens next.  More importantly when everything is pointing south, is the wrong time to be thinking about what to do.  Have you plan in place before you start.  

If you take the seven initials  OMLILPA and fiddle, you end up with LAMP-OIL, a rather perfect anagram

Done well Quality Indicators can shed a LAMP OIL  Bright Light on Quality Performance. 



Monday, January 2, 2017

Reflections on some Crosby Reflections




Happy 2017 to all.  

Recently I found a small book entitled Philip Crosby’s Reflections on Quality written by Philip Crosby himself.  It is not a standard Crosby quality book, like Quality is Free.  To put this book in context, when Crosby wrote “Reflections” he was 70 years old; he had long established his Quality bona-fides.  This was an opportunity for him to reflect on what was the essence of his message.  Most of his reflections are in the form of aphorisms (short, pithy observations of a general Quality truth), less than 140 characters.   These days this book could have been a series of tweets. 

I have been working on putting the final changes into our certificate course on laboratory quality management so I am drawn to Crosby’s The problem of Quality Management is not what people don’t know about it. It was what the think they do know (108 characters).  And I link that to another “The Quality Improvement process is progressive.  One doesn’t just go from awful to wonderful in a single bound.” (111 characters)

Over time we have seen a lot of laboratories and laboratorians that view Quality Management as the creation and maintenance of a quality manual.  They see Quality as the creation of an standard operating procedure (SOP) or the creation of rules around revising documents.  Worse, they view Quality Management as the creation of a “lots of good words” Mission Statement (for a example of nice words with NO action, see:   http://www.medicallaboratoryquality.com/2016/03/cum-minus-facerent-malum.html).  

It is not really their fault.  Indeed, many workshops both done here and abroad were done as “I will teach you how to write SOPs” or “How to maintain your documents” or “How to write a Mission Statement” without any quality context.  They were done as “cart before the horse” because they were easy to put together and easy to present; a lot easier than instilling a workable culture of Quality or a framework of Quality purpose.  All the workshops could be counted as could all the participants (over the last 3 years we put on 12 workshops and trained 168 people); but to what point?   

That was the way quality was taught in the “olden days”.  

Today we know better, and the horse comes first or at least beside.  In our course, and I expect we are NOT unique, we put a lot of time and energy into the why and context and culture.  Today we spend time and energy promoting replacing old habits with new and better ones.

And that brings me to my second (maybe my first) favorite Crosby Reflection about the progressive nature of improvement.  Juran and Deming started going to Japan in the ‘50s but didn’t see tangible evidence of success until the ‘70s and ‘80s.   The PEPFAR program and the ASLM (see:  http://www.medicallaboratoryquality.com/2016/12/a-continent-of-quality-success.html) started early near 2000, but it took to 2014 to see the first international accreditations.  At some point, when the concept of culture kicks in and if the mentoring is patient, it will all come together.

Success can follow when everyone is both persistent and patient, the true nature and purpose of Quality can shine through.

Hooray!


UBC Certificate Course for Laboratory Quality Management
starts January 11, 2017 www.POLQM.ca

Save the Date:  October 1-3, 2017
POLQM Fall Conference – Vancouver BC Canada