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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...

Wednesday, April 11, 2018

Quality Story Telling - take 1: An additional cost for quality??

There are many paths that lead to Medical Laboratory Quality Improvement; education conference and study, implementation of innovative programs, and working at the level of personal responsibility and in particular building a strong positive organizational culture that supports and promotes quality thinking.   In our course we put a lot of emphasis of highlighting all these approaches, and we do it through the process of storytelling, which is the way that adult learners share their experiences in a way that others pick on new insights.  
 Storytelling can benefit both the story teller and the story listener.  It is a great way to communicate and learn all at the same time.

So let me tell you a story.

The other day I was in a discussion with a person with a lot of responsibility for laboratory activities in our province.  We were talking about our province’s on-line reporting system for medical laboratory error, in part because of the two recent manuscripts that I and colleagues have recently had published on the subject.
(Medical laboratory associatederrors: the 33-month experience of an on-line volunteer Canadian province wideerror reporting system. Restelli V, Taylor A, Cochrane D, Noble MA. Diagnosis (Berl). 2017 Jun 27;4(2):79-86 and Laboratory error reporting rates can change significantly with year-over-yearexamination.  Noble MA, Restelli V, Taylor A, Cochrane D.  Diagnosis (Berl). 2018 Mar 28;5(1):15-19.
[Both available on PubMed].

 This provincial reporting system (the BC Patient Safety Learning System or PSLS)  is now about 10 years old, and suffers many of the problems of most 10 year old software; that being said, the system has far more positives than negatives and provides us with a lot of information and insights on the state of laboratory quality efforts in British Columbia.

It is a volunteer program where the reporter identifies a problem and goes to the on-line site and completes a reporting.  Sometimes, the same event can be reported by more than one person, each from their own perspective.  Sometimes an event that people wanted to report does not get reported because it was inconvenient at the moment to stop and report, and then people forgot or got otherwise distracted. 
Error reporting is not particularly balanced; there are some profession groups and some geographic parts of the province that are likely to report events and other seem to have little interest, and that was the topic of our discussion.

So I was having this conversation and this person came up with two comments the first was that the system is not helpful or user friendly because a laboratorian would have to take 5 minutes to complete an on-line report, and that laboratory physicians are far too busy to stop and take the required 5 minutes just to report an error.  
In this person’s mind consuming 5 minutes of their valuable time was some sort of terrible imposition that way overrides the systemic benefits of reporting errors.   As personal conviction, reports should not be entered until PSLS spends the money to revamp the software so the events can be entered in less time, caving these poor overworked souls 2-3 minutes a day.  Regardless of costs, their time constraints demand it. 

But then they went further; the reason that people don’t report is because there is no financial incentive to participate and report.  

Rather than pursue the conversation I decided to change the topic.  If what I thought was being said was indeed being said, our discussion would have turned into an ugly confrontation that would have benefited no one.  Surely nobody with a modicum of quality awareness thinks that the best way to enhance error reporting is to pay people to report.  What could possibly go wrong with that idea!!

In actual fact, the data in the two manuscripts points to the fact that this person was wrong.  Over the years, the rate of error reporting has gone up substantially.  It seems that increasingly people are using they system, despite what slight software inconveniences exist.    The system probably could be enhanced, tweaked, to make it a little more user friendly, but major overhauls would cost a ton and likely introduce all sorts of interface problems with not much benefit towards reporting.  

If we need to do something it is to work with the groups who choose to not report and find solutions to the barriers.   I suspect it is probably something as simple as being unaware, or “fear of the learning curve”.  I suspect it is more about habit than conviction.  And I suspect it has NOTHING to do with people begrudging the couple of minutes to report.  (By the way, if a laboratorian is having to report more than 2-3 errors a week, costing them more than 15 minutes there is something going on that needs a lot more attention.

The evidence to date is that reporting errors has a lot to do with quality awareness, and personal conviction and growth that comes with quality activity.
 Reporting progress does not need BIG thinkers, it needs engaged thinkers who see value in spending a few minutes to initiate a report and implement a corrective action.  

But if it requires extra MONEY to support a pay-for-reports program, then we are really in trouble.

Thursday, March 15, 2018

How Happy are your customers and how much do you care (Part 1)

Recently I have had the opportunity to start looking at laboratory Quality in a whole new light.   

Medical laboratories have only recently been introduced to the concept that they are businesses that have customers and that these customers have certain rights and expectations.   Quality oriented laboratories need to take customer satisfaction in mind because unhappy customers can make complaints that at a minimum can disrupt smooth administration, or they can create terrible publicity and public awareness, or the can sue.  In many parts of the world, they can drive business away and the laboratory can starve for work (and revenue).  

Unfortunately this is still all very new in the laboratory arena, and only the barest of minimums of activity are yet in place.  Few laboratories are much beyond the complaints form, and for those that are few are doing anything to really capture clinician or patient sentiment.  But to be fair, progress is slowly being made.

In many businesses, meeting satisfaction needs is only a minimum; more importantly they need to find the way to connect satisfaction to both business and revenue growth (welcome back, spend more, and bring a friend!).  This is being referred to as Service Excellence or “Customer Delight”.  (As an aside the term customer delight has been around more that 30 years, but in most English speaking countries it still sits very uncomfortably on the tongue.)

In the early 1980s Noriaki Kano, an academic in quality management and customer satisfaction wrote a lot about satisfaction.  Although his target audience was neither healthcare or medical laboratories, as I read about his model of satisfaction (referred to appropriately as the Kano Model) I can see how much of it directly is referable to the medical laboratory and quality improvement.

Kano wrote of 4 identifiers or attributes of product and service development in the context of customer satisfaction (A) Basic or Threshold (B) Performance or Linear, (C) Attraction or Delighters(!) and (D) Indifferent.

Basic satisfaction occurs when the customer gets used to having the product when they want it, then then get really annoyed when it is not available.   An example of this might be providing staff in the Emergency Department a simple point of care test to detect an infection, but then saying it will not be available for use on Wednesdays or the weekend.   

Performance of linear satisfaction is said to be positive when the service is performed and negative when the service is withdrawn.  A good example of this would be when an laboratory announces that in order to make the life of elder or very young patients easier, they offer to go to the patient’s home for sample collection rather than making them go the clinic, but then not providing the service when the driver or the collector goes on vacation for three weeks or if they decide they won’t collect the sample because maybe the patient has the flu.

Attraction or Delighter satisfaction occurs when the customer is REALLY pleased when the new service or product is available and enjoys its presence, but is not dissatisfied when it is not.  It is seen as something of special value.   It’s like when you go to the laboratory and get seen by a phlebotomist who is not only efficient and effective, but is also happy and congenial and helps take away the anxiety of visiting the laboratory.  Or perhaps when you receive a laboratory report there is an informative note that helps put the result into better perspective.  What Kano pointed out is that once an attraction/delighter action is first put into place, it is seen as something novel and keen, but overtime, everyone just assumes that it should be the norm, and gradually it shifts from being an attraction/delighter satisfaction attribute and becomes a basic one, that people expect all the time, and get really annoyed when it is no longer there.   

Finally there is what Kano called Indifferent Quality which describes quality efforts that the customer knows nothing about and is unaware if they are present of absent and have no tangible impact on satisfaction.   This with regret accounts for maybe 99% of the things that we do under the banner of Quality Management and Quality Improvement.  (We know, but nobody else is aware).

If (and that is a BIG if) documents like ISO15189 or other standards/guidelines start pushing for more innovation in laboratory customer service and more clients start demanding a higher level of attention and care, these concept are going to become very real and very familiar in your neighbourhood laboratory.

More to come,

Monday, February 12, 2018

Quality upside down and backwards

Warning:  This entry is deeply in the weeds.  If you are not a ISO-wonk or Qualitologist, this will drive you crazy.  For a quick read, jump down to the last two paragraphs.

The International Organization for Standardization (ISO) is a crafter of standards, but NOT creator of original thought.  Ideas exist, usually from other international organizations, but taken to their origins, from true original thinkers.  For example ISO/IEC 17025 first came to life as ILAC Guide 25, a document created so that international accreditors could have a single source against which to assess laboratories.  Similarly ISO9000 was derived from a combination of a British Standards Institute document and a UC Military Standard and another from the Canadian Standards Association, but ultimately they were derived from the teachings of Deming and Juran and Crosby.

The concepts of Plan-Do-Study-Act, Risk, Document Control, Corrective Actions all long proceeded their appearance in documents published by ISO.  Think of ISO as the iterator or popularizer or disseminators of ideas rather that a creator.

In my laboratory when we actively decided that this stuff called TQM or Quality was something that we should look at, we learned  about it through books (read Ray Bartlett’s classic Microbiology Laboratories: Quality, Cost and Clinical Relevance) and guidelines many from the organization then known as NCCLS (now CLSI). 
We had looked at the recommendations and guidelines on how to write an SOP or how to set up document control.   The nice part was that the books and guidelines that I learned from were written as books and guidelines whose primary task was to teach.  And importantly there was no pressure.  

I could take the information as given or fiddle with it or ignore it.  My laboratory, my choice.   

Today it doesn’t work like that.  Today laboratories generally don’t start from scratch.  They start from the perspective of what is written in ISO standards or from the expectations of an accreditation body.  And that is tough because ISO standards are not, were not and never will be designed as tools from which to learn.  They are designed as documents for rules setting. 

So here is my problem.  

For the last 17-18 years we have taken the view that the way developing laboratories need to learn about implementing Quality is NOT to start from the perspective of basic components, but rather to start from obeying the dicta of ISO.  And so far that idea is not working particularly well.  And further when we assess their progress we do it against an accreditation level standard.  

Recently I was in conversation with a person very involved in monitoring progress of laboratories in a developing country and was told that the laboratories were not doing particularly well by their measurements as assessors.  I knew what the problem was; it’s was not that they had no written SOPs, it was that their SOPs did not meet the requirements of ISO.  So what!!!

These laboratories are just learning about quality management and importantly, there were no small laboratories from developing or evolving countries that participated in any part of the ISO process.  They had no opportunity to object and make the point that the standard as written was not designed or intended for them.  This is really a round hole-square peg situation.  

We should be promoting them to learn and discover Quality in the same way as we did; start from having a purpose and finding a solution.  Allow them to play around with different versions of document management, or risk, or SOP production.  Allow them to discover and appreciate value and then refine.

 We should NOT be using ISO standards to promote quality in these laboratories.  
And ANY person who answers a question by saying “we do it this way because that is what is said in ISO15189” should be thanked for their service and shown the door.