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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...

Tuesday, May 22, 2018

Not GB Shaw but still a quality prophet

Not George Bernard Shaw – but still a Quality Prophet.
I have always been a Quality fan of Philip Crosby.  He was a hands-on qualitist (one who practices Quality) and qualitologist (one who studies Quality) with a lot of experience.  Crosby became a skilled speaker and writer and learned how to make essential points clearly and succinctly.  

His 4 absolutes have defined the universe of Quality in a way that has never been surpassed.
The DEFINITION of Quality is meeting of requirements (of both customer and process).
The SYSTEM (PURPOSE) of Quality is the prevention of error.
The PERFORMANCE STANDARD of Quality is Zero Defects (relative to both the customer and process).
The MEASURE OF Quality is the Price of Non-conformance.

I regret that by the time that I got really engaged in Quality he was doing more writing and less public speaking and passed away a short time later.  I would have loved to have shared a brew-or-two.

I was always interested in knowing if he had the opportunity to re-write DIRFT (do it right the first time) if we would have developed an alternative phraseology  that would have retained the message but softened the tone.

Actually I think he would have looked at me, shook his head and walked away, probably saying something about my total absence of any real competence or commitment (In Reflections on Quality he doubled-down with “the thought of error being inevitable is a self fulfilling prophesy.  If you think it has to be that way, it will be that way”)

On a related note, I was flipping through Google, as I am preparing for a series of presentations, and I came upon the affirmation, “Success is not about never making a mistake; success is not making the same mistake twice”.  It was ascribed to George Bernard Shaw, the famed Irish author.  I have always been attuned to that philosophy as the true extension of the four absolutes; learn from your mistakes and you will prevent the error next time.

I have learned that a lot of affirmations are nice words, but too often mis-ascribed or maybe even made up (Albert Einstein never said that bochum about the cause of insanity.) so I was a little concerned that I couldn’t find any reference to a GB Shaw play or lecture.  

 But I did find something even more important.

George Burnard Shaw never talked about success and blunders, but Henry Wheeler Shaw did, and wrote it in one of his books “The Complete Works of Josh Billings” and first published the phrase in another book in 1865.  (George Bernard Shaw did not start his writing career until 1884!)  

HW was born in Massachusetts the son, nephew and cousin of American congressmen.  He was a pretty good student until he got thrown out of school for pulling a prank (Yay!!). 
He made his career similar to his countryman Samuel Langhorne Clemens, including the creation of a pseudonym; Clemens became Mark Twain, and Shaw became Josh Billings.  Both were itinerant actors, humorists, authors on a range of topics from a down-home common-sense perspective.  “Success don’t consist in never making blunders, but in never making the same one the second time”.  He is also the guy who wrote in a poem that it is the “squeaky wheel that gets the grease”.
To put this in some sort of temporal perspective, Josh Billings predated Crosby, Juran, Deming, Shewhart, Ford and even Frederick Winslow Taylor.  So I guess that makes him some sort of Quality Prophet.  

From my perspective what makes Josh Billings so important to the Quality movement was that he was not an industrialist, not a qualitist, and not a qualitologist.  He was well-read and well-written, thoughtful everyday person  voicing some pretty important quality concepts from a common-sense perspective.
The message is clear; Quality is not something elite; it can be founded first in common sense and plain language, and, if you read some of “Josh Billings; Hiz Sayings” in humor. 
You can get this book through Amazon for 91 cents!!!

As a final note, there are lots of people who love affirmations, and love to buy those plaques and put them on their office walls as inspirational.  Just be aware than just because someone ascribes the words to some famous person, doesn’t necessarily mean those words came from that mouth or were framed in that brain.  If that doesn’t matter that is OK, but if you are more verification oriented, a little more checking may be appropriate.

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,