Sunday, July 12, 2015

When is a person like a car?

Here is a riddle for you.  When is a person like a car?  It is not a trick question and the answer is exactly what you think.  A person is never like a car.  

 A car doesn’t care how it is made.  The person making the car might be interested in things like keeping errors to a minimum, cost, efficiency, but the car doesn’t care.  It just rolls along the production line being prodded and bolted and sprayed and polished until it is done.  People do care how they are made; at least that is what modern investigation tells us through the magic of MRI and other cool instruments.  The fetus displays all sorts of signs of adverse reaction to noxious stimuli. 
Similarly when a car is being repaired, the car doesn’t care if the repair folks are inept and use poor procedures and cheap parts to put the thing back like it was.  The car doesn’t know or care about costs and efficiencies.  Again the owner cares at both ends of the spectrum, either when it costs too much or too little.  But for the car it is just another day.

It is kind of a silly way of trying to make a point, but there is a point.  People really care when they are the subject of repair.  Patient satisfaction makes all the difference between a happy hospital and a hospital mired down in civil suits and bad press.  Patient satisfaction differentiates between the choices of malpractice or no malpractice.  People care.  

While this is intuitively obvious, there is nothing better than documented study to make a statement go from “well duh” to “and that’s a fact”.  And that brings me to a recent article in ASQ’s Quality Management Journal: Cost-Quality Trade off in Healthcare; Does it Affect Patient Experience  (QMJ Vol 22, No 3/ 2015, ASQ) .
Basically the author (Sriram Venkataraman) was able to look at two sets of information, one being scores on patient satisfaction (aka “experiential quality”) as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a formalized satisfaction survey.

The other set of data came from information on physician-to-patient ratios, nurse productive hours, outlier payments, weighted Diagnosis Related Group (DRG) and other information including patient mix, and setting (rural, urban, large urban) and number of staffed beds.

When the comparisons were made, across the board, hospitals that had the greatest cost efficiency had the poorest satisfaction, and the longer the person stayed in the hospital the poorer the satisfaction level.  

To go back to the beginning, while Lean and cost efficiency is effective in industry with particular application to Toyota (ergo the riddle about the person and the car) patients do not like institutions that Lean out (or chisel out) every nickel.
Healthcare has made a number of strides towards Quality.  Fewer pharmacy accidents happen now, as do fewer nosocomial infections, although to be accurate there are still lots of pharmacy accidents and infections.  There are probably a lot less wrong legs being cut off.  

It we use crude markers of success, cost efficiency has reduced the number of lives lost due to hospital care.   But it is at a cost.  Patients do not get much sense of well-being while being hospitalized patients. 

Previously in this blog I have commented on patient satisfaction.  Given the state of healthcare today, the greatest “killer of quality” is the association of an endless supply of new patients with no impetus to providing good care and no consequence to giving poor care.  [see: ] We see this regularly in Canadian healthcare across the country.  What patients put up with is just astonishing.  Unclean facilities, indifferent staff, and facility management that is deeply deeply committed to cutting every nickel they can. 

There are lots of reasons for how we have reached this point, many out of them control of management.  The reality is that the global economy has gone through a pretty gruesome downturn that has not rectified itself in now 8 years.  Governments are strapped, and revenue in healthcare facilities has not kept pace with expenses, or indeed anywhere in the social safety net.  There are fewer staff and the ones that are there many are tired and frustrated.  They don’t want to be there anymore than the patients, except for the fact that they are all making a lot of money.  

As I see it (as does the author) cost efficiency creates as many problems as it solves.  In Canada, a litigious free zone, there is little expectation of ever returning to  better satisfaction.  But in the US, at some point the level of dissatisfaction will become a significant issue that needs addressing.  And that will not be done through the “affordable care act”.

In the next entry I will tell you what I think can make things better.

Friday, June 12, 2015

New steps forward in Laboratory Quality

Life in PT/EQA has been very busy in the last while for us in CMPT land.  Lots of changes, and all of them good; renewed certification, new contracts, new staff, and importantly a new accreditation.

As a Quality Partner, it is essential for PT providers to be able to demonstrate that they take their own performance and improvement as important as those that they assess.  ISO17043:2010 (Conformity Assessment -  General Requirements for proficiency testing) has become the cornerstone quality standard specifically designed to address the issues of proficiency testing providers, regardless of the communities and disciplines with whom they work.  The standard addresses the full cycle of PT from the planning of challenges through their development and deportment, and the analysis and reporting of results.  Similar to ISO9001 (Quality Management Systems) to which CMPT also adheres, ISO17043:2010 also closely monitors our own Quality Management processes.  Developed by the International Organization for Standardization, and supported by the broad community of countries, ISO17043:2010 is the recognized as the standard of achievement for proficiency testing by accreditation bodies and PT providers around the world.   CMPT is proud of its recognition of meeting all the requirements to this international standard.

In Canada, accreditation or international recognition is not a requirement at any level of government.  By its voluntary participation in this accreditation assessment, CMPT affirms its continued participation in the international community of proficiency testing providers.

CMPT has for more than a decade has been assessed with respect to our Quality Management System and have had it certified as being in compliance with ISO9001:2008 (soon to become :2015).  We started that early one when there were few choices for formal international recognition, and continued it on because 90 percent of our customers (the laboratories that participate in our programs) perceived ISO9001 as a valued marker of our quality and competence.  It is difficult to argue with those levels of support.  But now we have added in a newer level of assessment with much more focus on the technical/operational aspects of what we do. 

In the world of Proficiency Testing and External Quality Assessment, the rise of ISO17043 has been profound.  The document is only in its fifth year, but has been accepted and adopted in countries all around the world.  Indeed PT programs accredited to the standard can be found on every continent (except Antarctica).  It would be fair to say that I am knowledgeable about a few ISO standards as they pertain to Quality and Medical Laboratories.  I find it stunning how quickly and inclusively our extended community has embraced documents like ISO15189 and ISO17025 and ISO17043.  I think it speaks volumes to the commitments to Quality that we see in the Medical Laboratory and Testing Laboratory communities.  We take our Quality seriously. 

It is our goal, at least for the time being to continue to seek both levels of audit and recognition.  I suspect there will be few programs seeking recognition to both ISO9001:2015 AND ISO17043:2010.   But at a certain level it makes sense.  In my experience 17043 is significantly better as a marker of technical/operational interests while 9001 is similarly superior with respect to customer satisfaction and meeting customer needs.  The combination is powerful. 

Medical and water bacteriology laboratories that work with CMPT can have continued confidence in the rigour of our commitment to our own Quality and to the Quality needs of our participants.

PS: To consider another approach to our commitment to Quality for the medical laboratory, please visit:

The Future of Quality in Healthcare

The American Society for Quality has published a series of reports on the Future of Quality.  The collective is well worth reading.   I am responding to one of the reports by Devi Shetty who advocates for an approach to expand education and training to provide a greater supply of healthcare workers.

Devi Shetty gives a brilliant and innovative presentation on a vital piece of the Quality puzzle as it continues to perplex healthcare.  He correctly points out that the notion that international healthcare problems will always be solved by creating bigger institutions and better equipment is misguided, especially in developing countries.  The solution lies in having more locally trained staff with the skills to serve more people closer to home.  That, I believe is true, not only in with respect to cardiac and neuro surgeons, but throughout the whole complement of healthcare workers.

While my personal experiences in international healthcare are not as extensive as Devi Shetty’s I can say that I have had the opportunity to experience healthcare in southern and eastern Africa and in the Caribbean, and from those experiences I am concerned with the continuation of the secondary challenge.   Using the terms of a song first popularized nearly 100 year ago, “How Ya Gonna Keep 'em Down on the Farm After They've Seen Paree?"

There are many high quality training programs for healthcare workers in a wide spectrum of professions.  Many of these can be found in many developing countries including, but certainly not limited to Tanzania, and Jamaica.  The physician and nursing and laboratory worker graduates of these institutions are seen as “world class” and are welcome in countries all around the world.  And that becomes the problem; given a choice, many move to countries where they see more opportunity for themselves, and their families, and especially their children.  It represents the perpetual problem of the “brain drain”.  The home country suffers the double loss; the expense of the training, and at the same time receives none, or only a brief short term direct benefit.

The worst parts of the brain drain are that it is fair and unfair, reasonable and unreasonable, both at the same time.  Any person who has put themselves forward and learned a new skill has the right and obligation to give back to the community that provided them the skill, but at the same time has the right to take personal advantage and benefit from the skill’s potential.  If there are attainable positions with greater remuneration and associated perceived improvements for education and opportunities especially for children, it can create a difficult decision for many workers.  Sometimes, but certainly not always, the grass is greener on the other side.

Solving the brain drain challenge becomes not only a fiscal but a moral/ethical dilemma.  While some degree of mandated commitment to the home country (3 years? 5 years? 10 year?) may seem like a workable compromise, others may not agree.   I suspect that most or even all readers would agree that lifelong travel bans are not acceptable. 

So I as much as I agree with the value and importance of wider access to productive training and education, addressing improvements in healthcare through wider training may not be sustainable unless some broader challenging issues can also be addressed.

But it clearly is an important step forward.

PS:  For an interesting view of the Impact of Quality on Medical Laboratories, please visit:

Saturday, May 9, 2015

Customer Service Counts

There is a story going through the national media that makes two points that are critical to healthcare quality.  The first is that Quality falters in any system when there is an endless supply of customers (patients) and there is no benefit for good performance and no consequence for bad performance, which in essence describes most of our public health care system across Canada.  The second is that all healthcare organizations are surrounded by Quality Partners (educators, accreditors, proficiency/competency assessment, oversight bodies, etc.) but the most powerful effector of Quality change is an outraged public.

In essence this story is of a woman who is given an appointment to attend the hospital to have a cortisone injection.  Unfortunately prior to the 5 minutes it took to receive the injection, she sat and waited for an hour and a half, in part because the clinic booked 5 patients and the same time, and more importantly because the clinic staff decided to take an hour for lunch while the patients sat.  [see:

After a deliberate period of time, the patient decided to bill the hospital for her time, and to make sure that the public was made aware.  As she told the media in an interview “It’s the total lack of courtesy on the part of everybody at the hospital that really angered me.  It’s totally disrespectful.”  I suspect the hospital’s response did not make her disposition any better.  “We welcome constructive feedback that will help us to improve our performance and provide our patients with the care they deserve.”

The problems here are systemic.  

What on earth would motivate a physician and staff to take an hour for lunch with people sitting and waiting? Are they venal and nasty, intent upon creating harm? Not likely.  What is more likely is that they have become inured to patient inconvenience.  If this was a lifesaving crisis, they likely would have acted differently, but was not about harm, it was about petty inconvenience.  Harm is a big deal, in part because doing bad can have consequences.  Causing inconvenience does not.  
Public healthcare has little regard for customer service, other than what it puts into moto’s and brochures.  “We strive for patient-centred care…” or “We endeavor to put the patient first…”  Words, words, words.   

This has become a truth not only in emergency departments and clinics, it is a reality throughout this system, including, with regret the laboratory.  Take a look at ISO 15189, our international standard on Quality and competence.  The document contains almost no statements relevant to customer service.  This was not by accident; the crafters of the document were well aware of the customer service requirements in ISO9001:2008, but chose to not include hardly any.  

And accreditation bodies don’t help by not making customer service a priority for accreditation.  A telephone call to a laboratory’s pre-selected client doesn’t put across a message that competence at customer service is important.  

The day of reckoning is coming.  We live in a very different society today as compared to even 20 years ago.  The public has become much less interested in the authority of institutions.  The public  has found its voice through a myriad of social media vehicles.  The word about bad behaviour gets around very quickly.

Institutions will learn either on their own, on through the hard ways that customer service matters.  Good service may not have lots of rewards, but bad service will most certainly have consequences.  We, in Canada, may not have a litigious society; malpractice suits are not our style.  But public shaming can be very powerful and weasel words like “We welcome constructive feedback…” don’t cut it. 
Next time the hospital should try “We apologize for what was truly inappropriate behaviour.  We will improve our customer service and will put in every effort to reinforce the message that poor service has no place in our organization”

PS:  For those interested in Quality Conferences, be aware that we are hosting our 4th conference in Vancouver BC on October 28-30, 2015.  See:  

If you decide to register and attend, I would be interested on your thoughts about this blog. 

Friday, April 10, 2015

Attending Quality Conferences

Julia McIntosh of the American Society for Quality has created a really nice summary on why attending meetings promotes networking [see: ].  And many thanks for pointing to my blog on one of the challenges of meeting travel [see ]. 

To be clear, let me underscore that I absolutely agree with Julia.  First and foremost, I know there are some inherent risks, but on greater balance, attending meetings is  critically important to Quality and Communication.  As the old adage goes “the most important part of a meeting is that people meet”. 

When people get together, creative juices flow and innovation and collaboration and synergy opportunities abound.  It is tough (but certainly not impossible) to duplicate that over a telephone or by watching and participating through a computer or tablet screen.

But it is also fair to say that meetings can have costs which have to go into the planning mix.  Yes, even attending meetings is a Deming PDSA opportunity. 

You can’t be in two places at the same time, and sometimes urgent things can happen while you are way, and the longer the meeting, the greater the risk.  Also, it is pretty clear that the more flight legs it takes to get to a meeting, the higher the probability of a problem.  Lost luggage, missed connections, jet lag, and common colds, phlebitis, and more recently it seems, measles, can mess up your meeting.  And let’s not even talk about flying in or out of the North-east anytime between mid-December to early-March (?) with predictably unpredictable weather. 

And then there are the financials to take into consideration.  In my world, an average 3 day meeting can consume between 4 and 5 thousand dollars, for travel, hotel, registration and per diem costs.   

So I can agree that attending meetings is important, and you can optimise the up-side benefits and reduce the downside hazards, with the following:
1.    Ensure the meeting is worth the risk.  Are the people that you want to meet or listen to likely to be there?  In my world, ASQ meeting are right up at the top.
2.    And as an extension to the above, if you go to a meeting and talk only to your friends, or even worse, talk to nobody, that is opportunity lost.
3.    Look for meetings in the sweet spot, May-to-October, (maybe avoid August) to reduce risks of weather.
4.    Make it a meeting worth your while by balancing travel time against meeting time.  Do you really want to travel for hours-and-hours just to attend a one-dayer?  And on the other hand, do you really have the time to be away for 4-5 or 6 days?
5.    Look for meetings in locations that you can get to on one or two flights.  More than four flights is probably a guarantee for at least some lost luggage or a missed connection.
6.    And as another extension, look for meetings in places where you might like to visit. 
7.    Look to save some cash.  Book meetings at the Early-bird registration rate.   Usually the meeting hotel is going to give a good discount and sometimes, meals are included as part of the meeting. 

So ASQ World Conference on Quality and Improvement in Nashville, in a few weeks for most folks in North America would meet all those criteria. 

Where also would be an ideal meeting to consider, if you are in the medical laboratory/healthcare/safety business, is to think about visiting Vancouver BC and the UBC Program Office for Laboratory Quality Management Conference in October 28-30, 2015.