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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...

Saturday, February 22, 2020

Coronavirus from a laboratory quality perspective.

Call me paranoid or jaded, but I have become increasingly uncomfortable with the news about the current coronavirus outbreak.  

Over the weeks that all this has been going on what we have been told in the public media is that this is a new virus.  This is possible, but maybe not.  What is probably closer to the truth is that this is the first time it has come to light with the availabilities of today’s science technologies.  

Coronaviruses are ubiquitous, and while hardly ever tested, they and rhinoviruses probably are responsible for the vast majority of  common cold that circulate around the world all the time.  Some are found in non-human mammals (civet cats, camels, bats, pangolins), but many reside in humans and cause what is usually thought of a benign illness.

Note: while we all understand colds are a benign nuisance  in healthy children and adults, common colds are a significant cause of death in the very elderly (Hung IFN et al, Unexpectedly Higher Morbidity and Mortality of Hospitalized Elderly Patients Associated with Rhinovirus Compared with Influenza Virus Respiratory Tract Infection.  Int J Mol Sci. 2017 Feb; 18(2): 259. ), at a rate significantly higher than influenza or covid-19.

A new nucleic acid test was developed very quickly to help identify the presence of this new virus in people’s noses and respiratory secretions.  It was based on the nucleic acids of one of the first isolates found in China.  The test used is said to be  very specific, but I suspect that it was NOT tested for reactivity with other coronaviruses normally found in humans.  (Maybe I’m wrong on this but few virus banks would have enough common cold viruses available in their freezers.
The test that was developed was created in a highly specialized laboratories under very controlled ideal conditions.  There are very specific requirements for how the sample should be collected and how the sample to be kept cold (between 2-8oC) and be transported on ice.  If routine laboratory testing is taken as an indicator of how often that happens, we can say with almost certainty, many do not get that treatment.
Most people who are tested are either totally symptom free or have a mild cold.  That would be typical of about 80 percent of people living in the northern hemisphere in January and February.  That appears to be true for people who test positive and who test negative.  The vast majority remain that way from the beginning of their inspection to the end.  

If you go into a typical busy laboratory in North America the number of tests that get incorrectly labelled is very low, and often when incorrect labelling does occur it is usually with either infants or adults with communication problems (poor hearing or distraction or communication in a language other than what the laboratory workers communicate in).   Usually busy laboratories have a semblance of organization.  I suspect that when samples are collected by people working under stress, wearing hazmat suits and dealing with hundreds of stressed people, the rate of incorrect labelling goes up significantly. 

So just because the label says the sample came from John Smith, maybe it actually came from Joe Smith, or John Smithe, or Jane Smith, or maybe the guy who was in line but just after John Smith.

When these tests were designed it was in a controlled laboratory with research organized staff.  In the real world laboratory where there are hundreds or thousands of samples, the opportunity for error or confusion while testing mounts considerably. 
Finally, when tests are done in routine laboratories there are all sorts of Quality Control checks to make sure that the tests are working correctly.  

So in summary, this is a new test being used to test people who have no symptoms or any way to correlate with results.  The samples are being collected in chaotic situations with high stress.  And there is no other confirming test available. 
So with the highest regard for my laboratory colleagues, I suspect that the risks of errors going by undetected is considerable.  

Bottom line: 
Be VERY careful when you listen, watch or read in the media about what is going on.  The opportunity for the information to be at best misleading and at worse wrong is probably substantial.

Friday, January 24, 2020

Republishing Noble's Rules for better satisfaction surveys

About a decade ago (!)  I started to think about all the problems I was having trying to gather useful information on satisfaction surveys for my proficiency testing program and from my students.  Most of the results that I got back were either incomplete, or inconsistent.   Trying to look at the data was both an Advil moment and a waste of time.  
So I started experimenting with different approaches to see if I could generate better surveys and get better information.
In 2011 I wrote a block on getting better surveys through applying better rules.
Over the years I have revised them, but through the process I ended up corrupting the blog post.  

So for anyone interested, I am republishing the last version, put together in 2018

In the laboratory business we have always thought it was all about the science and not about the business.
But we were wrong.
ISO as well as WHO and CLSI (and before them, Deming and Crosby) all acknowledge the importance of “Customer satisfaction”.
It is not so much that the customer is always right, but that the customer should always have a voice and should be heard. There is an expectation to have some form of customer input on a regular basis, perhaps as often as once a year.
The reason that the standards development bodies have included this as a requirement and the basis for policy is because it doesn’t matter if you are an academic providing a course, or a laboratory providing documented information, or a manufacturer providing umbrellas, or a proficiency testing provider, or an equipment and reagents supplier, if your customers are not happy, then bad things start to happen.
In the private product or service sector that probably means customers stop coming. And that becomes the business killer.
In the public sector laboratory, the customer may not have a choice of which laboratory they have to use, but that won’t stop complaints, reputation slurs, increased threat of litigation. (Incidentally, this applies to accreditation bodies as well.)
Sooner or later you risk becoming the interest of the public and the media.  

Or even worse, think about the embarrassment and humiliation of a public inquiry.
All of those are major career killers.

So what to do. In the business world, the godsend solution for customer satisfaction has become the on-line survey. It is so easy to create an on-line survey and send it out to all your important customers. So easy, in fact, that it has become too easy. 

Anyone foolish enough to give your email address to a hotel or car-rental or restaurant gets inundated with surveys. We have become a world of survey send-outers and survey send-inners, and most of it is a waste of time.

Most surveys are poorly designed; are way too long, too complex, and far too diffusely focused. If a survey takes more than 2 -3 minutes to complete, you can guarantee that either it will not be completed, or will be completed with junk information. 

Also, you have to remember that responders  always have their own bias one way or another,and probably have interpreted the questions in ways that you never dreamed of. Creating most surveys has become high risk of being counter productive for addressing customer satisfaction. As they say “Fast, easy, slick and wrong”.

If you still feel compelled to resort to surveys, spent some time at setting them up so that you might get some information that you can consider. (We call that PDSA) . 

After years of learning the hard way, I figured out a set of simple rules  that anyone interested in developing a Satisfaction Survey can follow.  I arrogantly coined them as Noble's Rules for Successful Satisfaction Surveys Note:  They don't guarantee success, but not keeping them in mind will pretty much guarantee failure.

(1) Focus them to a single issue.
The more you try to pack into a survey, the worse it gets.  Pick a topic and get out.

(2) Ask the question that needs to be asked, even if you may not like the answer.  
It’s very easy to create surveys that will always give you positive feedback by simply avoiding any potentially controversial or challenging issues, but how can you study or learn what people think if you don’t open up the discussion.

(3) limit the survey to only a few questions , best is to keep it to 5-6 and NEVER more than 10, and make them as uncomplicated as possible . 
Get in, ask a few questions, and get out.  Don't give them a chance to get bored.

(4) make sure that it can always be completed in 3 minutes or less. Boredom is a guarantee for incomplete surveys loaded with random nonsense answers.  It would be better if they didn't send the response in, because the nonsense becomes pollution and the pollution leads to terrible interpretation. 

(5) Pre-test the questions to reduce (you can never avoid) ambiguity. 
Make your questions VERY simple.  Confusing questions get confusing answers.

(6) Avoid requiring an answer. That is the other  guaranteed invitation to bogus information. 
Making people answer questions, makes people angry.  Sometimes you can't avoid them, but keep them to an absolute minimum.

(7) Pick your audience and stick with it.  
General send-outs are a total waste of time.

(8) Where you can, avoid satisfaction surveys. 
More effective solutions for monitoring satisfaction is looking at objective measures.  For example, count how many complaints come in and how many are resolved within a specific time. 
Set up a system to catalogue every complaint, something that most laboratories never do. All those telephone and hall-way gripes are complaints and they need to be included.

You may not think they were important, but the person who mentioned them did.

Friday, November 29, 2019

A truly successful Quality Moment.

Every two years we put on a POLQM Laboratory Quality Conference here in Vancouver.  The overarching theme is always the same - what’s new in laboratory quality for British Columbia and Canada and beyond.  We focus on topics like updates on key ISO standards (like ISO15189 and ISO22870) and on understanding risk for medical laboratories (ISO 22367) and medical devices.  All important topics for laboratorians to know.
This year we had an additional theme on “Meeting the Needs” with particular reference to Crosby and his definition of Quality as Meeting Requirements and the Measurement of Quality as the Price of Nonconformance, which we modified to the Costs and Consequences of Poor Quality, underscoring that all too often it is the customer who pays the consequence of our poor quality.
We had a lot of information on today issues like Quality Control of Cannabis and Impact of Gender Diversity on laboratory services, and the role of patients, and caregivers in the education of health professionals and learning the skills of Leadership.  Plus much more.
From my experience putting on conferences is NOT a money generating activity. If we break even we consider that a success.  If we lose a little or gain a little that is our target.  (The university is pretty clear that we are not-for-profit, but we are certainly not-for-loss!!).  If we take in a lot of money, that usually means that I charged too much. 
What I enjoy from putting on conferences is the satisfaction of knowing that we contribute to quality education and quality improvement in a most immediate sort of way.  People get together, they talk, they question, they challenge, they make presentations and verbalize what they are interested in, and then they go back to home with new thoughts, new ideas, with a new enthusiasm to create a better care environment for healthcare professionals and patients and their families and the community.    It is a lot like our putting on our virtual classroom courses, but even more immediate and more intense.  It is the ultimate quality and improvement moment.
Those who attended shot forward in their appreciation of how much laboratory quality is advancing.  Those that did not, did not. 
First let me emphasize that with our activities we focus on those present; and spend little time thinking about those who did not.  But this time I feel compelled to comment a little to the negative. 
From three jurisdictions we heard about spending freezes in healthcare, with particular reference to cuts in staff education.  Lots of funding for leaders and administrators but none for staff education.  Different funding pockets we were told; very unfortunate we were told; financial crisis management we were told.  All of it BS.   It gives us pause when we think about the current status of patient care when institutions put such a low priority on continuing staff education and quality improvement.
The most significant saving grace we experienced  were staff members who traveled from afar to get to the conference, using their own funding and using their own vacation time to attend.  These are the people who will save healthcare in the future.  
We fatigue of the tiresome expressions of privilege and entitlement and arrogance in folks who should know better.  Laboratory improvement is NOT derived from the high price help.  It comes from the people who do the work of making laboratories better.
For people interested in seeing what we discussed at our meeting, visit https://POLQM.med.ubc.ca/2019-polqm-quality-conference/2019-conference-presentations/    after December 6, 2019.

When Quality Conferences end, Real Quality Improvement ENDS