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Tuesday, November 30, 2010

Assessing the Assessors

A number of years ago (2000-2001) I was invited to give a presentation about my proficiency testing program.  When I finished, I invited the audience for questions and comments.  A technologist stood and angrily complained that proficiency testing and accreditation bodies set themselves up as authorities, but were not required to meet any requirements or expectations.  She was absolutely right.   

So in 2001 I decided that we had to fix this, and in 2002 we were thoroughly assessed and our organization was certified has having a quality management system that served us well.  We have continued the process of external assessment and re certification ever since.  In 2010 a new ISO standard for Proficiency Testing bodies was developed (ISO17043:2010).  We are considering that recognition process as well.

My biggest regret was that I didn’t get the name or contact information of the technologist  who woke me up to the critical importance of demonstrating commitment to quality.

I tell the story for two reasons: the first to brag, and the second to make the point that despite my regularly raising the issue accreditation bodies in Canada have been much slower off the mark.  Indeed my above story could be almost as relevant today as it was 9 years ago.  

To be fair, in Canada we have a distributed responsibility health system with each province responsible for its own health oversight, so  there is no single oversight body that demands provincial accreditation bodies have themselves external assessed for quality and/or competence.  But it is not a matter of requirement.  It is a matter of obligation and commitment.

But now 2 provincial medical laboratory accreditation bodies (plus 1 more) have stepped up to the plate and achieved international recognition.

In 2004 the province of Ontario decided that it was time to get into laboratory inspections.  It was timely because the new international standard ISO15189 as a standard for quality and competence of medical laboratories had just been published.  The newly minted OLA (Ontario Laboratory Accreditation) arm of QMP-LS (Quality Management Program – Laboratory Services) created a standard that incorporated the new standard and others, to ensure that medical laboratories were implementing quality management systems (and other measures of competence).  They have become world leaders in ISO15189 accreditation.  ISO Accreditation in Canada is done officially under the authority of Standard Council of Canada, through its signatory relationship with the International Laboratory Accreditation Cooperation (ILAC).   

In 2010, my province of British Columbia, going a different route has none the less achieved international recognition through accreditation of its laboratory accreditation standards by the International Society for Quality in Health-care (ISQuA).  This is a complex process similar to the certification process that I underwent with ISO9001.  

There is a third organization which is not a provincial program, but a not-for-profit, independent organization known as Accreditation Canada which has for a long time run a voluntary program of accreditation of all (or nearly all) hospitals in Canada. A truly remarkable job.  Recently it has been working under contract in one province to assess its laboratories.  Accreditation Canada’s standards have also been accredited by ISQuA.   
To have standards accredited they have to be externally assessed and demonstrate the 6 principles of Quality Improvement , Patient/Service User Focus, Organizational Planning and Performance, Safety, Standards Development , and Standards Measurement (reference: www.ISQua.org).

The other provinces either don’t have a provincial accreditation body, or they have one that has not yet taken the step forward for external assessment and recognition.

There clearly are differences between the ILAC process and the ISQuA process, and their strengths and benefits for the clinical and laboratory settings can be debated for a long time.  It is similar to the discussion that sees value in differentiating between the accreditation process and the certification process. I’m not going to get into that at this point, largely because I see the argument is all too often driven by bias and competitive commercialism.   What is important is undergoing external assessment demands discipline and rigor and demonstrates a commitment  to quality improvement

So in Canada, we are fulfilling a process that I have been promoting for near a decade.  If Canadian oversight bodies want respect, they need to demonstrate they deserve it, and to do it by independent external assessment.

And so, congratulations to the province of Ontario OLA program, and to the province of British Columbia Diagnostic Accreditation Program and to Accreditation Canada (and to CMPT!) for allowing the external light of audit and assessment to be shone on their programs. 

And my heart-felt thanks to my anonymous friend who got me to get the ball rolling.

Please visit
for an important notice.

Saturday, November 27, 2010

Patience and Patients Safety.

I was reading my local newspaper and found a columnist discussing an article on Patient Safety and Hospital Error.  We can no longer be surprised that the things we do have become front and center in the cross-hairs of the media.  We have brought this on ourselves.  

The column reported on an article in a recent edition of the New England Journal of Medicine (how scary is it that a local paper columnist is reading articles in the NEJM!), which looked at the rates of “preventable harms” in 10 hospitals after 5 years of active process (2002 – 2007).  While there was a reduction (approximately 1% per 1000 patient days) the reduction was not statistically different, nor (my opinion) clinically significant, even if it was real.  This was true for each category from inconvenience to death.  This was despite active engagement in national and state patient safety training programs. The analysis was done by thorough and fair methodology with internal and external reviewers and appropriate reviewer comparisons.
The authors commented that harm from medical care remains high despite all the programs and the money being spent.  
 The study confirms reports from across the US and Europe about how little progress is being made.  The amount of evidence-based error reduction practices implemented so far has been modest.  All the things that can be done, including substantial improvement on handwashing (!), have not be implemented with any consistency or success.

A few thoughts. 
Systemic and personal behavior does not appear to be easy to change.  While there are folks within health care who are motivated for change, they are not having a lot of success, when measured by outcome.  Most of the money being spent on patient safety teams, training seminars, poster displays, and conferences is being wasted (unless your personal income comes from being on a team or charging for putting on training seminars).  Change is not happening.

My concern is that if healthcare management and healthcare unions wanted change, then change would happen.  I could suggest that there are other vested interests at play, but that would be unfair.  But if neither altruism nor fear of malpractice litigation is insufficient to drive change, then what does it take?
At some point the media will care enough and the public will care enough and the politicians will care enough and we will end up with a healthcare version of the Transport Security Administration and we will have our own version of an intrusive airport pat-down.  And folks will say, well it may not be fun, but it makes our lives more secure.  
For example, the regulators, and legislators always have lots of options, like perhaps a variation on pay-for-performance.  Rather than institutions getting a reimbursement bonus for good deeds, every year that they miss their goals, they lose 1%.  And insurance providers can start jacking up institution protection rates.  

“They” say that carrots work better than sticks, but sticks work.

From my vantage point, hopefully medical laboratories might be having some more success in error reduction because as much as we are a complex distributed activity, our activities are more focussed than hospital admissions.  Some centers have demonstrated some levels of reduced error, at least on a short term basis.  But we need to have an institution perform the longer term year-over-year study like the one above to observe if trends can be seen as improving.  I suspect that most are afraid to look.   

The media already cares, and the public is become more aware.  
Strike 2.


PS.: The article is “Temporal Trends in Rates of Patient Harm Resulting from Medical Care” by CP Landrigan et al.  N Engl J Med 2010;363:2124-34.

Thursday, November 25, 2010

Thanksgiving, Family and Quality

Thanksgiving is a day for family time, and the beginning of the family season, and so it is unfortunate that it is also a time to become aware of discomfort.  Today we learned of the death of David Crosby last week. 

David (Dave) Crosby was the younger brother of Phillip Crosby, and a quality management expert in his own right.  Perhaps not as well known as Phillip, David was a regular author and quality contributor.  He worked in the Quality arena for 50 years.  He wrote two books,  "The Zero Defects Option (How To Get Your People To Do Things Right)" and ""Zero Defects Option".  He was a prolific contributor to the Quality Digest (www.qualitydigest.com).

David was committed to the notion that it is possible to create a Zero Tolerance culture.  Committed to the notion that zero tolerance is a leadership choice   Zero tolerance for defects or error was not the original thought of David Crosby, nor of Phillip Crosby.  It was included in the 14 points of W. Edwards Deming, and was a guiding principle in aeronautics and missile development.  Regardless of who expressed it first, it is none the less a desirable goal.  Now I know and understand the concept of slips and human foibles, but I also know about systemic error that fosters human error. 

Zero tolerance for error is a valued goal.  As one critic has commented: If by buying the book, it prevents only one defective product or service, you are way ahead of the game.  There are no $25.00 errors. 

Phillip was 4 years older than David and created his quality consulting company one year before.  And his fame rating was probably higher.  That being said, both brothers can be found in my library. 

For my American colleagues, enjoy a belated Thanksgiving (we Canadians celebrated out a few weeks ago).


Tuesday, November 23, 2010


 American Society for Quality has a number of  journals, and some excellent, and others pretty good.  One of the latter category, at least in my opinion, is the Journal for Quality and Participation.  Without wanting to be harsh, I tend to find articles, while generally interesting,  tending to be more  opinion than fact.  (The irony of me, an opinion oriented blog writer making this distinction is not lost!).

Nonetheless there were three interesting articles in the October 2010 edition that I received today.  One was “Improving Project Performance with Three Essential Pieces of Information” by Portnoy, and another “Creating a Self-Confident Workforce” by Denton.   The last one is  "Training on Trial” by Kirkpatrick and Kirkpatrick.  

I don’t intend to go into any (the journal is available at www.asq.org/pub/jap) in detail other than to say that the first article made the point that when designing a project briefing (the deliverable) it is useful to make it brief and unambiguous.  The point was that the more the number of words and the more jargon included, the more variable is the document's interpretation.  The training article was making the point that training can have a lot of challenges demonstrating that it actually provides a service that will address significant business results.  And the third article made the point that workers are more self-confident with less stress when they are empowered to make certain decisions on their own.

I can support all those points.

Which brings me to the heresy. 

At a laboratory where I was working, I often found myself in conversations that suggested that some of the standard operating procedures (SOPs) were so detailed and so “precise” that in my opinion, they were largely unfollowable.  Even with an adjoining process map they were unfollowable.  They were better when pictures were added in,  but especially better when pictures were used in place of words.  In the process of trying to make SOPs that were all encompassing, I felt we were laying the foundations for error.

And so I started to think that maybe it is not so important to tell microbiology technologists how they have to hold and streak a petri dish, but to let that happen on its own.  And defining precise colony counting methods was so rigid that it likely wasn’t followed anyways.  And trying to define all the combinations and permutations of bacterial growth was confusing.  
Now there are many procedures involving many pieces of highly precise equipment that do need precise instruction (I understand that) but if we pollute those instructions that are challenging to follow, I think we run the risk of some documents  that need attention and clarity getting lost in the shuffle.  

So my point is that SOP writers and trainers and supervisors need to take a closer look at the procedures that they create to make sure that they actually are useful for training, and more importantly allow the business purpose of the procedures to come through.  Its not only about the value stream, but also creating documents that give technologists the professional autonomy.  Smaller and selective documents, it  seems to me, make the procedure and much of the decision making process both more efficient and more effective.

And how heretical is that?

Monday, November 22, 2010

Getting the story right?

I have a long abiding interest in things Quality, and especially for the concept of continual quality improvement.  (We may not be perfect today, but we can be better tomorrow).  From my perspective the single most important concept that underlies continual improvement is the cycle of planning an activity – doing the activity – checking to see if what you thought was done, was in fact done – and then acting to adjust the outcome.  And then do it again and again.  To me that is the Plan-Do-Check-Act cycle which I know and understand was adapted from Walter Shewhart, and created by W. Edwards Deming.  Later in life, Deming modified the terminology to Plan-Do-Study-Act (PDSA), but PDCA is the cornerstone of Quality, it is the cornerstone of ISO9000, and it was created by Deming.  So imagine my interest and surprise when I read that I was wrong.  

In this month’s (November 2010) edition of Quality Progress (QP) published by the American Society for Quality is a fascinating article entitled “Clearing up the myths about the Deming Cycle and seeing how it keeps evolving”.  It is written by Ronald Moen and Clifford Norman.  Apparently Moen worked with Deming in the early eighties, and includes within his references for this article a letter written to him in 1990 by Deming himself.  

According to this article, while the first part of what I understood was correct, that Deming adapted the cycle first developed by Shewhart in 1939 to a new version, in 1950, that was not the Plan-Do-Check-Act cycle.  Not only that, but while Deming spoke of a PDSA cycle for many years, he did publish it as the Plan-Do-Study-Act cycle until just before his death in 1993.  Having checked my highly valued reference "The Deming Management Method" written by Mary Walton with W. Edwards Deming in 1986, at least part of what the article says is confirmed.

Without going into further details, I recommend this article as essential reading, especially for those who are interested in the history of Quality (www.qualityprogress.com).

It is fair to say that in the Quality Arena, Deming was (is) a larger than life character.  Indeed in the same edition of QP, the lead article is called the "Guru Guide: Six thought leaders who changed the quality world forever" (Shewhart, Deming, Juran, Crosby, Ishikawa and Feigenbaum).  At a time when the world industry needed order and structure and change, Deming was there.  His books and presentations and 14 Points and 7 Deadly Sins and the famed Red Bead Experiment are the very foundation of Quality, and as relevant today as they were when they were written.
So I might be able (in time) to accept Moen’s and Norman’s thesis that Deming didn’t establish the PDCA but it does not change my view of the man nor his role in history or indeed the present or future.
Just as long as no one interferes with my beliefs in Robin Hood, Sherlock Holmes, or Santa Claus.
PS: The author of the Guru Guide article, who is an assistant editor for the journal, provides a different history than does Moen and Norman.  Go figure.

Tuesday, November 16, 2010

The Royal College Meeting (Plus)

So I went to the Royal College meeting in Ottawa today and heard more about the plan for Pathology and Laboratory Medicine in Canada to get more engaged in the Quality process.  Considering all the high profile  negative media events that have shone far too bright a light on some not-so-fine laboratory practices in Canada over the last decade, its about time.

So I have to say that I was less than thrilled when almost the first resolution raised was "well we should create a new committee".  But as the day went on and the dialogue and refinements massaged the message, the vision became a lot clearer, and maybe more hopeful.

In Canada we have created a structure that many other countries have been able to bypass.  We have a national constitution that says that health care (and education, and roads) is a provincial jurisdiction and as such the national government does not have the mandate or authority to make binding national health policy.  And while national organizations can, none of them have the authority to make them stick.
That being said, I suspect that the Royal College of Physicians and Surgeons of Canada could make said policies and could make them stick because when push comes to shove they are the professional  maintenance of certification  granting authority and if they wanted to use the risk of certification censure as a stick, they could do a lot.
But that is not where they want to go, and perhaps with good reason. 

But what was important about this meeting was the recognition by a large group of Pathologists and Laboratorians was that something has to be done, and that it (what ever "it" is) should revolve around a higher profile for improved Quality activity.  An to the extent possible, it should be created once, and be used nationally rather than being created 13 times (10 provinces and 3 territories).

So that is good.  Good for laboratorians, good for health care, and good for Canadians.  (We can call that a win-win-win).  And so we will see what happens next, understanding that at these levels, "next" does not mean the same thing as "tomorrow".

In the meantime as I was coming home on the plane, I had some time to read the new PLUS 9001: The ISO 9000 Essentials.  As mentioned before this is a series of books created by the Canadian Standards Association as handbooks for implementing ISO standards.  This edition (the 4th) came out in 2009. 
We use this book for our course (www.POLQM.ca)

Well let me tell you, while I have been pleased with other books in the series, this one is amazing good.  The first 60 pages should be mandatory reading for ANYONE interested in organizational management, and that especially applies to health care laboratorians. 
It is clear, it is precise, it is descriptive, it is comprehensible.  I look forward to teaching with it.

It costs about $70.00 and is available on the CSA website www.shopCSA.ca
Or get it though the course.

Sunday, November 14, 2010

Better Late than Never!

 A recurrent theme is that Laboratory Quality is not an independent activity, but rather is dependent upon the work and effort of its Quality Partners.  The laboratories’ quality partners include (a) standards development organizations, (b) accreditation bodies (c) proficiency testing providers (d) equipment and reagent suppliers (e) education providers and (f) professional organizations, and (g) the public as manifested by the litigators, regulators, and legislators.  
So when one of Canada’s largest professional organization has finally decided to get into the game, that is a very BIG DEAL.

The Royal College of Physicians and Surgeons of Canada is the official authoritative body responsible for medical specialists in Canada.  It is the Royal College that authorizes schools to develop and maintain resident training programs.  It is the organization that maintains the requirements for training content and the specialist examinations, and grants the specialty designation.  It is the organization that defines and monitors the maintenance of competence for all medical specialists, including pathologists and medical microbiologists, medical biochemists and medical haematopathologists.

On Monday the Royal College is holding a special meeting to discuss the Quality agenda and where it sees its roles and responsibilities.  It should be an interesting meeting.

Well Gee Whiz, what took you so long!!

I can only speak for the specialties that I know where the training agenda for Quality it by-and-large absent and the examination questions related to Quality trivial.  The Quality agenda has been not even a passing fancy.  It has been so barely noticeable, one might say it has been invisible.

Now I know and understand that in an era when there is so much new medical knowledge it is hard, maybe impossible for authorities to keep their collective fingers on the collective pulse of training.  But at the same time, Quality is not new, and never should have been marginalized to the extent that it has.  I mean Deming was promoting Quality Management 70 years ago and  the IOM To Err is Human was written 9 years ago.  So it seems to me that the Royal College has to take some of the responsibility for the persistent and ongoing challenges to Patient Safety.  Laboratory Quality Management has to have a higher profile by our oversight body.  And its not like this was never raised as an issue before.

At my university we have a 10 hour seminar series for residents on laboratory quality management every two years.  (Well that is a bit of a stretch because 2011 will be the second time that I will have put the series on, but I see no reason that we would ever stop the program).
Additionally we are having increasing numbers of final year residents taking our 20-week on-line LQM Certificate Course.  In addition we have had residents from other universities also take the course.  So we are doing our part (self-indulgent pat-on-the-back).

With our meeting this week it appears that the Royal College is awaking to the new Quality imperative and that is a good thing.

Fingers Crossed.


PS: To be fair, I suspect that Canada is no worse off than most countries when it comes to providing Quality Management training to residents in pathology and laboratory management.  Any one with information is asked to comment.

PPS:  Those interested in learning more about the course are invited to go to www.POLQM.ca

Thursday, November 11, 2010

Organizing the Meeting

The UBC Program Office Laboratory Quality Management Weekend Workshop will be a valuable meeting to attend and participate in.  We are putting a long of time and engery into its orgnaization.  The formal advertisements will be going out in a few weeks time. But the structure is coming together vey well. 

The following is advance notice.

Opening session: Friday June 17, 2011
Meeting sessions: Saturday and Sunday June 18-19, 2011
Vancouver BC

The meeting themes will be:
(A) International Quality – Developments and Opportunities
(B) Implementing Quality in your Laboratory
(C) Working with Quality Partners.

The meeting objectives are:
(A) To provide a discussion forum for laboratorians with interest in Quality
(B) To focus on topics of consensus and controversy
(C) To provide an education opportunity for students, including residents in laboratory medicine.

Meeting structure:
(A) Plenary Presentations
(B) Break-out sessions
(C) Submitted Poster (and oral) Presentations
(D) Open discussion opportunity time.

Who should plan on attending and participating in this meeting
(A) Medical Laboratory Professionals (Administration, Managers, Physicians, Scientists, Technologists)
(B) Residents and Graduate Students
(C) Quality Partners

Speaker List and Program to follow shortly.

For folks who have not visited Vancouver before, it is Canada's third largest city sitting on the shores where the Fraser River meets the Pacific Ocean, protected by the local North Shore Mountains.  Forty minutes from the Canada-US Border.  Easy access through the International Airport (20 minutes from downtown). 
If you have the time to fit in a longer stay, consider visiting Stanley Park, Capilano Suspension Bridge, the Vancouver Aquarium, or Gastown, or Dr. Sun Yat Sen Gardens or the UBC Museum of Anthropology, or shopping downtown on Robson Street or Granville Island. 


Monday, November 8, 2010

Quality and the Zarbo Manifesto

There are many articles  that get published in the medical literature every month.  Some of them actually get read.  But every once in a while one finds a “must read”.  In the September 2010 edition of the American Journal of Clinical Pathology (AJCP) the editorial by Richard Zarbo (A Call to Change in the Status Quo in Approaching Health Care Quality, Once Again -- - Am J Clin Pathol 2010: 134/  361-365) is one such must read.  
 It is as clear a statement, a manifesto, in the purest form of the term “A public declaration of principles, policies, or intentions, especially of a political nature"..

Richard Zarbo is an anatomic pathologist at the Henry Ford Health System in Detroit.  He has been an ardent supporter of LEAN and the Toyota System for many years, and has documentation of some success in his institution.   
Importantly Zarbo recognizes that LEAN is not just about time and motion studies and spaghetti diagrams.  It is an integrated program of lessons learned by Taiichi Ohno in part from Ford, in part from Piggly Wiggly supermarket, all superimposed on quality as iterated by W. Edwards Deming and Walter Shewhart (Plan-Do-Check-Act).  It is a system of many integrated parts that can come together and create success.  

As pointed out in the editorial, all the Quality systems, however named (LEAN, or TQM, Continuous Process Improvement, or ISO9000, or ISO15189 or ISO17025) focus on reducing variation through standardization of process, and connections, and work activities, and through the monitoring of, and action upon objectively measured information both about successes and challenges (nonconformance or error).

But none of the approaches to quality have a corner on success; indeed most tend to the opposite.  Regardless of which approach is adopted, there will be some successful applications and many failures, because, in large part, of the variability of application, and lack of sustainability.   

The problem is that adoption is done by word only and not by action.

And that brings us to what I am referring to the Zarbo Manifesto for Quality Success. 
For purposes of this blog, I have paraphrased this Call to Quality as:

1: There must exist one Culture of Quality that will drive clarity, cohesiveness.  Absence of a binding culture is a leadership failure.
2:  Leaders and managers must adopt the principles of process improvement.  The spirit of participation will spread horizontally, but top management must drive adoption from the top.
3: Leaders must adopt the role to continuously work on improving the system of work to drive the new culture.  
4:  Structure must be established to teach and adopt PDCA and standardization throughout the organization.
5:  Structure must be established to teach and adopt continuous process improvement.
6:  Organizations must adopt structures to sustain success and recognize the importance  value of engaged workers.

Anything less is a licence for failure.

So the message is clear.  Leaders have an obligation to lead.

Count me as an advocate.

Saturday, November 6, 2010


The following comes from Mike Richman, who is the Editor of the Quality Digest. 
I follow the QD on a regular basis, because it is a good source of Quality information.  The QD has been around for a long period of time (founded in 1981) and has a good track record for consistent quality Quality information.
Medical Laboratories are not one of its main target audiences, but that is what is so interesting and positive and connecting about the Quality community.  The principles are independent of specific  applications. 

By Mike Richman

A recent article appearing in the Quality Digest Daily e-newsletter (“Why Lean? Why Now?” by Dean Bliss  http://www.qualitydigest.com/inside/health-care-news/why-lean-why-now.html) discusses the value of Lean in a health care setting. In his editorial, Bliss writes about the manufacturing origins of Lean and why he believes that Lean tools translate so well into a health care environment.

If you scroll down to the “comments” section at the bottom of the article on our site, you’ll see an exchange between two Quality Digest columnists, Tripp Babbitt and Mark Graban (with some additional feedback from reader Chet Marchwinski). Babbitt and Graban often take opposing views on certain aspects of quality improvement, particularly relating to Lean. Their comments on this particular article uncover a longstanding argument, namely, can Lean tools be successfully adapted from manufacturing environments and applied to service industries such as health care?

Process improvement specialists are an imitative sort, and in many (but not all) of these cases, imitation is the sincerest form of flattery. “Benchmarking” is a hallowed tradition, practiced by practitioners of practically every stripe. It therefore makes sense that Lean tools, first pioneered by Toyota within a manufacturing setting, would be adapted by organizations in various sectors, including service industries. Certainly, health care, in which success is often measured in lives (not just dollars) saved, was ripe for a Lean revolution, and in a sense, that has happened in recent years.

The core of the argument isn’t the inherent value of Lean; that’s pretty well established. My sense is that proponents seeking to define Lean more narrowly feel that the practical results within manufacturing, such as a lessening of rejected parts, don’t apply to service, in which improvement often has to do with “softer” metrics like customer wait times. Those that support a wider view of Lean believe that the methodology’s underlying philosophy dictates that pretty much anything and everything can be improved through a relentless focus on “waste,” however that phrase is defined for a particular process.

So, like many long-running debates within the quality industry, this one can be looked at as a matter of semantics. What constitutes “waste,” after all? Must it be a rejected product or part, or can it also be unnecessary time, steps, or effort? Can linked health care processes “flow” in the same manner as assembling an automobile or fabricating a semiconductor?

I don’t know the answers, but it’s fascinating to hear the experts duke it out. Their points are enlightening and well taken, and provide great food for thought. So what do you think? Is Lean well suited to health care environments, or is it best left to manufacturing? If so, why? If not, why?

The Quality Confab – Part 2

The other day I wrote a brief note on one aspect of one presentation from the Quality Confab which was held this year in San Antonio, Texas which among other things is the home of the Alamo where the conflict between Mexico and the Republic of Texas occurred.  (We can probably blame Walt Disney for confusing us, but this battle of the Alamo occurred almost a decade before Texas became part of the United States.  But I digress!)
In any event, San Antonio is a great location for a great meeting.  Lots of good meeting hotels, and lots of great restaurants.

The Confab has become over the last 4 years, perhaps the single most important meeting for the medical laboratory Quality community in North America.  As much as it is dominated by US issues, such as CLIA and CAP, the reality is that it is the Canadian presence that is leading the way.  Each year Canadian laboratories win top prizes in the poster presentations, and each year Canadian presenters are front and centre.  Sometimes, unfortunately that Canadian spotlight is not exclusively from a positive perspective.  This year for example there was a lot of attention on the problems of Eastern Health in Newfoundland and Laborador, as well as the Quality challenges in New Brunswick, Quebec, Ontario, and Saskatchewan.   (The Americans must have wondered about all these strange named places and what do they have to do with a meeting in Texas!).
On the other hand, the Accreditation Program of Ontario go a ton of good attention, as did the Program Office for Laboratory Quality Management (and this blog), and also so very positive comments about LifeLabs Medical Laboratory Services in Ontario.  

The meeting follows a certain pattern with “plenary” sessions in the morning and “breakout” sessions in the afternoon, and enough break time for interaction. 

If I have any problem with the meeting, it has to do with the Question and Answer time at the end of each presentation.  Now I will tell you that Q&A is ALWAYS problematic because some audience folks, left to their own inclinations, get to an audience microphone and use the time to pontificate rather than ask focused questions.  So Robert has gone the other direction and requires all questions to be scribbled on to cards rather than being verbal.  But this inhibits questions and questions and discussion.  So I guess we have not yet figured how to do Q&A well, yet.   

But if that is the only problem that I have with this meeting, then it is fair to say that I have no problems at all.  And that is about as RIGHT as you can get.

So congrats to Robert Michel for hosting the meeting, and congrats to the Quality community for finding and supporting it.


Thursday, November 4, 2010

Quality Confab and Disconnection

I attended Robert Michel’s Quality Confab in San Antonio this week.  For those who do not know about the Confab, it is slowly become one of the sentinel Quality Meetings for those interested in medical laboratory quality.  (More on the other sentinel meeting shortly).  Lots of good speakers giving lots of good summary presentations.  Enough material for lots of folks to learn.  Enough material for lots of folks to discuss, ergo the title “confab”.  I gave a presentation about the challenges associated with examination phase error.  I will post the presentation on www.POLQM.ca.
But that is not what I want to talk about.  For me the most interesting and intriguing 10 minutes of the whole 2-day meeting, and perhaps for the year, was a brief discussion by Michael Astion (University of Washington) on the concept of Disconnection.
Michael is a long time leading Quality Guy, with a variety of insights on laboratory error, and as it turns out a lot of common sense concepts on Management theory and Human Resources.  In previous meetings he has talked vividly about human slips and foibles that contribute to error.  But this time he addressing error from a broader management perspective.  One point that jumped out for me was that one of the reasons that laboratory workers  make errors is because they have become disconnected from the clinical reality, and that being disconnected contributes to more focus on the self and less on work contribution.   
A solution for this is to reconnect and revitalize by bringing patients to the laboratory and the laboratory to the patient.
This sparked about whole slew of images for me. 
In many microbiology laboratories, not only is the technologist disconnected from the patient, they are disconnected from the specimen and even the requisition.  In some laboratories the technologist working on the culture doesn’t even get to see the patient gram stain.  For them the whole patient care experience is looking at some petri dishes.  Not only does this contribute to formulaic microbiology, it is also extremely difficult to sustain a sense of clinical perspective if you are completely eliminated from any vestige of the customer and patient care. 
The same is probably the case for chemistry and haematology technologists as well, although I suspect being involved in blood transfusions or smears with leukemic cells may snap folks back to something closer to the clinical realm.
A number of years ago there was a lot of discussion that there could be a lot of value in taking a technologist off the bench, and have them make ward rounds with clinical staff to assist with laboratory and testing issues.  The concept was essentially developing a laboratory equivalent to the clinical pharmacist.  By putting a laboratory person on the ward would be beneficial for the patients and clinical staff because they would gain insights from the laboratorian, and the laboratorians would benefit from the clinical exposure.  It was a great idea, but never seemed to take off.  I think it was just a too far ahead of its time.

So this notion of disconnection as a interference that could be reversed has been around for a while, and it is still an intriguing today.

On the other hand, laboratory folks are not the only workers stuck in the ME generation.  Someone once said that hospitals changed for the worse when  they stopped primarily being places where unwell people would go for care and attention, and started being places whose primary focus and function was to hire nurses.  There is lots of clinical staff who have all sorts of access to the patient care experience, and who still focus most of their time and effort working and worrying mainly about themselves. 

So count me intrigued by the concept of disconnection.  I have a lot more thinking and hopefully some reading on the topic.
More on the Confab shortly.

PS - With respect to the other sentinel meeting, eserve June 18-19, 2011 for the UBC Program Office Quality Weekend Workshop in Vancouver.