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Sunday, January 30, 2011

Communicating Quality and the Principles of Adult Education

In recent while, I have been engaged in the active promotion of  medical laboratory quality in a variety of forums, including writing this web-log, providing an on-line course, hosting single-site lunch time education,  hosting the resident seminar series, and organizing and participating in workshops and conferences.  All of them have provided me with the opportunity to consolidate my own philosophy towards Quality.  
There is a lot of differences between all these activities; some have been held in Canada and others are international, some are one-off events while others short-term multiple events, and others yet are long multiple events, some of them are at no-charge to the participants while others are at substantial cost. Some of the participants want to be participating while others they are there because they feel compelled for one reason or another.  It would be easy to say that the only thing they have in common is a common topic, but there is something of far greater commonality; all the participants are adults.
Teaching adults is a special event because adults learn in their own special way.  There is tons written on adult learning.   For a quick summary you can visit Principles of Adult Learning at the University of Hawaii site.  

There are lots of reasons that people attend courses.  For learning, the most successful reasons are when they believe there is something in it for them; it is a topic of interest or there is an opportunity for career advancement.  Sometimes it is less about knowledge, and more about the social aspects; is a way to meet and connect with others, or is better than just being bored.  These folks may not be focused on learning, but they might connect.  Sometimes folks attend solely because they have to; it is a requirement and attendance is being taken.  This never turns out well.

Adults are autonomous and self-directed, and learn on top of their accumulated knowledge and life experiences, which means we learn what we want and how we want and accept the knowledge if it makes sense and is consistent with what we already know.  And we learn if we see the purpose to the information and especially it is meets our own goals.  And we are practical and pragmatic learners; if the information is not organized and timely then we turn-off. 

Adults tend to learn best if motivated, especially if we can link the information to what we do as a matter of competence or promotion, or job enrichment.  (Some say we learn better if there is money on the line.)  
For the educator, this means that the successful ones make the information relevant to what people do, is consistent with what they already know and link the knowledge to competence and enrichment.  Keep the information organized and timely and interesting.  For me, I have been involved as an adult educator for over 30 years.  When I think back to what I was like when I started, I can say with confidence that I am a lot better today than I was back then.  And one of these days I may actually get it right.  
One of the most successful educators I know has a formula.  He has 3 points to make (4 points a maximum).  He makes his points and reinforces them with stories and humor.  When he has delivered his points and told his stories, he stops.  I’m pretty good at the selecting 3-4 points and the telling stories.  I am pretty weak at the humor, and tend talk until I run out of time, rather that knowing when to stop.

Memo to self:  with widely divergent groups, some folks are there because they want to be there; others are not.  Remember the motivation; point of why knowing about Quality is an important   component of competency and enrichment, and can have an impact on promotion.  Be organized and know when to stop talking.  After than, the rest is largely out of your control, so don't worry about it.

m

PS: I am accumulating the post seminar series data now.  Will share the results soon.

PPS:  Big changes at www.POLQMWeekendWorkshop.ca  Lots of NEW information.


Tuesday, January 25, 2011

Persistence

I received a comment on my posting of Science? Hardly!  It was a great comment; so much so that rather than post a response as a comment, I thought it better to create a new post.

The comment read in part: "PS. I am very interested in Quality concepts. Recently, I have tried to share some of my finding with people I encounter on a regular basis. The answers or comments have been shocking to say the least. With so much attitude working against quality, how have you been able to keep sane and to continue teaching this subject day in and day out against all odds?"

I appreciate the sentiment intended, but disagree with the premise.  My experience is that the number of folks NOT interested in Quality is very few, and most that are truly not interested pretty much fall into a category of dangerous behavior.  They are the folks who wake up and do say, "I wonder what I can  do today to screw things up?"

It is my distinct impression that most are interested, Most think they are working within the bounds of acceptable Quality and don't realize that small changes can reduce error and the amount of time they spend fixing and repeating. Many have never connected the dots between applying quality principles to their actual work, and making their own lives better. 

Small changes in Quality result in big TEEM savings.

Its kind of like golf lessons.  A small change in alignment before you hit the ball results in a lot less time looking for your ball in the weeds and woods. SMALL change - BIG affect.

Part of this is the fault of qualitologists who talk nonsense. We all have met those  "small q" quality people who say things like "Well CLSI says you have to write all SOPs in 35 pages."  or  "Well we have to keep all records forever.  If we don't then we will loose accreditation, get fined, or sued, or worse." or "If you make a change in a document you have to use red ink and no scratch-outs are allowed.  All changes must have a single line that goes through all the characters but does not obscure their readability."  or "I don't care what we do with regular specimens, test that PT sample again; in fact do it 3 more times".

No wonder Quality gets a bad reputation.

None of this is about making the laboratory work better; none of it is about being making the task easier.  That old style quality was more about power and making up rules and arrogance than improvement.   Laboratories have some serious issues to address.  Costs are sky-rocketing, the light of public awareness is making some of us very uncomfortable, and we are talking about ink colors!

In the golf lesson analogy, its like focusing on if you don't keep score with a 3 inch pencil then it doesn't count.  Wrong information and wrong message.

New Quality,  is about setting understandable and achievable goals and objectives and  policies and then setting out mechanisms to follow through.  New Quality is about creating simple techniques to capture problems and seeing if we can prevent them from happening again.  New Quality is about working with Quality Partners, not against them.   New Quality? Deming Quality? ToMAto - Tomato.

So I don't see Quality as against all odds.  I see it as a challenge and a mission, but one for which I have a lot of time and a lot of patience.

m

PS: TEEM: Time,Effort, Energy and Money.

PPS:  On a some what related note, visit Mike Mickelwright's RANT "We Gotta Make Quality Cool Again" at wwwlqualitydigest.com



Sunday, January 23, 2011

Science? Hardly!

Most of MMLQR has been committed to the positives.  Where I have been critical I have been more general than specific.  This entry is different.

Western medical care prides itself on being generally science based, so called evidence based.  While there is a role for the so called art of care based on experience and feeling, the strength and power of medical care is predicated on the weight and influence of study and and analysis.  As "scientists" we learn our knowledge from our own study and from reading of studies by others.  This of course is based on the assumption that the material we are reading  is worth reading.

While simplistic, there is commonality between Scientific Method and Deming Quality.  One asks a question, creates an hypothesis, and establishes a method to collect and measure information (PLAN), then one does the measurements (DO) and evaluates the results (STUDY) and draws a conclusion and focuses on the next step of hypothesis (ACT).  You might think that Deming was some sort of scientist.  Having earned a Master's degree (U Colorado) and a PhD (Yale) n mathematics and physics supports that he was certainly inclined in that direction.

Unfortunately, much current (and past) medical information doesn’t bother with either science or quality.  For example, a few days ago I received a copy of a the Journal of Infection and Public Health (Volume 3, Issue 4, 2010) with an article about urinary tract infections in a neonatal intensive care unit.  The methodology of the study was to do a retrospective look at urine culture reports and distinguish infection into 3 categories: definite, possible and contamination, based solely on recovered bacterial count.  This is what we call nonsense.  There is so much wrong with this, it is hard to know where to start.  The data was collected before the hypothesis.  The data was not examined to get rid of confusers like prior antibiotics or other even more important  pre-examination and examination factors that would influence the measurement.  And the interpretations of the information collected were trivial and superficial, at best.  

I am not sure whom I am more annoyed with, the authors who decided to create a crude examination of information based upon test results that were never designed or intended to be the basis of critical examination, or the reviewers that looked at this crap and said that it was sufficiently interesting that it should be published, or the journal publisher who was so obviously desperate for something to print that they printed the article in some vain attempt to give themselves some credibility and sustainability.  That it was a from a Canadian institution in an international journal made it that much more embarrassing.

I have been around this block a long time, and I too have in the past written junk like this so that I could go to a meeting, or get an extra line on my cv.  But all this accomplishes is that it creates noise, and diminishes the quality of reading time.  And, as we are now ensconced in the 21st century, we should be learning from past mistakes, not emulating them.  

So qualitologists have an obligation.  Given a choice between structured cohesive manuscripts and junk, go for the former.  Given a choice between structured cohesive manuscripts and not contributing to literature, go for the latter.
Its kind of like a variation on the old proverb, better to submit nothing for publication and have people think you have nothing constructive to say, than to submit junk and have them know.

m
Lots of progress at www.POLQMWeekendWorkshop.ca

Wednesday, January 19, 2011

Communicating Quality

About 15 years ago I decided that if CMPT was going to progress we had to develop an electronic presence, so with the assistance of my son, we created www.CMPT.ca.  I was so pleased that I had made this huge jump into the future, or at least the very current present.   I had a web site.  It took about a month for me to realize that a website had to be fed new material on a regular basis, and gradually it started to take over as a major preoccupation.  Gradually, what started as a hobby became the full time work of a number of people.  The problem, of course, was that we had never budgeted for the expenses.  The message to self was that you need to make sure that your organization gets benefit from electronic presence because it is going to become time (and money) expensive.  

Well the world has changed since the early times.  Web presence has become common.  Today, folks can spend their whole work day and their social life in the web world.  Communication outreach is world wide and immediate.  But the old messages continue to be true.  To be effective, the electronic world consumes TEEM (time, effort, energy and money).

I state the obvious because progress in Quality in every organization, regardless of size needs communication.  In an earlier time, Deming, Crosby, Juran were committed to quality communication by way of books and lectures.  They were prolific communicators.  If they were working today, they would have been within the first wave to embrace the Internet because it would have expanded their outreach.  
Evidence this by the myriad of sites that promote and communicate quality; www.darkdaily.com. www.iso.org, www.csa.ca, www.qualitydigest.com, www.westgard.com, www.asq.org, and medlab-eqas.blogspot.com, just to name just the ones that I get to follow on some sort of regular basis.

But what is so interesting to me is that communicating quality has evolved so far from the organizational website.  Outside communication is now about the website and the vehicles that transport to the website, like the web-log (I have taken on an aversion to the “b” word) and social media like Twitter and Facebook, all of which have become destination sites with their own messages.  
Outside communication has on-line courses and on-line conferences, extending beyond information and on to knowledge.  And  Inside communication is about intranets, and organizational email blast outs.

This is not to say that the concept of holding a meeting so that people can meet is now obsolete.  Meeting in person has powerful effects that Skype or GotoMeeting or videoconferencing will never duplicate.  But many organizations are shying away because of obvious costs.

And that brings me to my message to self:

1: The laboratory cannot succeed without Quality and Quality cannot succeed without Communication.

 
2: Communication is critical valuable and at the same time can be hugely TEEM consumptive.

 
3: For Communication to be implemented it requires the same level of rigor of Quality implementation and management as every other laboratory essential.  It has to be planned, and be implemented with forethought.  The implementation requires study and opportunities for improvement acted upon.  Over and over.


4:Quality requires Communication and Communication requires Quality.

Saturday, January 15, 2011

So many things to do - so little time!

January is the beginning of my busy season.  The Resident Quality Seminar Series is on, the UBC on-line certificate course in Laboratory Quality Management begins, and it is grant and project season. 
Fortunately all these things are linked and so they can all blend.

We had Week 2 of the Resident Seminar Series 2 days ago and addressed discussion on Laboratory Error, Costs of Poor Quality and Introduction to Standards.  The information was good to put together, and started to generate a lot of group discussion which is Extra Good. 

One slide created a lot of discussion.  From my own work, which I think I have mentioned before, when reported incidences are invested in total, the time to fix an error can range from 20-1000 minutes with a mean time of 130 minutes.  One second to create and 2 hours to fix. 
If you take that and put it into context of FTE time in a variety of settings (small, intermediate, large, and super laboratories) the number of error correlates with size, although not necessarily in a direct linear fashion.  More importantly the cost of error goes up.
If you think of a superlaboratory with 250 personnel providing multi-discipline services (chemistry, hematology, bloodbank, microbiology, anatomic pathology, immunohistochemistry, etc) for a distributed network of facilities  30-40 errors a day would be not atypical. 
The attached looks at percentage of total FTEs that spend their time fixing errors.  What the proponents of laboratory consolidation see is that as the laboratory size goes up, the percent of total FTE working on error goes down.  That is a good thing.  But when the global budget is $200M and 10 percent of the laboratory forces is spending its time fixing errors, that is one HUGE chunk of money.
My point is that many errors are preventable through an effective Quality Management system. 
Regardless on what is spend implementing the QMS, as Quality improves the number of errors will go down and there will inevitably be considerable cost savings.


m

PS:
The POLQM Quality Weekend Workshop is coming together extremely well.  All the speakers are in place and we are starting to get traction at the URL www.POLQMWeekendWorkshop.ca 
We have had our first early registrations.
June 17-19, 2001 is a ways off, but this is going to be a GREAT workshop.

m

Monday, January 10, 2011

A brilliant Quality seminar.

This is a notice that will  be considerable interest to the microbiology community across Canada and in the US especially the North East, but should have special mega appeal to Medical Laboratory Qualitologists in the same regions. Maybe even bigger.

The clinical microbiology crowd is already aware of the annual Canadian Association for Clinical Microbiology and Infectious Diseases (CACMID) conjoint conference.  This meeting has been an annual event in one form or another since (I think) 1965.  It is the premier Canadian microbiology conference.  The Canadian Association for Medical Microbiologists and the Canadian Infectious Diseases Society (now collectively named AMMI-Canada) holds its meeting conjointly.
This year this conjoint meeting will be in Montreal from April 6-9, 2011 (visit http://www.ammi.ca/annual_conference/index.php)

Every year for the last 16 years we have hosted a Quality Seminar in conjunction with CACMID, usually on the first day (or pre-conference day).  This year it will be a 4-hour seminar on  April 6, 2011 starting at 1:00 PM.  The theme of the conference will be Communicating Quality.

I have to tell you that as good as all the seminars in this series  have been, I am especially proud of this one.

The meeting will have 4 presentations:
Michael Noble - Developing a comprehensive communication strategy for Quality.
Julie Coffey from Quality Management Program - Laboratory Services Ontario will present on on-line education in Quality.
Robert Michel the Editor of the Dark Report and the creator of the Dark Daily will present on developing a comprehensive Quality Communication Information Strategy
Sara Garcha of LifeLabs BC will present on Communications as an integral part of Quality Culture.

This seminar is a must see for anyone charged with developing and promoting a quality system in their own laboratory, or as is happening more and more, a network of laboratory sites.

The session is cheap ($80 Canadian), indeed under valued.
If you are involved in clinical microbiology you probably will come for the pre-conference seminar and stay for the whole meeting.
If you are interested in Quality, but maybe not from a microbiology perspective, I strongly recommend that you consider this meeting, even if it is only half a day.
At best you participate in a brilliant education seminar with knowledgeable excellent speaker-presenters  that will give you ideas that will change your quality practice for years to come.
At worst you attend an excellent meeting and get to have dinner in Montreal. 

It is difficult to see the downside.

You can register for the quality seminar on the CACMID website
https://notes.htgsports.com/HTGM.nsf/Reg?OpenForm&hoteleventid=&ParentUNID=6734DD638B69D28C852577A8004DA067&lang=EN

m

Sunday, January 9, 2011

Quality and Laboratory Medicine - Who is in charge?


As I continue with the Resident and Graduate Student seminar series, I have a dilemma.  I did a pre-course survey, in part to develop an objective measure of the course effectiveness in transferring knowledge. 
 
One of the questions asked in the survey was “When implementing a Quality System in a medical laboratory the single most critical procedure is “. 
The responses provided included:
     Regular and Frequent Management Review
     Regular Internal Audits
     Document Control
     Developing and Maintaining a Procedure Manual
     Regular Accreditation Assessments
     Robust and Regular Quality Control
     All included.

Only one answer (Regular and frequent management review) was deemed as the correct answer.  Of interest of 26 responses to the question, the number selecting that answer was zero.  The most common response was “all included” which was probably a poor inclusion on my part, but that does not take away from the absence of recognition of management as arguably the most critical part of implementing a quality system.

I don’t have to reiterate Deming’s stories about the importance of management to quality, because everyone interested in Quality knows and understands that to Deming, the absence of interest by top management results in failure to establish quality.  It is relevant that in the book “Out of Crisis” he makes the point that Management is responsible for 94% of error.  
Feigenbaum also made the point in Total Quality Management  when he said that by using the slogan “quality is everybody’s responsibility” we ensure that quality is “nobody’s” responsibility.  Quality is somebody’s responsibility and that somebody is Top Management 

I should not be too surprised that a group of residents in pathology and laboratory medicine would fail to recognize the importance of management in quality,  because most training programs do not have a tradition of recognizing how much of the work they will be doing will be management.   This is an excellent example of systemic failure.

Not to overstate the case (well maybe to overstate a lot!) laboratory chairs who feel it is acceptable and  appropriate to “game” or ignore accreditation and proficiency testing are unlikely to see a value and purpose in establishing quality management as a key component of their own laboratory or as a component of resident training.   To them quality is solely an operational responsibility, somebody else’s job.  In those laboratories that may well be the case.   

Pathology and Laboratory Medicine may well be at a cross-roads.  I wonder which path we will take.

Thursday, January 6, 2011

Quality Education

Today I started my Quality Management Seminar Series for residents and graduate students in Pathology and Laboratory Medicine.  It is the second time that we have done the series, the first time being in January 2009.  I know that in Canada this is the only Quality Management Seminar Series provided for residents.  I am sure that there are other centers around the world that provide this information, but I do not know where.  Such is the reality of the communication networks in Quality.

A few things of note.  This year I have applied a PDSA to the series by having a pre-course survey which will be compared and analyzed to a post-course survey.  The results of the pre-course survey are in themselves instructive.  The survey included 10 knowledge questions that were pretty basic.   All questions were answered as single right answer with the list of responses being randomly positioned to avoid answering bias (if you don't know the right answer, then answer the 2nd in the list).  The style of questions included "what is the international standard for medical laboratory quality and competence?" or "in which phase of the medical laboratory cycle do most errors occur?". 
Of the 10 questions, the best response was 91% of responders getting the right answer, and the poorest response was 0 getting the right answer.  The mean, median, and mode for correct response was all around 40%.   So as they say, there is room for knowledge improvement.  When we have the post-course results collected and analyzed, I think the information derived will be a useful contribution to the resident education literature. 
I was tempted to attach the quiz to MMLQR, but I learned from the last survey that is unlikely to get many responses.  If anyone is interested, if you contact me I will send you a link to the survey.

Today's presentation included an introduction on why residents in training need to be more aware of Quality issues.  I reinforced the message with a series of news releases from the Canadian press highlighting high-profile error in the medical laboratory.  The list was put together by Robert Michel (of the Dark Report) and shared at the Quality Confab in San Antonio, and I thank Robert for letting me use this as an instructional exercise.   I was able to expand this list with a few more events.  The point of the exercise was to point out that once the public starts shining the light that results in change, it tends to not turn the light off.  And further, shining light does not result in confidence building; indeed it points out that public trust and confidence are fragile.  It is fair to say that for many the era of "I am a doctor. You can trust me"  is over.

The seminar series will continue for 3 more weeks.

While not posted yet, the presentations will be available on www.POLQM.ca

m

PS:  I have not mentioned the POLQM Weekend Workshop for a while. 
We have put together a brilliant group of speakers on a variety of topics highly relevant to education and practice of medical laboratory Qualitology.   Plus we are inviting posters and podium presentations.
Please visit www.POLQMWeekendWorkshop.ca



Monday, January 3, 2011

Quality and Obama Care.


Welcome to 2011.  

I suspect that most folks missed an interesting story that was published on the Times wire in US newspapers just before Christmas.  The article described how new regulation set to take effect in January will direct a substantial portion of insurance premium dollars away from executive pay packages and overhead and instead will require increased support for medical care and health care quality improvement.  Apparently insurance companies now can retain 25 percent of premium revenue for non-medical costs, but under the new rules they will be able to retain only 15 percent.  

Well that sounds good, especially the part about increased spending on quality improvement. 

I suspect that the way this is will play out will be that insurance companies will not reduce the actual amount of money for salaries and bonuses, but rather will just increase the premiums.  If I do the arithmetic correctly, that will require an increase in premium rates by about 66%.  Again if my arithmetic is right, this will not go over very well.  A massive raise in health insurance rates may not be perceived as a totally positive step forward.  But we will leave that battle to someone else.  

But I think there is an important question here, and that is, is there is a way in which money collected through the private sector can be allocated to quality improvement with a reasonable expectation of success.  My guess is that this will be a major challenge.

Let’s see if we can break this down.
1: If money collected by individual insurers remains in the hands of the insurer to do good things, there is little  reason to believe that each insurance company would develop an effective distribution process to move funds into the appropriate sectors to improve clinical and laboratory care.  Further, development of distribution offices within each insurance company would require massive costs and result in huge redundancy.  As US insurers do not cross state borders, this would result in a huge amount of geographic mal-distribution of funds and resources.

2: If each insurer was required to transfer the funds to a central government office, it would likely be perceived as a new tax, and would probably get tied up in a series of court cases ending at the Supreme Court.  That would take years and cost a fortune resulting in quality improvement money mainly support legal staff.

3: If each insurer was required to pass funds to a private sector central Quality Improvement Office operated by the consortium of insurers, the costs of redundancy would go down, but process and distribution costs would go up.  In addition there would still need to be an active oversight agency to establish and monitor rules, and that too would create even more costs.

So while the idea sounds great, my cynical self sees more opportunities for failure than success.  It will be interesting to watch to see what happens.  But I am not holding my breath.

In the meantime, in Canada and other countries where this is a public health funding model, there is every reason that agencies be designed for Quality Initiative Allocations with independent oversight.  In Canada we would still end up with redundant spending because of our obsolete structure makes health a provincial responsibility with trivial federal funding support.
The reality is quality initiatives programs would create net savings not net losses, so there should still be an incentive to implement these agencies.  So far the answer is that they do not exist.

With so much to gain, one wonders why.

m