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Sunday, October 2, 2011

The Ins and Outs of Canadian Laboratory Quality


Ross Sutherland wrote a comment to a MMLQR blog post.  This was an introduction for me to a book that he has written False Postive: Provide Profit in Canada’s Medical Laboratories (Fernwood Publishing 2011).  I guess his personal word-of-mouth awareness campaign was successful, to the extent that I bought a copy of the book and had a chance to read it.

It is not a bad read.  Well researched and referenced and well written.  The thesis of the book is focussed largely on the commercial laboratories that provide service primarily within the community setting in nearly all provinces.  Since in my career I have worked in both public and private sectors, and have been a patient in both as well I feel entitled to my opinion which differs somewhat from Ross’s.  That is not particularly uncommon in Canada where there tends to be political overtones when it comes to points-of-view of the Canadian healthcare system.  I suspect that this contagion is about to spread to the United States as well.

But this is not about that politic.  It is about some comments that are made about Canadian laboratory quality, a topic about which I know a great deal.

Sutherland talks about the difficulty that we have in Canada finding out how well or unwell Canadian laboratories perform in Quality assessments.  I absolutely agree. 
If you want to know about roofers, or car dealers, you can go to the Canadian Better Business Bureau and follow a company’s track record.  If you want to know how well schools perform on certain provincial examinations, that information is published annually.  If you want to find out about a restaurant you can get all sorts of reviews.  But to find out how a laboratory performs is very difficult. 

What most Canadians may not be aware is that in most provinces (not all) laboratories are expected to be accredited every 3-4 years following in on-site inspection that is fairly encompassing.  And most provinces (not all) expect laboratories to participate in proficiency testing (EQA – external quality assessment).  What is very difficult, maybe impossible, to find out how well they performed on the assessments.  Part of the reason is that governments choose to not make this information available, which is strange, when one thinks about Canada’s long and recent history of questionable performance and provincial inquiries.

One can think of a number of reasons why provincial governments don’t post the information.  First is that they likely don’t want to get into that because they might have to do something about the poor performers.  Second it would probably set them into a political minefield with provincial medical associations and healthcare sector unions.  And third, why make waves when clearly the general public doesn’t seem to care enough to ask or demand. 

CMPT does not share the information because we have a contractual relationship with the medical laboratories that respects confidentiality.  We share their results with the accreditation bodies, only if the laboratories agree.  If the laboratories choose to not, then the accreditation bodies receive that information directly from the laboratory. 

On two occasions (September 2011 and October 2010) I have presented information about aggregate performance, and I have made our Annual Report available on our website (www.CMPT.ca).  But we can not and do not release any individual laboratory.

But I do take umbrage about one comment that Sutherland makes about laboratory quality assessment.  Reading from a government report written in 2003, he quotes the author who said that medical laboratory quality is only assessed on a technical level and does not address pre-examination or post-examination performance.  Not only was she wrong in 2003 when she wrote it, Sutherland was wrong in 2011 when he quoted it.  The word irresponsible comes to mind to describe both the writer and quoter.  It reinforces two points:  just because you are paid as a consultant, it doesn’t mean you know what you are writing about, and just because you read it in a book doesn’t make it true. 

Canadian accreditation looks thoroughly at all three phases of laboratory performance.   Canadian proficiency testing, in particular CMPT focuses at least as much attention what information is written in the report as how the information was derived.  And for the last 10 years we have monitored pre-examination decision making through paper challenges.   The information is again in our Annual Report.

So I expect a “mea culpa” from Ross.

2 comments:

  1. Ross Sutherland wrote a response to this entry. For convenience I have posted it here.

    See below.

    Ross Sutherland has left a new comment on your post "Welcome to the world of DTP reporting":

    I would like to thank Quality Doc for the comments on my book. I hope a partial "mea culpa" will do in reply.
    The focus of False Positive is on the effect of for-profit laboratories on cost, integration and accountability in publicly funded health care. It is not possible to consider these issues without touching on other key public policy concerns, specifically quality and accessibility: in no small part because these directly affect cost, integration and accountability.

    I would be the first to admit that your knowledge of quality issues is likely greater than mine and that the book only introduces some quality concerns related to ownership. CMPT’s pre-analytic testing would seem a useful program. It reminds me of my role as a nurse. We are trained to be a double check on doctor’s orders, but it is still a secondary function after making sure that physicians order properly. As valuable as that role is it is not a full quality program. It does not monitor rates of appropriately ordered tests, the post analytic concerns of what is that actual turnaround time and whether the information is used properly or identify the barriers that cause errors in both these areas.
    My research indicates that in all areas of laboratory work, not just microbiology, pre- and post-analytic quality are negatively impacted by the presence of parallel public and private systems, though this is a thesis demanding more research. Whoever undertakes this project will be severely hindered by the secrecy surrounding medical laboratory quality, again a problem enhanced by the presence of private providers, which brings us back to accountability in an essential service.

    Thank you for your blog on medical laboratory quality. While these are specialized concerns they significantly impact the effectiveness of our health care system and your insights are welcome. Ross.

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  2. Ross Sutherland, the author of False Positive: Private Profit in Canada’s Medical Laboratory writes: “My research indicates that in all areas of laboratory work, not just microbiology, pre- and post-analytic quality are negatively impacted by the presence of parallel public and private systems, though this is a thesis demanding more research”.

    It is an intriguing thought but one that would be a challenge to investigate.

    Reading False Positive reminded me that I had an old book on my shelf “Use and Abuse of Diagnostic Services: The Canadian Experience”. It was written in 1982 by O.C. MacIntosh, a pathologist at St. Martha’s Hospital in Antigonish Nova Scotia. I met O.C. while I was working in Halifax in the late seventies and early eighties.

    The two books, written some 30 years apart, are quite complementary and help put Canadian diagnostic services in perspective.
    I am glad to have both of them on my shelf.

    In Canada, our public and private medical laboratory services serve two very different groups of patients, in that the public system still tends to address the needs of inpatients and hospital associated outpatients, while the private system tends to focus on non-hospital affiliated ambulatory patients.

    I suspect it will be very difficult to set sufficient experimental design to do an effectiveness/efficiency comparison of the impacts of servicing inpatients, outpatients, and ambulatory patients on issues relevant to pre-examination handling of samples.

    There are huge differences such as who collects the sample, where they collect the sample, and the distance between the patient and the laboratory. Too much "apples and oranges".

    I

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