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Friday, February 24, 2012
Teaching Laboratory Quality
I was flipping through my February edition of American Journal of Clinical Pathology and came upon an editorial article written by Michael Laposata about the article written by Ronald Weiss et al in a recent previous edition (November 2011) about a “consensus curriculum” for laboratory management training for pathology residents. Both articles are worth the time to read.
A few things about the Weiss article. First, the title of the document as a consensus curriculum is not really accurate. What the article provides is a series of responses to a number of questions asked to residency training directors. The information was used as a basis for the creation of a curriculum, not presented in the manuscript. What it does present is some sort of moment-in-time snapshot of what the training directors were doing at the time of the survey (2009). Basically (as pointed out in the editorial) they were providing some sort of didactic program 1 hour a month throughout the 4 year residency on topics that include: Quality Assurance, accreditation and regulation, test validation, risk, and some cost issues like accounting and purchasing. The number one tool was being involved in either a real or mock accreditation. Some of the residents had a period of a month or so as a “Junior Laboratory Director”.
I think it would be fair to say that the editorial presented this month was not particularly impressed, based upon the combination of the results of the survey and his own considerable experiences. From my own experiences, I get his point.
It is really tough to create a sustained, effective, measureable program to train medical laboratory residents in the skills they will need to be effective leaders and managers for laboratory Quality, at least in today. From my experience, most laboratory physicians have at best a rudimentary foundation of Quality, and are scarcely in a position to be effective educators or mentors. For many (maybe most), Quality begins and ends with writing SOPs and doing a quick preparation for accreditation. Throw in a side-by-side evaluation as part of test-validation, and that is about it. They are hardly in a position to convey topics like understanding the foundations or application of standardization, or approaching continual monitoring for error and improvement, or developing Quality policies and objectives, or working with Quality Partners. Quality Indicators include turn-around-time and temperature charts, and little else. Their laboratory is first, foremost, and only a technical operational center.
Having personally been involved in resident training from a variety of aspects, I understand the problem. The reality is that Quality Management is related to, but very different from the traditional disciplines within laboratory medicine, and all adult learners tend to be attracted to the topics that interest them, and tend away from the topics that don’t. Trying to teach Medical Microbiology to a person interested in Clinical Chemistry is a challenge and try to teach either of those to a person interested only in tissue pathology is even worse. Talking about laboratory safety or laboratory quality to a person focused elsewhere is a lot like being a dental patient or going to a classical music concert if your tastes run more to medal and rock. While there are some folks interested, most are not and requiring them to be there is deadly.
What I have been doing is creating a knowledge core that looks at the quality in a historical and academic perspective and trace the links between poor quality and laboratory error. We talk about defining core beliefs into a Quality Policy and how that policy can become a driver of action. We talk about Quality Partners and try to stress the point that proficiency testing and accreditation are tools that let you learn what you are doing well, and importantly what you are not doing well, so that you can develop a plan to improve. We talk about using Quality Indicators (including monitoring complaints) and Internal Audits to your advantage. And then we stop. Four sessions (maybe 6 hours) and out.
For those that are focused elsewhere, they have some core knowledge which they can use or not use as they go forward. For those for whom Quality is an interesting topic we provide our extended 20-week on-line course in Quality Management (Each year we get 2 -3). And for those with advanced interest, there will be advanced opportunities at the Masters and PhD level for those that are sufficiently interested that they seek academic and research fulfillment.
To address Michael Laposata’s question of “what skill set are we trying to impart?” the answer is to discover their level of interest and how they as adult learners can optimise to their personal advantage.