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Monday, April 29, 2013
The Big Value of Smaller Conferences
In the Quality arena, especially in health care related organizations, it is critical that we distinguish between what we want and what we need. There are all sorts of things that we would like to have: a better and more extensive Quality library stocked with both on-line and paper books, new Quality platform software, a new statistical software package, a 5 member Quality Team, opportunities to visit other organizations to learn from their Quality system, and all the time necessary to visit every Quality oriented blog and web-site on a daily or weekly basis. And if you can do all those things, congratulations, you are extremely well-funded, far beyond most of us.
But there are some opportunities that do not fall into the “nice-to-have” category, and much more in the “need-to-have”. You need to have the time and where-with-all to be doing some internal audit process. You need to have the knowledge and skills to have some form of regular Quality monitoring such as Quality Control and/or Quality Indicators. You need to have some form of Continuous Improvement program. And perhaps the most important, you need to have a mechanism that will enable effective Continuing Education, for as many of your people as possible.
And that brings me to the topic of conferences. There are many organizations that are giving up on sending people to conferences. Travel is too expensive, the amount of social time as compared to learning time is too great, and the amount of tangible take home information can be too little. Sending your people to an education oriented conference can be heavy on the cost and weak on the benefit, unless some work is put into selecting the right meeting with the best chance of return value.
From my perspective, big international conferences that attract people in the thousands are great for networking and maybe for some highly selective trade-show information, but generally are very low on the education and information side. The crowds tend to be too large, the number of concurrent sessions make getting to the sessions you want very difficult, and getting direct contact with the informed faculty is almost impossible. All too often the faculty-to-participant ratio is around 1:100, giving little opportunity for meaningful conversation. What may be useful for the individual person interested in networking is less satisfying for the person there to pick up tips and ideas.
At the same time, the small local meetings can have limited value in the other direction. Local meetings usually mean that people are expected to attend and work at the same time. The small local workshops tend to be short half-day events, usually on a single topic only, and usually with a limited faculty. Good if the topic on discussion is the topic that you are interested in, but otherwise you just have to wait your turn. Faculty-to-participant ratios tend closer to 1:50, better than the former, but still not very effective.
So does that mean that meetings are complete waste of time? Not so. I think what it argues for is the intermediate regional meeting. The meeting of 150-250 people is actually an ideal size. It is large enough to attract a faculty of knowledgeable speakers on a subject theme, but at the same time it is small enough that folks get to chat and brain storm in reasonable sized groups. It is large enough that you can meet and network, but small enough that you can actually get to know someone beyond just sharing a business card or Linked-in address.
In October 2013 we will be hosting our POLQM Laboratory Quality Conference. We anticipate about 200 laboratory technologists, residents, students and pathologists, all interested in laboratory Quality. Many will be from Western Canada, but there will be folks from across Canada and the Pacific North West. We already know of some people coming from outside North America. It will be a good group to network with. The faculty, all knowledgeable experts, will be there in ideal ratio, about 1 faculty to about 8-12 participants; a perfect opportunity to pick some brains. The location (Renaissance Hotel in Vancouver) will provide a comfortable environment conducive to good conversation. And there are sufficient sponsors for those that want some tradeshow experience and the opportunity to garner a variety of laboratory supplier information.
If you want a cast of thousands, this is probably not the meeting for you. But If you want or need an opportunity to network, discuss, and learn this is going to be a VERY good meeting.
It’s like Mick said: “You can't always get what you want, but if you try sometimes well you might find you get what you need”.
For more information visit www.POLQM.ca
Thursday, April 25, 2013
PT Bonus Opportunities: would your laboratory benefit?
Frequently we talk about the benefits of Proficiency Testing as a method for the detection of systemic error in laboratory testing, especially as part of the examination phase. Once you accept that Proficiency Testing challenges have been thoroughly quality controlled and are highly reliable, then it becomes, as my old calculus professor used to say, intuitively obvious that the greatest probable cause of deviation between a clinical laboratory’s result and the PT program’s result is some form of problem within the clinical laboratory. It likely is a slip or distraction by someone in the laboratory’s testing chain, but it may reflect a larger systemic error that is otherwise is being not recognized or is under-appreciated. Discarding deviations in PT performance can be lost opportunities for improvement.
But recently we had two interesting results come to light that reinforce that systemic error in the testing pathway detectable with proficiency testing materials can come from all sorts of places.
As per our normal routine, our PT coordinator was checking the laboratories that had not yet sent in their results 48 hours before the due date, and found one such laboratory and contacted them. [As an aside we can provide that extra level of service because we are a small program. Large programs with thousands of participants could never provide that extra assistance.]
The laboratory checked their records and came back on the phone and said that the problem was on our end, because the laboratory had never received our samples in the first place. We were the problem. So a check was made through the courier service and what was found was that the samples had been delivered on time as committed, and that the delivery way-bill had been signed off within the laboratory. A call-back was made and sure enough, the box was sitting in the refrigerator where they had been placed, un-opened.
The story has two messages. First, if this happened with our package, this could have been a one-off by someone who simply forgot (call that a human slip) or perhaps this happens more commonly than the laboratory is aware (call that a system error). Second, our system informs the laboratory on the day the package goes out. If there is going to be a problem it would be captured within 48 (max 72) hours. If someone had called us and checked, the box would have been found immediately. That this didn’t happen either means that a distraction resulted in the call not being made, or that the laboratory has an inventory-control problem which needs checking.
Either way the point is that even without being tested, this PT shipment has resulted in detection of two problems (is it OK to call them errors?) that the laboratory now has the opportunity to check-out. Either they were a chain of simple human foible, or they were a manifestation of failures in the delivery handling and monitoring procedures.
A second story is similar, but starts not from us contacting the laboratory, but the laboratory contacting us with an apology for a 5 day delay in submitting results. Apparently, there usually was a Quality technologist whose job it was to submit PT challenges reports, but that person had recently retired and no one had yet been appointed and so the job was “slipping through the cracks”.
We understand that people do retire; that is called “business as usual”. But if the PT reports are not being submitted, are there other tasks that are not getting done. If quality control testing is being delayed, and reagent defects are not being identified, then how many hours are going to be lost having to remediate erroneous test reports? Or worse, what if quality control testing isn’t being done at all?
My point is that PT samples are more than just a material to challenge the examination phase of laboratory testing. They are known and traceable and regularly received materials that can be used to monitor every aspect of the laboratory cycle. Usually everything works as it should, and sometimes it does not. It is when things do not go well that these “safe” opportunities arise for checking for system error.
Opportunity accepted or opportunity ignored?
Sunday, April 21, 2013
Clinical Microbiology Proficiency Testing (CMPT), the PT program that I chair, has just successfully undergone our 10th annual assessment visit by our certification body (SAI Global). We are the only Proficiency Testing program in Canada or the United States serving medical laboratories with a continuous 10 year track record of successful external evaluation.
Congratulations to us.
Voluntary oversight is an interesting activity in which to be engaged. In Canada, at least for the time being, proficiency testing bodies providing services and challenges for medical laboratories are not required to be externally audited by any agency in any jurisdiction. We can be accredited to ISO 17043:2010 if we want, or we can be certified to ISO9001:2008, or we can do nothing. It is our choice. If some authorities know what we choose, nobody officially seems to care. To the best of my knowledge, we have one organization that is voluntarily accredited to ISO 17043, and there is one organization certified to ISO 9001 (that is us). The remaining programs, large and small have to date decided that oversight provides them no particular benefit.
I suspect that the laboratories to which we provide service see the world a little differently. When we surveyed our laboratories, they reported that most see our certification as providing evidence of our Quality and provided a basis for trusting our Quality and Competence. That being said, there is no evidence that laboratories make any decisions in which PT program they will participate, based on Quality oversight. Further, there is little doubt that if the cost of our program was perceived as too high, or if some of our “competitors” decided to become more aggressive, many of our laboratories would drop our program. Loyalty goes only so far.
More to the point, I suspect it would be exceedingly difficult, to develop any evidence that would suggest or support that laboratories that participate with over-sighted PT programs make fewer errors or provide a higher level of patient safety.
I will take this one step further. I am aware of only one medical laboratory accreditation body in Canada that has sought external assessment, and I can see no evidence that would suggest that laboratories accredited to that program are safer or better than those accredited by non-oversighted accreditation bodies. [That being said, we do have some anecdotal evidence that laboratories with NO accreditation may be inferior].
So there is a reality that if we think we are following our Quality journey for some tangible benefit to patient safety or medical laboratory improvement, we probably would be wrong. The benefits of Quality lie almost exclusively for us, with some intangibles that go outside the house.
First off, by working through a structured quality process we catch our mistakes earlier, and prevent most from repeating. By learning from our mistakes and keeping our errors in–house, we save substantial amounts of time, and energy and money. I estimate this saves our bottom line probably 5-7 percent.
Second, we are a real-life example of the phrase “Quality improves Culture and Culture improves Quality”. CMPT has a very powerful Culture of Quality. After 10 years, our Quality system is at the core of everything we do. It is the basis of our innovation efforts, our internal communication, our discipline of continual improvement, and our dedication to providing the best service that we can for the laboratories that work with us.
When we plot our culture map we are very high on Market (customer awareness) and Adhocracy (innovation) and Clan (intergroup dynamics) and a lower on Hierarchy (internal leadership and requirements). We are exactly where we want to be.
There are some lesser tangibles that result from our Quality strategy. We get a lot of recognition from other countries and are perceived by many as a leader in method development and innovation for proficiency testing. Considering that we are really a small group, that recognition is a real plus and driver for us.
And perhaps very importantly, had CMPT not embraced Quality, then we would never have reached the point of opening our sister program, the Program Office for Laboratory Quality Management, and would not have experienced all the huge pluses that have accrued from that.
With all that said, we are absolutely certain that going down the Quality path when we did has given us a level of success that is off-the-scales.
A truly brilliant decision of which I have absolutely no doubt.
Wednesday, April 17, 2013
Twelve Core Quality Messages in Plain Language
Over the last while in this blog I have raised the challenge to medical laboratorians that it is time to start changing our report writing style.
In the past our reports have been written by us, and by-and-large not with the customer in mind, but rather to suit ourselves. As much as we like to lay the fault with the Laboratory Information System (LIS), we were the ones that picked the words and style. We are all to blame, but I would argue that the two most guilty have been the tissue pathologists and especially microbiologists.
In microbiology our reports are so full of jargon and subtlety that I am surprised that anyone can figure out what we are saying. We insert microbial name changes at the drop of a hat, we use terms like “GAS” and “GBS” and “no anaerobes detected” and “no significant growth” and “normal flora” as if everyone understands what they mean. Newsflash. Few physicians and virtually no every day patients have a clue what any of those terms mean and creating reports with those terms is not helpful.
But if that is a problem, pity the poor person trying to get a grasp of Quality without taking a course. Our area of interest is so loaded with jargon and gibberish I suspect that most of us have at best only partial understanding. Agile, scrum masters, waterfalls, kanban, poke yoke, green belts, black belts, DMAIC, scorecards and OFIs; it goes on and on. If we want to develop a consistent concept of Quality, then perhaps we need to start developing a more direct, interpretable language that can be understood as clear language. [For related reading see: http://www.medicallaboratoryquality.com/2011/09/quality-and-tower-of-babel.html ]
Consistent with that message, recently I was to prepare a lecture for some students that have an interest in international public health, but have essentially no laboratory contact and even less contact with the concepts of Quality Management. A tough exercise at the best of times, but to provide the information and immerse them in Quality terminology would be a mind numbing, eye-glazing, nap promoting experience. I have endured those lectures before. Stone cold killers.
So this gave me an opportunity to see if I could create a lecture in a way that would allow them to at least grasp the concepts of Quality and remain if not alert, at least conscious. I figure if I can get the concepts across in plain understandable terms I can make Quality relevant. At a later time, for those who might develop an interest to discover more, we can start to introduce the specific terms.
To that end I created the following, which I think covers the main messages that we think about when we decide to implement a Quality system. Each message is connected to a specific Quality Process.
I call the following:
Twelve Core Quality Messages
• Quality is everybody’s business, but Management carries
80 percent of the load
80 percent of the load
• Employees need to know what you believe
• Employees deserve to know what their job is
• If performance is not right, it is wrong
• Everyone should read off the same page
• Think before you Do; Check and Fix what you Did
• The earlier you detect mistakes the better
• The error you prevent is no longer an error
• Learn from your mistakes
(OFI and CONTINUAL IMPROVEMENT)
(OFI and CONTINUAL IMPROVEMENT)
• A second look is very helpful
• An outside look is better
(EXTERNAL QUALITY ASSESSMENT)
(EXTERNAL QUALITY ASSESSMENT)
• If Management doesn’t check, then it doesn’t know
Maybe I am deluding myself, but I think this is something that I can use, and might work.
Wednesday, April 10, 2013
In 2002 I made a decision to separate our Proficiency Testing program (also referred to as PT or External Quality Assessment or EQA), the Clinical Microbiology Proficiency Testing (CMPT) program from our colleagues by going the extra step of implementing a true and effective Quality Management program. In my world of medical laboratories this was not so much a competitive advantage in a business sense because the collective group of EQA programs did not compete for laboratories, but perhaps did so more on the basis of positive recognition. In the absence of an EQA specific standard at the time, we decided to develop an intact, active, vital quality program consistent with ISO9001. By 2004 our Quality System was registered and we have been certified or recertified every year ever since.
By about 2006 or 7, we were very proud of what we had accomplished and decided it was time to crank things up a notch by having ourselves assessed for a Malcolm Baldrige National Quality Award. It was at that time that we learned that getting an MBNQA in Canada was not an option because Baldrige was a US program designed and intended for US organizations. What I didn’t know, and perhaps should have was that there was (and is) a Canadian counterpart, the Canada Awards for Excellence (or CAE), that would clearly provide the boost in ego status and recognition for which we were gunning.
Today CAE continues to exist, but under a new and different name, Excellence Canada. As an aside, Canadian organizations love that type of name structure – Trans Canada Airlines became Air Canada; Canadian Council on Health Services Accreditation (CCHSA) became Accreditation Canada, and the French language arm of the Canadian Broadcasting Corporation became Radio-Canada. But I digress.
Under its new name of Excellence Canada, the organization continues to thrive, but perhaps a little under the radar. Recently I found a blog entry dated two years ago to the month which said “As a Canadian I have to wonder why no federal or provincial government has ever thought it reasonable to initiate a Canadian award for Quality and Excellence.” Embarrassingly, it was written by me [see: http://www.medicallaboratoryquality.com/2011/04/power-of-voluntary-quality.html].
Fortunately I was a quick learner and in 2012 I wrote informatively about Accreditation Canada and CAE. [see: http://www.medicallaboratoryquality.com/2012/09/malcolm-baldrige-national-quality-award.html ].
Canada, Excellence Canada, and CAE have much to be proud of, and the organization deserves a higher profile in Canada than I was apparently appreciating. Of interest and of note (I hope I have got this right!) the CAE was first awarded in 1884 and predated the Malcolm Baldridge Award by 3 years.
What is typical of Canadians and our Canadian institutions is that we tend to be very poor at recognizing deserved visibility and respect. Perhaps there are some exceptions to the rule, such as the Toronto Maple Leafs, and Jim Carrey, but I would argue that for those two, the less the recognition the more appropriate it is.
I note that my fellow countryman Daniel Zrymiak has similarly written about Excellence Canada [see: http://qualitevolution.blogspot.ca/2013/04/excellence-canada-for-canada-iso-9004.html ]. I follow QualitEvolution with a certain degree of regularity, and I will say that we tend to see things with a similar point of view. So it does not surprise me that we both view Excellence Canada as low profile That being said, I would have to call it harsh to describe Excellence Canada as “somewhat irrelevant for a global organization”. Pretty harsh for a polite Canadian.
As an addendum, if I have left you with the impression that CMPT has sought and earned a Canadian Award for Excellence, that would be misleading. It is something that we are still looking at.
Thursday, April 4, 2013
Another Successful Quality Seminar
In Canada we have a variety of medical laboratorian organizations whose primary function is to bring people together for an annual meeting. For microbiology technologists, scientists, and physicians the predominant organization is known as the Canadian Association for Clinical Microbiology and Infectious Disease, which is abbreviated as CACMID. To some the word CACMID brings to mind hacking and gagging, not in a polite way. The organization has been around and active since 1974.
In 1994, I proposed to create a side seminar to highlight the interests and activities of Canadian microbiology oriented Proficiency Testing programs. It turned out to be pleasantly successful, and there was a thought that we should do it again. Well we did, again and again, and yesterday we did it again, for the 20th time.
With the probable exception of the annual conference of the American Society for Quality, I would not be surprised if our 20 year run is the longest run of conferences dedicated solely to Quality in any industry. If someone knows of another series or other series, I would be interested in hearing.
Over the years both the hosting organization and the Quality seminar meeting has evolved. Now there are two hosting organizations CACMID and AMMI-Canada (the Canadian Society for Infectious Diseases and Medical Microbiology). The Quality seminar has moved from its focus exclusively microbiology and PT. Over the years we have high-lighted accreditation, standards development, Quality education, and suppliers; in essence we have covered the spectrum of Quality and the collective group of Quality Partners.
This year was another evolution as we focused on a variety of laboratory Quality tools. One speaker was a clinical chemist who gave a very interesting discussion of Six Sigma calculations and how they can be used to describe and monitor error in the medical laboratory, not only with respect to quantitative assays but also for qualitative ones. In the medical laboratory we see six sigma as a valuable shorthand that can reduce very complex numbers to very small and simple numbers. This is very analogous to pH as a measure of hydrogen concentration or logarithms for that reduce 1,000,000,000 down to 109. Already we hear laboratory folks talking about having an error rate around 4 (meaning an error rate around 0.5%) so we know that the shorthand is taking hold.
The second talk was one to which I am very committed. In North America jurisdictions are falling over themselves consolidating many laboratories into 1 mega-laboratory; very financially efficient, but maybe questionable on effectiveness. An adage in healthcare has long been “closer to home” meaning that the facility near you knows you as a person while the mega-lab doesn’t know much other than you as a number and a vial of blood. Our second speaker was talking about implementing Quality into a laboratory in a small town hospital. It we can keep these smaller facilities up-to-date and up-to-Quality, we extend and enrich their value far greater than shipping samples down the road to the big house.
The third presentation was on another subject that I enjoy; implementing internal audits in new formats that increase interest and attention and focus and knowledge. It moves audits from the section called “mundane and boring” to “interesting and fun”. Sara (the presenter) did a great job of conveying enthusiasm.
The fourth presentation was on a better way to look at Risk as it applies to decision making in the medical laboratory. I have previously written in this blog about Risk and Uncertainty and Severity-Occurrence as a value monitoring tool. This was my first time to do a live presentation on the subject of Risk. I was pleased at how well it went, but it still has opportunities and potential for improvement.
For those interested we have posted 3 of the 4 presentations at www.POLQM.ca for public
One of the presentations is going through a review, because the spectre of copyright infringement has been raised. I suspect it is more speculation than fact, but we are checking it out rather than facing off problems. It likely will appear next week.
So with another successful meeting under our belt, some decisions are being made about what happens next. Personally I have to do a motivation check after every seminar these days. The process of getting new and fresh speakers is getting tougher. But at the moment, I am pleased with 20, but now we are thinking of shooting for 25.
Time will tell.
Monday, April 1, 2013
Quality – not only for the Adult Learner.
I was reading the other day in the Apirl 1st edition of the Canadian Business magazine (the Innovation Issue) a special report on “35 Radical Ideas to kick-start Canadian Economy”. Some of the ideas were for companies to hire a chief innovation officer, think globally, and embrace your mistakes (don’t be afraid to fail). All interesting ideas, but the idea that caught my attention was #3: Start teaching entrepreneurial skills to five-year olds.
Without specifying what skills exactly they think are a good idea to start early, the notion is that early introduction would foster the early-blooming creative thinkers, but would help create a generation of people for whom concepts such as creativity, problem solving, invention.
I don’t have a problem with that approach, but I trust that the author understands that as far as being innovative is concerned, he is pretty yesterday; my son was actively involved in the schools-based program called Future Problem Solving International nearly 20 years ago. FPSI is still active in many school programs around the world as early as age 11-12. From my experience it was pretty competitive, hand-picked students getting extra attention with the possibility of going to provincial or national or international competitions, but that is also consistent with entrepreneurial spirit. If my son is typical of the FSPI alumni, they are very successful at doing exactly what this author was talking about.
But on a related note, every year for the last several, I have been giving lectures to a group of early university level biology oriented science laboratory students on the subject of Quality in the laboratory. As I talk to this group, I clearly get the message that the information that I am presenting [Quality Control, Error, and Process Management etc] is completely new to them.
While some of these kids may have come to science very late in their academic stream, I would imagine that most of them would have been involved in some level of science study in grade school and high school. They have had some laboratory experience at some time.
I am disappointed that somewhere along the way the concepts of laboratory quality have not been introduced sooner. It suggests that they are still doing “recipe” experiments without knowing what they are trying to discover, or if their equipment is working properly, or doing chemistry, not knowing if their reagents are stored and maintained properly, or they are doing behaviour experiments but without any controls.
I suspect that many teachers would say that they know that the equipment and reagents are working, but they do that after hours, in order to not waste the students learning time, but that would be a wrong decision. Teaching science is not about doing experiments, it is about doing experiments properly.
Many of these students are going to end up working in some form of human biology oriented research laboratory or diagnostic laboratory, for at some part of their future. Some of them get the idea, and absorb Quality into their science knowledge. Many do not. We see that in all too many laboratories where the first financial cuts go to proficiency testing, quality control, and accreditation. Early cuts would also go to terminating internal audits, but since they don’t exist, there is nothing to cut.
My point is that from the very get-go students should be understanding that science is not about developing theories, it is about defining knowledge through designing and performing experiments using the principles of Quality performance.
That is something that our schools should be teaching five year olds.