Healthcare Customer Satisfaction: More Talk AND More Action Customer satisfaction (Voice of the customer) is a recurrent th...
Sunday, September 21, 2014
It is a given that if a Qualitologist wants to improve quality, one of the first things to do is reduce error, and to reduce error, one needs to understand who causes error, why they cause error and what we can do to help turns things around. Turns out that may not be so easy.
Yesterday I had the opportunity to attend a workshop seminar put on by the Canadian Society for Safety Engineering who had invited Sidney Dekker. I have written of Sidney Dekker before. By academic background and training a psychologist, and by avocation a pilot, and by profession a thinker and writer and speaker/presenter on Error.
Dekker has honed a fine craft as a speaker/presenter. He is fast and edgy, personable, with more than a a touch of cynicism and sarcasm. Presentations are more a flow of consciousness than a formal focus on a topic. But it works out OK if you can stay on board.
The Dekker message is the error is complex, with the system contributing a lot, maybe most of the fault. If the system was better, there would be fewer errors. That is a message that I can live with, mostly, but not completely.
Dekker has come up with an interesting notion. If a standard or an instruction or a standard operating procedure says to do A, and the worker decides that it is better to do B, the difference between A and B is not called a “non-conformance”, rather it is a reflection of “resilience”. That is to say that if the worker chooses to go his own way, to break ground to find another solution, that is a good thing. It reflect mostly on the inadequacy of the standard, or instruction. As he puts it, there is the way the task is written and the way it is going to get done, that these two approaches may not be the same. In his view, there is great power in the young and new recruit learning at the foot of the wizened old-timer with a ton of experience. “I’ll show you how that really gets done”.
Well that certainly is interesting.
Now don’t get me wrong, my own philosophy and approach does not differ all that much. For example, from years of trying , I understand that one of the hardest things to do is write a standard and an SOP. An old exercise is to write an SOP on something like making a paper boat by writing the instructions on how to hold and fold the paper. It becomes pretty clear in a real hurry that given to 10 people you are very unlikely to get more than two boats looking alike, and those that do were likely a mistake. There are better ways to prevent chaos, for instance, pre-testing the SOP to see how many people understand what they are supposed to do (and keep in mind that in many worksites, there are many for whom English is a second language. So rather than work with traditional SOPs, consider supplementing with pictures and audio and video clips.
And I am pretty OK with writing flexible SOPs where the person has some choice in low risk steps. I don’t mean things like knowing how to find and hit the POWER OFF button, but if a step requires about a minute pause, but the requirement doesn’t have to be exactly a minute, then the SOP should not be framed around words of precision.
Also, I am a firm believer in the apprentice process, where junior staff are not just trained by a “teaching tech” as we call them in the laboratory, but that they sit side-by-side and learn for an extended period of time before being able to work on their own.
But I do have a problem with framing non-conformance as a positive (resilience). If someone does find a better way, there is a better approach for fixing the problem for everyone.
And I have a problem with Dekker’s notion that there are no people who are accident prone. They are not “bad apples” and they are not “morally suspect”, but they do exist. Some of them exist from silent incipient health issues that go unnoticed. Some are due to non-work related issues including family or time stress. Some may even be as a natural inclination that everyone else is wrong and they only they are right (that might even include me and others that I know and have met.) They may not only be a risk to themselves, but they may be a risk to others, and finding workable solutions can be a significant challenge.
But for me the bottom line on the workshop/seminar was that I came out at the end of the day with a ton of questions and challenges that will stimulate a lot of thought and action. And that is about as good an outcome as one can expect.
Thursday, September 18, 2014
It has been a while since I have felt the need to vent in this space, but the events of today lead to exasperation and venting here in public/private seems like a good way of dealing with it.
I will tell you that I have spent nearly my whole career in and around standards development, some at the very local level, some provincial, and some national, and a lot international. In the beginning, I think my major motivating driver was ego, that I was in a space where I could “impose” my ideas on a larger professional group. After a short while this wears off, and the driver gets replaced by being motivated to have your profession steered by sound principles that come in large part from understanding customer needs. By listening to what other laboratorians tell me, I am told that I am competent at translating those needs into requirements that work well in standards at all levels.
For example, when working with laboratories in developing countries it was pretty obvious that the best way to introduce quality management principles was to break a sophisticated document like ISO 15189 (medical laboratories – requirements for quality and competence) into bite size pieces and introduce them on chunk at a time, along with mentorship assistance until they have worked through a series of implementation and gap analyses until they are ready for international accreditation.
That is now a very common and popular model for success.
I have had my successes and I have had my failures, perhaps the largest being my inability to get the measurement of uncertainty removed as a requirement from biology based laboratories. From what I can see, after 20 years of experimenting with uncertainty, few laboratories get it, and the consequence is that they throw some numbers into a formula and get a number which they then ignore, as quite rightly they should.
I will say that from the laboratorians that I talk with, and increasingly the number of accreditation bodies that have to work with the standard, I see that the tide is slowly turning, and in time I will be vindicated. Sooner or later, the customer is always right.
But today was not about MU, it was about a clearly and shining arrogance displayed when some standards developers are intent on pointing out how smart they are and how dumb are the people that are going to be required to use the documents they are creating.
One person actually relayed a story about how he went to talk with a significant user and asked why he was concerned about a new standard version being created and was told that the new version was not going to work well with his peers. He felt the new version deviated substantially from the existing version.
As he recounted his story his response was along the lines of “this fellow is a nice guy and I consider him a friend, but in this case he was dead wrong and his opinion was garbage.” Good way of listening to the document users.
Then he went on to say that the document that was being created was complicated by including definitions of terms when they could be equally found in another document. The solution was simple. Take them out of the new document and require users to buy two documents, one with the standard, and another with the definitions. “When you buy a book, if you don’t understand the words then you go out a buy a dictionary.” Good attitude towards addressing customer needs.
What was interesting that this group also thought it was be a good idea to go through a document validation process before making a decision on next steps. For those unfamiliar with the concept, document validation means going to a group of users and asking them if they understand the document and discover if their understanding is consistent and compatible with what the crafters intend. It actually is a good idea, but can be a lengthy and complex process, and requires an open mind and the ability to accept criticism. It is the Check step of PDCA.
With what I heard today I think we have all the makings of a new PDCA – Plan, Do, Check, and Argue that the customer is a jerk and just doesn’t appreciate how much smarter we are than they.
Deming would be livid.
So am I.
Monday, September 1, 2014
Over the last decade I have become a firm believer in the use of ISO 9001 as a guide to implement and maintain a Quality Management System for my organization. Our proficiency testing program has been strongly enhanced as a direct consequence of our commitment along with the annual review by our certification body. While our Program Office is not similarly certified, for practical and pragmatic reasons, we follow many of the same processes, which has enabled us to be accredited within our university system.
As anyone who knows ISO9001, customer satisfaction is a central component. For our programs, seeking and listening to the Voice of the Customer is critical to understanding where the organization is and where it is going
[see: http://www.medicallaboratoryquality.com/2012/11/voc-voice-of-complainer.html]. In my experience, even though we work in a public sector university environment, in the absence of VoC, the laboratories that participate in our proficiency testing program would gradually fall away and the program would lose its raison d’etre. In the absence of listening closely to the voice of our course participants, new participants would cease to register and the course would end. We may be academics working in an academic environment, but it is all business all the time, and Quality is essential.
But in the last while I have had three experiences that have given me some pause about the universality of the place of Quality, especially in the public sector. I am less convinced of how much of what we do and study really works in the public sector and when it does, why.
Recently I have been with my one son and also my daughter-in-law as the applied for visas associated with travel and work requirements. In both cases we had to go to the border security office at an international boarding crossing. I am sure that you think you know how this story goes, but you would be wrong. The office was set up as “customer friendly” with many fast moving lanes. The personnel were clearly all business, but not in a demeaning or officious way… courteous, but definitely to the point. In both cases the outcomes were positive, and the business was completely. What impressed me was that these officers had nothing to gain by making the process so efficient and effective, other than for their own professionalism and making their own work day more relaxed and enjoyable. They were never going to see us again, and there was absolutely nothing in it them if I told others that they were jerks or good guys. Their job is not dependent of good will. There will always be an endless supply of people needing travel documents.
Recently I have been a patient in our public health care system, requiring for my first time, seeing doctors and having tests and procedures performed. To date everyone has been very pleasant, indeed very similar to the story above. But the system stumbles so frequently, one wonders how anything gets done. An example: I received a phone message that I have an appointment coming up on a specific day and time to have a test done. Two days before the procedure I get another message as a reminder, but I was told to come at a different time. I got to the office and was told by the receptionist that there was a mistake because there is no appointment, but I when she checks she finds out that I have, but the paperwork was never created and now she has to do that. As that is being completed, the technologist comes and says that I have missed my scheduled appointment. Eventually we worked things out, but here we have a typical situation where nobody knows what is going on. If that was the only episode, I would write it off to a bad day, but it seems that with this group every day is a bad day. Once again everyone was friendly, but chaos ensued. The system was neither efficient nor effective, and for a moment, no one was very happy. There seems to be a real lack of learning from the past, and no improving the process, and I suspect that on my next visit I will go through the exact same exercise. Being friendly may be a small part of customer satisfaction, but only a small part.
The third story has to do with a colossal mess in my home province with a public sector teacher union on strike for months with little chance for resolution. Without going into any detail what this has in common with the other stories is that the sector has an endless capture of students (one customer) and the process has not only faltered, but failed. But in this situation, the union has made it all too clear that not only do they choose to not listen to their customer, they don’t even know who their major customers are. Hint: it is not the kindergarten kids.
What ties these stories together is that they all involve public sector workers with an endless capture of customers independent of word of mouth; one succeeds, one falters, and one fails.
So to me, here is the bottom line, ISO 9001 can work in a public sector environment, but only if conditions are right and if people are committed to a culture for Quality.