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Wednesday, April 11, 2018

Quality Story Telling - take 1: An additional cost for quality??

There are many paths that lead to Medical Laboratory Quality Improvement; education conference and study, implementation of innovative programs, and working at the level of personal responsibility and in particular building a strong positive organizational culture that supports and promotes quality thinking.   In our course we put a lot of emphasis of highlighting all these approaches, and we do it through the process of storytelling, which is the way that adult learners share their experiences in a way that others pick on new insights.  
 Storytelling can benefit both the story teller and the story listener.  It is a great way to communicate and learn all at the same time.

So let me tell you a story.

The other day I was in a discussion with a person with a lot of responsibility for laboratory activities in our province.  We were talking about our province’s on-line reporting system for medical laboratory error, in part because of the two recent manuscripts that I and colleagues have recently had published on the subject.
(Medical laboratory associatederrors: the 33-month experience of an on-line volunteer Canadian province wideerror reporting system. Restelli V, Taylor A, Cochrane D, Noble MA. Diagnosis (Berl). 2017 Jun 27;4(2):79-86 and Laboratory error reporting rates can change significantly with year-over-yearexamination.  Noble MA, Restelli V, Taylor A, Cochrane D.  Diagnosis (Berl). 2018 Mar 28;5(1):15-19.
[Both available on PubMed].

 This provincial reporting system (the BC Patient Safety Learning System or PSLS)  is now about 10 years old, and suffers many of the problems of most 10 year old software; that being said, the system has far more positives than negatives and provides us with a lot of information and insights on the state of laboratory quality efforts in British Columbia.

It is a volunteer program where the reporter identifies a problem and goes to the on-line site and completes a reporting.  Sometimes, the same event can be reported by more than one person, each from their own perspective.  Sometimes an event that people wanted to report does not get reported because it was inconvenient at the moment to stop and report, and then people forgot or got otherwise distracted. 
Error reporting is not particularly balanced; there are some profession groups and some geographic parts of the province that are likely to report events and other seem to have little interest, and that was the topic of our discussion.

So I was having this conversation and this person came up with two comments the first was that the system is not helpful or user friendly because a laboratorian would have to take 5 minutes to complete an on-line report, and that laboratory physicians are far too busy to stop and take the required 5 minutes just to report an error.  
In this person’s mind consuming 5 minutes of their valuable time was some sort of terrible imposition that way overrides the systemic benefits of reporting errors.   As personal conviction, reports should not be entered until PSLS spends the money to revamp the software so the events can be entered in less time, caving these poor overworked souls 2-3 minutes a day.  Regardless of costs, their time constraints demand it. 

But then they went further; the reason that people don’t report is because there is no financial incentive to participate and report.  

Rather than pursue the conversation I decided to change the topic.  If what I thought was being said was indeed being said, our discussion would have turned into an ugly confrontation that would have benefited no one.  Surely nobody with a modicum of quality awareness thinks that the best way to enhance error reporting is to pay people to report.  What could possibly go wrong with that idea!!

In actual fact, the data in the two manuscripts points to the fact that this person was wrong.  Over the years, the rate of error reporting has gone up substantially.  It seems that increasingly people are using they system, despite what slight software inconveniences exist.    The system probably could be enhanced, tweaked, to make it a little more user friendly, but major overhauls would cost a ton and likely introduce all sorts of interface problems with not much benefit towards reporting.  

If we need to do something it is to work with the groups who choose to not report and find solutions to the barriers.   I suspect it is probably something as simple as being unaware, or “fear of the learning curve”.  I suspect it is more about habit than conviction.  And I suspect it has NOTHING to do with people begrudging the couple of minutes to report.  (By the way, if a laboratorian is having to report more than 2-3 errors a week, costing them more than 15 minutes there is something going on that needs a lot more attention.

The evidence to date is that reporting errors has a lot to do with quality awareness, and personal conviction and growth that comes with quality activity.
 Reporting progress does not need BIG thinkers, it needs engaged thinkers who see value in spending a few minutes to initiate a report and implement a corrective action.  

But if it requires extra MONEY to support a pay-for-reports program, then we are really in trouble.


  1. As I was reading your blog, I kept thinking of ways to reframe the money incentive so that it becomes more palatable for all stakeholders. Costs of Poor Quality (COPQ) came to mind.
    When COPQ, those hidden chasms of expenditures, are not recognized throughout the laboratory, budgets easily can overrun.
    Begin talking the language of money.
    In the sensitization with the individual sites when meeting with key stakeholders:
    Show them how you are using the data.
    Make connections with improvements that came out of the data.
    I have found, through my connections with SLMTA (slmta.org), that providing a prescriptive how-to approach must follow the hook. This could include:
    A training packet that management can use or easily modify to engage the staff responsible for reporting the event.
    A simple job aid demonstrating how this quality goal can be turned into an achievable objective that can demonstrate continuous quality improvement for the site (performance and conformance). Provide how the steps along the improvement process appear using an example.
    Of course in SLMTA, we don’t stop there. Supervisory site visits serve as the follow-up component (CHECK and ACT).
    Thank you for letting me share how SLMTA engages and supports sites, including those sites that have never collected or used laboratory-based data before entering the SLMTA training approach.

    1. Many thanks. In my opinion, SLMTA has done a huge amount to advance the progress towards better quality for laboratories even if they do not end up going to accreditation.
      And given a choice between a prescriptive how-to versus a proscriptive (or required) how-to, your approach is better.

      "Pay-to-report" still seems to me to be the last and worst approach. For some, it can become a cheap revenue stream, for others it becomes a bribe to inform; it adds cost without confidence or reliability.

      Unfortunately I see this only in the starkest terms; when laboratory principals demand to get special payments, just to be transparent about error, they are nowhere near the goal (or even the starting line) for quality improvement.

  2. Very interesting perspective Dr Noble. I totally agree with you that if laboratories have to be paid to report, it makes the system very unreliable.

    In fact, it is that kind of thinking which makes some laboratory staff think that quality management is extra work, and therefore needs extra pay. If you have a manager thinking like that, the poison is likely to infiltrate the rest of the team.

  3. Thanks Mutale
    I always appreciate your insights.