Saturday, September 18, 2010

Rant #2 - Where does Quality fit.?

In 1967 Anthony Hech, an American poet wrote "Merely to have survived is not an index of excellence...".  Every time I heard or read this, I wonder about what W.E. Deming and Phillip Crosby would have thought about it, and I wonder about Quality in the public 3rd party payer health care system.  If the system survives year over year, it doesn't mean it is getting better, it only means that business continues.  Most laboratory errors cause more inconvenience rather than harm.  If the answer doesn’t fit the clinical findings, then the clinician will either ignore or repeat.  So it is easy to see why CEOs and Department Heads are reluctant to spend the money on improvement.  (I know this sounds a little heavy on the cynical side, but bear with me!) 
In a health care system where the government pays for health care, and neither the physician or patients has a  financial stake, then where are the incentives for "zero tolerance for error" or  "doing it right the first time".  If neither the patient nor physician has any "skin in the game", then can laboratories really compete and differentiate for business by promoting "Quality is Job One"?  And if the public sector hospital  laboratory is absorbed into a global institutional budget are then any quality benefits, and if there are, where do they accrue?
So expression like “Quality is the right thing to do” or “”Quality means better patient care” are not going to sway many arguments.

If Quality Programs are going to find their place in the laboratory community they need to have good reasons.  In that spirit, I present the following:
1:  Losses from laboratory error represent substantial internal loss of time, effort, energy and money.  On average laboratory quality errors cost an average of 135 minutes to address (range 30-1000 minutes).   On a given day even a relatively error-free laboratory can count on losing the productivity equivalent of 1 person per shift.   And that does not include the costs of sorting out cause and developing solutions.  (I have purposely left physician and patient inconvenience out).
2:  In some situations, quality efforts reduce risk.  Think Eastern Health in Newfoundland, or the Maryland General Hospital in the United States.  The problem is that one institution can predict where the problem is going to come.  In the past the problems have occurred in high profile area like breast biopsies, or HIV testing, or Hepatitis testing, but it can be equally said that what makes them high profile is they attention that follows a Quality disaster.   If you think about other bad outcome causers a list might include:
-STD testing
-False Blood Culture results
-False TB results
-False PSA results
-Blood Bank errors
-False Troponin results
(Yes, I am aware the list is showing my microbiology bias).
In Canada these are problems that lead to inquiries.  In the US they lead to litigation.  In either event they represent significant money loss.
3:  Accreditation.  My personal bias is unfortunately that North American accreditation bodies tend to be pretty relaxed, and all sorts of problems slide through un-noticed, un-recorded, and ignored.  But at some point even the weakest accreditation body will find and report on the bad thing, and can potentially create enough noise that licensure is threatened.  At the sake of making non-friends, more accreditation bodies have got to start “stepping up to the plate” and being the monitoring agents they are expected to be.  (Sorry for digressing here.  More on Accreditation later).

So, if Quality Managers want to have an impact, there are good and sound business justifications.  And leave the “Quality is Job One stuff” to the folks who really compete.

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