Tuesday, August 16, 2011

Quality means never having to say you are sorry ... TWICE

Jim writes a very contributory comment about Quality.  It is consistent with the Crosby view of Quality (Do it Right the First Time). 

Quality is the doc ordering the right test and the lab drawing the right specimen on the right patient.  The test result is right (correctly reflects what is going on in the patient) and is sent to the right person. And the price/cost is right (we're spending taxpayers money). 

It is completely consistent with the Four Absolutes that the definition of Quality is conformance to requirements, and that the system of Quality is prevention.  The performance standard for Quality is zero defects and the measurement of Quality is the price of non-conformance.

My problem is that this is all about the ideal, and not the real world.  Slips happen and mistakes happen.  They don’t happen all the time or even at regular or predictable intervals. They annoyingly occur like atrial fibrillation, irregularly irregular.
 And as our laboratories have become more consolidated and more complex and with more highly sensitive and intricate equipment, they happen faster and in ways that many never get detected until it is far too late.  Remediating early errors is often an easy fix.  Detecting and fixing downstream errors is ALWAYS a pain.
Every day the nonconformities happen; and they never seem to stop.  Fortunately, the vast majority of nonconformances are minor and don’t affect patient care or management or result in poor outcomes.

That is not to say we should be untroubled about error, but I think that Crosby was excessive in defining Quality by the ideal.  Deming was about 20 years older than Crosby but was still very active in the 70’s which was Crosby’s heydays.  Demining wrote extensively on hazards of slogans and the anxiety they raised. He was very unimpressed by the notion of Doing it Right the First Time.

I think Deming was closer with his sense of Continual Improvement.  It is not only about putting out fires, but catching them early before they get out of control and sorting out why they happened and fixing that.  When I look at reports of patient error, if you knock out the repeat problems the total number of errors drops ... dramatically.  

So I am going to argue the following:
Since errors happen often silently and beyond your control, the effective measure of Quality is the prevention of and the rapid detection of errors in order to avoid or at least reduce customer inconvenience and harm.

Quality is never making the same mistake twice.

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