Sunday, October 9, 2011

Improvement through Disaster.

I have always believed that Quality improves with the help of Quality Partners and the Partner with the greatest power is a motivated angry public.  

Today we heard the Quebec hospital (Honoré-Mercier hospital in St-Hyacinthe Québec) agreeing to the terms of a class action suit for harm (and deaths) resulting from an outbreak of in-hospital (nosocomial) diarrhoea caused by a bacterium (Clostridium difficile) that was likely spread from patient to patient by less than hygienic practices.   The amount that each of the aggrieved will receive is small in comparison to settlements in other countries, but the implications will none the less be significant.

The institution will hire more infection control practitioners and improve their cleaning services either through more cleaning staff or a more extensive outsourced contract.  We understand that this will not solve their problems (and I am sure they do as well), but it at least has the potential to reduce the number of outbreaks and hopefully create the conditions to stop them faster. 

For Patient Safety issues this is all for the good, recognizing of course that when the next outbreak happens you can “hear” the finger pointing.  (“You assured me that if I hired you more staff, this wouldn’t happen.  Well I did and here we are.  THIS IS YOUR FAULT.  Once we are out of this mess you caused you are so-out-of-here!”).  On the more positive side, hospitals have long been hotbeds for injury resulting from insufficient staffing and inattention to detail.  Falls, medication errors, microbial transmissions. 

There is nothing like a lot of negative publicity and class action suit to get improvements. 
So what does that mean for laboratory practice and laboratory Quality?  From the half-empty side, since it is a challenge for us to get the public enraged enough to a class action suit, it could mean that laboratory quality will wait a long time to build that level of attention.  From the more-than-half-empty side, since budgets are a zero sum game, if budgets get expanded on the one side, the money is going to have to come from somewhere, and traditionally the laboratory has been an easy target.  
The reality is that clinicians often “price-in” poor laboratory quality, or at least what they perceive as poor laboratory quality.  “That result makes NO SENSE.  I don’t understand.  I never trust that D**N lab anyways.  Let’s just repeat the test and see what happens.”  The patient has no power in the exchange.  The patient never sees the result, never has the opportunity to put it into context, and has no discussion.  If the question is asked, there is usually a diffuse response.  The fact that the test was collected incorrectly, or transported late, or was mislabelled never becomes part of the conversation. 

Many laboratorians and their administrators have loved this because it provides the laboratory with a lot of buffer.  It may put them in a dangerously low profile position, but at least the negatives on budget result in only a slow (and persistent) leak.

But things are about to change.  As mentioned previously, some “commercial” [I prefer the terms “community-based” or to a lesser extent “private”] laboratories can now present results directly to patients.  Already CMS in the US has made rule change proposals to allow or oblige laboratories in the United States to do the same, even when state regulations prohibit.

Sooner of later, the conditions that result in upset public are going to happen.  Wrong result to the wrong patient.  A critical False Positive (a suicide from a false positive HIV).  A critical False negative.  An uninterpretable report.  An inadvertent crosslink between files and passwords.  But this time the patient will receive the result directly.  You know I am right because these things happen all the time today.  There is no reason for them to suddenly stop.  The only difference is that at this point the patient will receive the report directly and get angry. 
No one thinks of angry customers or law suits as good things.  They are not good things.  They are the consequence of poor practices.  They represent inadequate care.  They represent (sometimes) the consequence of persistently shrinking budgets, too few technologists, and too many personnel who are undertrained. 

So I say thank you for engaging the public directly.  I say let’s embrace the risk.  The smart laboratorians will figure this out before hand and mitigate the risk through pre-emptive improvement.  The others will learn the hard way. 

Nobody says that good things can’t arise from the ashes of disaster. 

To my Canadian colleagues, I wish you a Happy Thanksgiving.



  1. At least good comes out of something bad. It would be nicer if we don't need to call class action attorneys, but that's what they're here for.

  2. I agree Bradley, I think of disaster as a way to rebuild and grow bigger.


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