Saturday, September 28, 2013

The Better Way to Move Quality Forward

There are two ways that we can introduce Quality to medical laboratories in resource limited countries; one is to sell them accreditation and proficiency testing services from large international organizations, and the other is to help them develop their own programs.  

Canada is a good model to look at.  In the 1960s many Canadian laboratories recognized the value of accreditation and proficiency testing, but had no programs, so they did what made sense; they purchased the services from the United States and the United Kingdom.  After barely 10 years the province of Ontario began to realize that in the long run they were far better developing their own programs.  Ontario was joined by Quebec and then Manitoba and Saskatchewan and Alberta and British Columbia, each developing a local authority with the capability of taking care of their own Quality needs.  If they shared another provinces program they did so knowing they had a seat at the discussion and decision table.   Over time a community of accreditation bodies and a community of proficiency testing programs developed that served the needs of Canadian laboratories in a typical Canadian style, progressive and innovative and with participant involvement.  Today the Canadian programs are arguably among the best in the world, no longer needing outside programs.  In 50 years we moved from nothing to being world leaders.  

Countries that buy programs from other countries make a big mistake and here is why.
1:       Countries that sell their program do it primarily to generate revenue.  Let me be clear, I may be a Canadian but I am not a socialist.  I have no problems with the concept of generating revenue.  What I do have a problem with is a country making samples that are designed for wealthy country sophisticated laboratories and then multiplying them multi-fold and selling them to laboratories that are working with (by our standards) archaic equipment and in basic beyond basic environments.  The samples are designed to address very sophisticated issues which are not remotely close to the issues in these new laboratories.  They are samples that have no clinical relevancy to those laboratories.  If proficiency testing is not clinically relevant then it is a total waste of time.

2:       In order to make samples made by the thousands to survive in extended travel they have to be freeze dried (lyophilized) turning them all into basically white crystal powder that requires reconstitution when they get to the destination.  Freeze drying may be OK for instant coffee, but it certainly is not appropriate for simulated medical laboratory samples.  They don’t look right and they don’t act right.  If they don’t look right or act right then they don’t meet any international standard for proficiency testing, and more to the point they don’t serve as any form of competent measure of laboratory Quality.  They are a waste of time effort and money.

So we are part of a process to do it better.  Rather than sell countries our samples, we train them how to make their own.  When they join us for the training program (and yes we do charge for the training program) we point out the tools on how to sort out what kinds of clinically relevant samples they need for the laboratories in their own country, and then provide the tools to make samples that are as simple or as basic as they need.    We train them to make samples that will survive transport in their own country without freeze drying.  We train them on making their samples value added to ensure they meet the continuing education and continual improvement needs the laboratories have in order to meet Quality and accreditation goals.  We provide them with the opportunity for follow up, to get back to us with questions and challenges.  We provide them with the opportunity to take their expertise and share it with their neighbours.  

With luck and perseverance, they will be able to create a network of Quality Partners that took us 50 years by trial and error, perhaps in 25 years.  

This is a win-win-win-win.  We win because we generate revenue and help countries.  The countries win because they learn to tools to develop new and better programs that meet the needs of their country.  The laboratories win because they have access to systems that can have a positive impact on their testing processes.  And the patients win because their sample results are better Quality assured.  

To date we have helped 8 countries.  We have 3 more countries booked for later this year.

Thursday, September 19, 2013

Laboratory Proficiency: Closing the Gap?

Laboratory Proficiency: Closing the Gap?

I have written on the subject of proficiency testing as a measure of laboratory quality before, especially on the consistent reality that large laboratories have consistently and progressively out performed small laboratories for the last decade.  [see: ]. 
In our program this was not always the case, and indeed in the early years, based upon our program structure, all the laboratories performed equally on their category appropriate challenges.
Note:  In our program, we have an approach that works on the premise that large complex university based or similar laboratories often receive complex samples from complex patients, while smaller outpost laboratories do not receive as many complex patients and as a result tend to not see as many complex samples.  Thus we send complex university based laboratories more complex proficiency testing challenges, and send more basic samples to the outpost laboratories. 
Note within the note:  We know this is not always true.  These days people on dialysis or on cancer chemotherapy drugs can live almost everywhere.

Over the last 10 years. In direct correlation with a national drive to reduce laboratory access through closures, we have seen a consistent drop in the quality of laboratory proficiency in all microbiology laboratories except the largest and most complex.  The large laboratories primarily found in large urban centres, and often associated with university teaching hospitals have consistently maintained a proficiency well above 90 percent.  On the other hand, the smaller laboratories have not fared as well, As the size and complexity lowers, so does their proficiency.  This is magnified because we do send them the less complex challenges, and some have considerable difficulty, with a mean proficiency much closer to 70 percent.  We argue that this is not about finding fault, other than of the ministries of health who under-funded and under-supported these laboratories with fewer (or none) opportunities for continual improvement or refresher programs, and reduced their supervision by microbiologists to a near non-existent level.  Given the choice between supporting these laboratories or killing them off, the ministries have strongly moved to the latter. 
This may be effective use of resources, but the physicians and patients who live in these areas have not been getting much of a fair shake. 
But this year, it appears that something has changed; for reasons unclear there has been a substantial improvement in the proficiency testing scores of the smallest laboratories. I am not sure why.
I know it is not an arithmetic error.  I know it is not a knowing shift in the degree of difficulty in the challenges. 
It may be a geographic shift in the sense that the number of C1 laboratories has increased and that most of the laboratories are in one province, and many of them are laboratories recently downgraded by their province.  Maybe more of these laboratories have a higher level of local support 

At the moment I cannot say if the improvement is a transient bleep or a heralding of better laboratory performance yet to come.
Only time will tell.
Fingers crossed.


Wednesday, September 11, 2013

World Standards Day 2013

I have written on World Standards Day (WSD) before, first in 2011 [see: ] and again in 2012 [see: ].  And as I settle in to write again on WSD in 2013, on a personal level I can say now THIS is a BIG DEAL.

What I knew at the beginning was that the international community has recognized WSD for over 40 years, going back to 1970.  WSD was fixed to October 14th because it was the anniversary of the meeting in London to develop an organization committed to international standards.  By coincidence, October 14th also W. Edwards Deming’s birthday in 1900, so it is a particularly poignant  day to look at Quality and Standards together.

What I have learned over the last couple years is that Canada has acknowledged WSD for many years, not exactly as a national holiday, but as a day worth marking.  Usually Standards Council of Canada (SCC) has held an event in Ottawa, which had relevance, but maybe not too much resonance.

In 2012 due to some incredible luck and timing, we were able to create a new opportunity and a new event.  SCC had already been ruminating about taking the WSD event on a road trip to increase awareness and outreach when I opportuned by planning a Quality meeting in Vancouver.  The mutual benefits were too obvious to ignore, and in October 2013, SCC is holding its national celebration of WSD in Vancouver, in conjunction with our Quality Conference for Medical Laboratories.  

How good is that!

As it turns out Monday October 14th is Canada’s Thanksgiving Day holiday and part of a long week-end, so our two meetings will begin on Wednesday October 16th, 2013,  giving folks a day to eat far too much turkey and then another day to travel and recover.  

The two events have coordinated themes that focus around standards, both international and domestic, that impact on healthcare and Quality.  We will share the same conference room in the same hotel in beautiful downtown Vancouver BC (Marriott Renaissance)  and have some common audience.  We will share some speakers and social activities.  I know that many of the folks planning to come to the Quality Conference will come early to participate.  I am hoping that the same will happen in reverse, that some coming for WSD will stay and participate in the conference.  Time will tell.

The audience of the Quality Conference is already international in nature.  In addition to folks from across Canada, people attending will be from the US, Australia, Oman and Saudi Arabia. I suspect, perhaps unfairly, few if any have ever heard of WSD.  (With my own personal bias strongly in hand, if any group is aware, it will be the Australians.) At the same time I suspect that the collective group will be very interested in participating in our Canadian WSD.  Who knows, some of them may go back to their respective countries and encourage their standards boards to become more visibly engaged in their own WSD events.

So October 16, 17, 18, 2013 are going to be very busy days for Canadian Quality.   The action is in Vancouver, but the spirit is national and international.  

I am really happy to be fully engaged.

To register for the Standards Council of Canada World Standards Day event go to:  [ ].

To register for the POLQM Quality Conference for Medical Laboratories, go to: [ ]

See you in Vancouver.

Monday, September 9, 2013

The Quality Carry-over

The Quality Carry-over

Others have written on this topic, and I have alluded to it previously as well.  Quality is an interesting arena in which one can work because once you have bought into the philosophy it tends to spill over into other work and non-work areas of your life.
You might say that other professions do this as well.  Physicians and nurses often find hobbies related to health information, such as becoming health historians or health artists, or becoming health information apps developers.  Chefs often become sophisticated foodies, searching out the perfect tomato or traveling to the out most regions to savour the perfect dumpling.  Metal workers become sculptors.  Profession becomes hobby.

But Quality is different.  True, Qualitologists often find themselves creating their own personal OFI lists, and finding ways to maintain personal records and receipts in a way that would paralyze a “normal person”.  Quality Carry-over goes beyond that because the qualitologist starts seeing the “flaws” in the world around them and then starts to try to do something about them.  This is not profession becoming hobby; it is profession become obsession. 

An example.  Over the last while I have had some health issues that have required me to stop being a physician and start becoming a patient.    And that is rarely a good thing because as a general rule we are not very compliant patients.  We suffer from “I know better”.

But there are some areas in which we do know better.  Over a short hospitalization I was seen by 3 medical specialists and probably 8 nurses and 5 technologists.  All of them had tests to record and reports to write, so that you would imagine that there would be a lot of information generated.  But when I visited the out patient clinic, none of the records or reports (NONE) was available.  In addition, none of the information was conveyed to my family doctor (NONE !) even though I was informed that he would be responsible for my follow-up.  My prescription was written by one physician who informed me that I should go to my family physician for refills which I would take for an extended period, but no one told him was I was supposed to be taking.  And finally while in the clinic I found that there is another fellow with my same first name but with different last name, different age, different birthday, and they still managed to get the two of us and our records mixed up.  Worst off, his wife and my wife happen to be good friends, so the issues started to become a breach of personal confidentiality.

I suspect that many people would be miffed, and some would probably get angry.  In some countries, not Canada, we might even be getting close to the law-suit level of discontent.  But I didn't go there.  Instead, I wrote a memo to the person that I perceived as the one most likely to “get it”.  I understand that this is the system in which she normally works and probably sees  as problematic but normal and don’t see any way around it. 

I mentioned that as a healthcare savvy person I was going to be able to manoeuvre through this mess, even if it meant writing my own prescriptions and refills.  But for many of their patients this would be chaos, and the risk of a bad event would be substantial.  I suspect they happen all the time, but they just get lost and missed in the shuffle.

I mentioned to her about occurrence awareness and management, and how to organize an Opportunities for Improvement (OFI) list, and offered my assistance in helping their group develop a strategy and goals for quality improvement.

To date there is no answer.  I will wait a while and re-contact her.  If that doesn't work, I can always kick it upstairs until I get a response.

Saturday, September 7, 2013

Education Opportunities in Quality Management 2014

Education Opportunities in Quality Management - 2014

Adults learn in a variety of ways; some learn by individual reading from books or the internet, while others benefit from the shared experience of faculty and peer participation.  When it comes to learning about Medical Laboratory Quality Management there is always choice.

The UBC Certificate Course in Laboratory Quality Management provides a 21-week structured on-line virtual small group classroom experience with interested peers and committed faculty.  The course provides comprehensive learning with textbooks, international standards, structured presentations, discussion, assignments, quizzes, comprehensive examination. 

The course is intended for people with ongoing work experience associated with the medical (or veterinary) laboratory.

The course provides a broad curriculum that includes:
  • ·        Standards and Quality Management
  • ·        Regulatory Framework for Medical Laboratories including Safety and Risk Management
  • ·        Costs of Poor Quality
  • ·        Modern Tools for a Culture of Quality
  • ·        Root Cause Analysis
  • ·        Introduction to Lean and Six Sigma
  • ·        Monitoring Quality

Ninety percent of participants consistently rate the course as Very Good or Excellent

POLQM is now accepting applications for January 2014.

For additional information visit

Tuesday, September 3, 2013

Doing it Right or Doing it Wrong?

Doing it Right

Recently I was reading the recent (August 2013) edition of ASQ’s Quality Progress and came across an opinion article by Bob Kennedy who jumped into the fray between W. Edwards Deming and Philip Crosby and said that in his opinion that Crosby’s first essential, Do it Right the First Time (DIRFT) was wrong on every level.  The foundation of his argument was that Deming proscribed against slogans and therefore Crosby and DIRFT was wrong.

 I have to say that Crosby was NOT wrong, and that DIRFT was NOT wrong.  I am not sure that Deming’s concerns about sloganism was meant to include concepts like DIRFT, but if they were, then in all due respect, in this circumstance, I would have to side with Crosby.  Even a pioneering genius like Deming could not always be correct all the time. 
When is comes to concepts like DIRFT, Crosby was spot on, and Deming should have acknowledged it.

First off, let me put some context around my opinion.  I understand Deming’s point of view.  There are some slogans that I think are unhelpful.  “There is no such thing as an Accident” .  “Accidents poison to our organization”.  “Time is money – time loss kills growth and progress”.  These are not slogans, they are less than idle threats that lead people to hide slips and simple mistakes.  There is little place for threats in the workplace.
But DIRFT is not a threat, and indeed makes sense.  Given the alternative I would hope that a neurosurgeon makes triplely sure he does it right the first time.  And by the same token, the same goes for the airplane pilot.  Even the woodworker says, “Measure twice and cut once”. 

DIRFT is in fact a reiteration of a concept that Deming was so proud to adopt, even if he did not state it, “PLAN DO CHECK ACT”.  (For the origins of PDCA see Deming did not create PDCA.  [ ] .

What DIRFT was intended to mean was before you do something, make sure that you have organized your thoughts before you put a plan into action.  It is the essential corollary to PDCA.  Think before you do

In the medical laboratory we have tons of examples where things don’t work that way.  Tests get implemented without proper validation.  Tests are done and reported before checking the Quality Control results.  Reports are sent to the wrong person before confirming who was truly was the intended receiver.  These happen all the time and in every instance they result in external failures with potential false reports, misleading information, loss of confidentiality and huge cost of poor quality.  And most of them were pointless and preventable. 

A few seconds or at most minutes of thought and planning could prevent most of these problems, and save the laboratory from embarrassment or potential liability, and save the patients from inconvenience or harm.

Perhaps in Deming’s time, folks were very aware and sensitive to threats in the form of slogans.  Labor protections, either under the umbrella union protection or workplace legislation either did not exist, or were in their infancy.

That is not the world in which we live today.  Today we live with 40 character headlines and 140 character tweets, and thirty second commercials.  We live in a slogan society, and we by-and-large put them into a more current context.  We may see slogans as jargon and trite or sophomoric, but we don’t see them as threats.

Personally I see DIRFT as rather aspirational.  I fatigue of avoidable errors, or repeated mistakes.  I embrace the notion that doing things RIGHT is better than doing things WRONG, and believe that many errors result from automaton-like behaviour.  I absolutely support “Plan before you do; Prevent the avoidable error”  and even more importantly, “Learn from mistakes; support continual improvement”.

So to Bob Kennedy I think with respect it is OK to relax on the absolute adherence to Deming’s word.  It is time to embrace context and circumstance, and to acknowledge that it is also possible to acknowledge that both Deming and Crosby were giant contributors to our current concepts of Quality.