Wednesday, June 18, 2014

Standards People

Standards People

So we have just gone through another very successful conference and Annual General Meeting for the Canadian Standard Association (CSA).  Canada is a very large geography with a very small population, but CSA continues to demonstrate its commitment to being a national (and international) organization by ensuring that the AGM travels across the country, touching every province through its cycle.   

In my short connection with CSA AGMs I have been to 3 different provinces and with the now established plans there will be 5 different provinces over a 6 year period.  

The AGM is an interesting mix of organizational information, standards oriented presentations, and working committees, and a broad array of expert presenters, all put together to bring together a very eclectic group of folks with interest or passion for national and international standardization.  

We standards people are indeed an interesting lot, who all approach the field from our own perspectives.  There are some who are truly entrepreneurs with a commodity perspective, some seeing income generating consultant opportunities.  There are some who focus on the production of standards with a purist point of view; create good standards for the sake of making good standards, while there are others, who are passionately involved in their work sector and approach documents as a way of improving service to their own field of interest.  Then there are the regulator types who like rules creation; they are balanced by the educator types who are mostly interested in standards mostly as valuable opportunities for research and outreach through academia.  And then there are the “just curious” and the the rest who just like being there for the sake of being there and having a good time.  Motives for attendance and participation are wide and varied, but it seems to me that there is something for everyone and solid reasons for being there.  

As for me, I see my motivation as being a combination of many of the above.  I am certainly committed to healthcare and see one of my roles as a Quality leader and educator and standard developer, and am not ashamed of finding opportunities to intermittently promote my knowledge as a consultant and public speaker.   but I can honestly say that I am also at these meetings because I get to meet interesting folks and have a good time.  

This range of views attitudes is actually very important for standards development.  If we were all of one point of view, the standards that get written would likely become very narrow, and very difficult to use.  Without diversity of opinion, there is little need to seek out consensus.  

I personally do not see standards as black-or-white precision documents; you might say I have a more nuanced, shades-of-grey perspective.  In most cases, at least in my area of interest, standards need to include a significant sense of flexibility that is, within a certain range, open to interpretation.  If they are going to be available on tablets, they have to be of the electronic kind and not Mount Sinai stone.  

But I also recognize that if all standard people approached documents my way, the products would be too fluffy to be of value.  On the other side, the precision-driver-obsessive-compulsive-kill every-loop-hole folks without my counterbalance would create tomes that best belong in tombs.  

So this is my point, folks interested in being engaged in standards are always enhanced by attending conferences with people with the broad range of views.  We get the opportunity to express our point of view and at the same time experience tempering through competing ideas. 

Working on standards in isolation of diversity of opinion makes for bad standards.  

Three cheers for AGMs

To learn more about Standards Development, visit and consider joining our Certificate Course in Laboratory Quality Management.

Saturday, June 7, 2014

Taking Charge - Taking Responsibility

Recently I had the opportunity to talk to members a clinical division within our university’s department of Internal Medicine.  It was an invitation of long standing.  I am not sure how well it went.  While the group was certainly polite, I was personally having difficulty in sorting through some important strategic differences in the structure of our two groups.  In the clinical divisions, the physician group have management responsibility that covers the group of clinicians and the house staff whom they train.  The nursing staff, and all other allied professionals that work with them are independent of that group; they are hired by the hospital and their lines of authority are very separate.  The clinical group has some opportunities for influences of request, advice, and perhaps persuasive professional authority, but when push comes to shove the authority to do much is pretty limited. 
On the other hand, medical laboratorians are hired to be managers or co-managers of certain defined sections of the laboratory.   The laboratorian has a much more direct influence on the quality of the work performed in and around the laboratory.  In a Feigenbaum-like sense, medical laboratorians constitute that group that bears the 80 percent of responsibility for Quality. 
To express the differences from another direction, Quality from a laboratorian perspective is based on a completed total testing cycle where laboratory tests require correct decisions and actions throughout each and every step of the whole testing cycle to ensure correct and valid results and it is the role of the medical laboratorian managers to ensure this improbable series of events actually occurs.
One question asked was if Quality management can truly save money.  There is from the laboratory perspective, and from the ISO9001 perspective, lots of evidence that quality systems can reduce failure costs, reduce repetition costs, and reduce process costs through continual improvements, especially through the application of lean measures.  But the answer in clinical medicine and in health care in total is probably more difficult to measure. 
But that is why the concept of TEEM costs and Extended costs is so very important.  Through TEEM we take into consideration Time loss, Effort and Energy (stress and strain) as well as finances (money).  In the laboratory we are historically poor at following failure costs, mainly because we don’t budget for failure, don’t include a line listing for failure, and tend to roll up the costs of failure in a variety of places, including repair of equipment, replacement of reagents and supplies, overtime, which together probably represents about half of the true costs of failure. 
Extended costs are rarely taken into consideration, unless there is motivation for a fuller enquiry.  These are the costs borne by the patient(s), the clinical staff, the community and the environment that result from delayed or faulty diagnosis, spread of disease and contamination impacts.  They are the fall-out from contagion is its broadest sense.
The reality is that in clinical medicine, costs of poor quality are rarely borne by the perpetrator (that’s probably not likely to be a popular term) but are much more in the TEEM and extended group. 
In Canada which is fundamentally a litigation –free zone, error costs rarely impact clinical practice. 
One can compare and contrast the physician office with the food service industry.  If a restaurant were to have a quality break that resulted in an outbreak of Staphylococcal food poisoning, once the authorities shut down the place to clean up the kitchen, there is a high likelihood that clients would find another place to eat.  The business would be gone. If a physician office is the nidus of an MRSA cluster, or an influenza outbreak, the place might go through some careful discrete clean-up, but patients may or may not find out the problem, and regardless, they would be back in the waiting room the next day. 
I am not suggesting that physician offices should be closed, but it makes the point that the consequences of less-than-quality behavior are borne by the extended group and not the core. 
What this means is that healthcare qualitologists have to look at quality improvement from a broad aspect.  But the bottom line, from my perspective, is that there is a cost to poor quality, and if a person is going to be put in a position of responsibility, they do need to take charge of ensuring quality of care. 
Responsibility and taking charge; can’t have one without the other.