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.

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