Monday, December 1, 2014

Competition and the Quality Partner dynamic

In 2011 I introduced into our Certificate Course the concept of medical laboratory Quality Partners to remind the participants that the laboratory is never alone when it comes to developing an shaping a quality managed laboratory.  [see ].  I created a definition for these Quality Partners as the network of organizations that develop and promote and provide services and assistance with the goal of supporting an effective laboratory foundation that is conducive of better patient safety and care.  The network includes Accreditation Bodies, Proficiency Testing Schemes, Education Providers, Professional Organizations, Materials Suppliers (including equipment and reagent bodies), and Standards Development Organizations.  These bodies surround the laboratory and provide documents and guidance and education, and assessment and support.  Taken as friends, these groups can help defray (mitigate) most of the risk of error that laboratorians bear when providing essential information that has direct impact on patient care and patient safety.  

But about a year or so later, I realized that I had left out an essential quality driver… the Public and its representatives including the media, the regulators, and the legislators.  As we have seen throughout many developed country, when the public experiences what it perceives as a loss of trust in the health system, change will inevitably result.  In the United States, that loss of trust resulted in CLIA.  In Canada it lead to a series of public enquiries including the Krever Commission and the Cameron Commission, both of which forced dramatic change.  We may not like the results of all the media attention and consequent change, but an angry public will always have its way.  

This lead to a revision of the Quality Partner graphic which indicates the light of public scrutiny exposing the potential warts and blemishes of laboratory error.
But recently I have realized that there is another driver that has great impact on Quality.  Competition.  I have written about this before.  Unfortunately we have lots of examples that indicate that when an organization has an endless supply of customers, with essentially no threat or consequence to counteract indifferent behavior, then performance may sink to the lowest level.  

I have mentioned before, the performance of some (but not all) public servants and other organizations.  When left to their own devices, it seems to become all to easy to stop meeting the Crosbyan and ISO definition of Quality. i.e. Meeting Requirements.  

Over the last while I have been on the road a lot, putting in a lot of air travel.  In the last few weeks I have spent well over 50 hours sitting in economy section seating, as airplanes have flown nearly 30,000 miles.

Now I understand that airlines are all now public corporations, with their primary responsibility being to generate profit and benefit to their shareholders.  And I also understand that running an airline is a risky and costly venture.  There is an old adage that says, the easiest way to become a millionaire is to start as a billionaire who runs an airline.  The reality is that while some airlines at the moment are experiencing a rise in stock value, this is not likely to be a permanent state of affairs.  Sooner or later, most airline companies will lose their value and their investors will lose their money.  

But as anyone who flies knows and understands, with the exception of the few business section travellers, customers are stuffed into seats too close together with little leg room.  Meals are either available only for purchase or if provided are of questionable quality and literally tossed.  There are insufficient toilets and insufficient cabin staff, insufficient luggage storage space and insufficient walking or exercise space.  

Don’t like it? Then you have two choices, either pony-up thousands of dollars or don’t travel.  Change to another airlines?  No difference.  They have you.  There is no tangible competition because they all work the very same way.  

But if you want to think of contrasting services in the travel industry, think about hotels and restaurants.  Those owners know and understand you can spend your travel dollars anywhere you want, and the place with the most comfortable bed or the best food wins, regardless of which price point you look at.  

So where there is competition the customer requirements are met, and where there is none, the customer has little choice but to tolerate the absence of meeting those needs or requirements.  

And so I have again revised the Quality Partner graphic.

And so here is my question to medical laboratory management.  We are a service industry, with by-and-large little competition.  We can, if we choose, ignore patients’ complaints and concerns with relative impunity.  

Which model do we want to follow, the airline or the restaurant/hotel? 
The choice is ours.


  1. Thanks very much for another thought-provoking post. Your concept of quality partners is interesting and bears some similarity to ISO 9001:2015's new requirement to understand the needs and expectations of interested parties (clause 4.2).

    With a greater emphasis on enabling integration in the new revisions of ISO 9001 and 14001 and in the new ISO 45001 standard, might we see the concept of interested parties or quality partners in the next revision of ISO 15189?

  2. Many thanks for the comment. I will mention parenthetically that my concept of Quality Partners arose from a meeting that I attended 5-6 years ago, when a pathologist mentioned that he alone was responsible for the level of Quality in his laboratory, to which I responded that in fact he was surrounded by organizations whose sole task and responsibility were to support laboratories in their efforts to focus on Quality and improvement. The details have followed and have been progressively modified.

    With respect to 15189, I have raised this concept several times, but it has never made it into any of the published versions, even in the preamble. For those in Canada who purchased the CSA ISO15189:2007 Plus guidance text, the point was raised there. And of course it is a central concept in our Certificate Course.

    It is soon 2015, and in theory work on the next version of 15189 will need to start relatively soon (maybe 2016?).
    But ISO Central Secretariat does NOT view 15189 as a quality management document in the same way as it views 9001 or 14001. Rather it is their expressed view that it is a derivative of ISO17025 with a sole purpose of conformity assessment or accreditation, which is unfortunate on a whole series of levels, not the least of which is that medical laboratories are not now and not likely ever to be conformity assessment bodies. There are no documented "Standard Methods" texts that define how medical laboratories function.
    I will write more on this later.

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