Monday, March 28, 2016

Cum Minus Facerent Malum

Cum Minus Facerent Malum

It was not our plan, but my wife and I had quite the adventure this weekend.  We set out for a relaxing urban adventure but in the blink of an eye the adventure turned to rushed visits to two Emergency Departments and some emergency surgery.  A few days have passed, but it has given us the opportunity to reflect on what went well and what did not.

First off we do understand that we live in a busy big city and this was a vacation weekend, but taking all that into consideration, this still would not be considered a totally happy experience. 

A little background first.

In Canada, our healthcare story has been quite a ride.  At the beginnings of Canada the crafters of the country’s confederation saw health care as a matter best left to the province.  It was not that big a deal or interest for a national government to get engaged with.  All that changed almost 50 years ago (to the day) in 1966 when the federal government decided that if healthcare was going to be seen as equal sea-to-sea-to-sea, the feds would need to get engaged, and made an absolute commitment to contribute 50 percent of provincial costs.  Public attitudes were mixed, but the politicians of the day knew better and so the path was set.  It was written in stone. 
It took about 10 years to figure out that this was costing a bomb and government of the day decided to erase the stone and renege on payments. The stone was re-written with a new written in stone commitment called the Canada Health Act.   

Ever since the creation of the new Act, the Canadian system has been progressively gutted, less and less federal funds, and the closure of mental health hospitals, and consolidation of health facilities, and continuous reductions of staff.  It has been an experimental Leaning of healthcare on a national scale, without any Keizen.  (If only they had implemented a Poke Yoke – error prevention – program).

All of which brings me to this weekend.  We were sent to one gutted emergency department to find overly busy, swamped folks trying to cope.  The emergency doc, did what he could do and then we were put into a taxi to go to the the other
ER because they were the only ones who had an appropriate surgeon working that day.  

It felt like we were living an episode of M.A.S. H. 

At the other place the mess was infinitely bigger with stressed out staff absent of any vestige of interest or care. After being shuttled around we ended up sitting with a herd of patients in an open corridor without any interest or care or food or medication or even water.  (When I told the staff my wife was in a lot of pain, the nurse on staff to me to get out of her staff room).  This in an institution that proudly pronounces its mission statement “Embed patient-centered practices in the delivery of all care and services.”

After too many hours in the back hall we were finally seen by the appropriate surgeons and had the definitive measures completed. 

So when the smoke cleared, if you use life versus death as the outcome measure, our adventure was a roaring healthcare success; but by any other measure, not so much.  

The number of Opportunities For Improvements were far too many to enumerate, with the exception of the one where the first ER informed the second ER that we were coming but got the name totally wrong, so that when we arrived, no one knew who we were or what was going on.  Of the ones that I will not mention here, two were serious breaches.  Not many, perhaps, but those were the ones that I observed in one afternoon on one day, and I wasn't seeking them out.  

So as much as this sound like a personal grumble, that was not the point.  It is to make the point that for the last 50 years politicians and consultants have made step after step, to get healthcare under control and they have failed miserably.  All the major Leaning initiatives have been failures.  The care has not got better, it has got worse. 

As a Quality oriented healthcare person, this gives me serious pause.  What we are seeing is a lot of Doing and Checking and Acting but either with NO Plan or worse a TOXIC Plan. Deming would be shaking his head.

Nobody can be proud of this mess.

Sunday, March 13, 2016

The Quality Value Proposition

The Quality Value Proposition

I have been reading (always dangerous) recently in the Patient Safety arena about a concept  sometimes called the Quality Value Proposition.  It proposes that one can take the ethereal construct of  Quality and divide it by the tangible construct of Cost, and thereby determine the Value of Quality.  

(In mathematical terms it would be Q/C=V). 

The argument is that if the goal to be achieved is Quality of effective and high value, it is achieved first with the least cost, i.e.achieving more Quality per dollar or best bang for the buck.  Alternatively if costs are not reducible, then the Quality has to be of a higher grade to achieve a better value.


This scores higher than most in the contest for the most inane concept presented anywhere.  That it gets published and repeated talks more to the challenges of some of our great thinkers.  Shame on them.

So let’s take this apart.  

There are multiple views of what is Quality.  I refer you to the Quality classic Zen and the Art of Motorcycle Maintenance by Robert Persig.  If you didn’t read it when you were young in the 70’s you were either too young in the 70s or were just not cool.  

Quality as an intangible, a sense of being more perfect or more satisfying.  A Cadillac versus a Ford, A Harley Davidson versus everything else.  Or you can think of Quality in a Crosbian “meeting customer requirements”  or achieving customer satisfaction.  In any case it is still an intangible, and both a real and ethereal wisp.   You might want to quantify Quality by saying approaching or achieving error free, but it would be still difficult to put a number on it.  (Indeed accreditation bodies may pronounce an organization as having achieved 98% Quality.)  The point is that Quality is an achievable state, but is not a substance to be divided.

Cost I understand.  Cost of Quality – Cost of Poor Quality – Costs of Error reduction.  These are all real numbers and numbers in depth.  You can calculate them almost to the penny, provided that you can put a specific amount to stress and strain, two critical outcomes of error.  

I think that calculating true costs by looking in depth not only at the costs of prevention and appraisal, but also internal and external failures is a valuable exercise.  Something that everyone can do at some point and with certain projects to really appreciate how much money is lost on error. 

But most organizations don’t do that.  What they do is look at prevention costs and appraisal costs and then decide that they are spending too much on Quality Control and Quality Assessment and Continuing Education and then announce with regret that these are unaffordable costs that have to go.

Calculating Quality Value turns into a Lean Reductive strategy.  If I cut out 25 steps and use my reagents twice, then I have saved money and my costs go down, so now I am achieving the same "Quality" but with less expenditure.  This must make my Quality more efficient and therefore of higher value.   (Just in case you are reading this and this this makes sense, I will tell you  this is all about sarcasm.) 

What they don’t realize, because they probably choose to not look, is that when Quality Prevention and Appraisal activities and costs go down, Quality much sooner than soon will start to deteriorate.  More errors will inevitably occur.  

You have not made Quality better…. You have made Quality worse. 

So I understand how people all want to be like Einstein and create a simple formula that explains everything.  But this Quality Value Proposition is not it, and will never be it.  

As the cop on the beat says when there is a big splat in the middle of the road..   "Move on folks, Nothing to see here".  

This is a bad idea that has had more than its share of 15 minutes.   

Time to shut this sucker down.

Sunday, March 6, 2016

Another look at costing Quality-2016

So we have been talking about Costs of Quality in our course this past two weeks.  This has been a long time topic of interest in medical laboratories.  Most literature about Costs of Quality, while being informative, has been pretty generic, and a challenge to apply to the medical laboratory.  The most recent document by CLSI “QMS20-R: Understanding the Cost of Quality in the Laboratory; A Report”, now about 2 years old does a pretty good job.  After reviewing if for a year along with some other choices, we decided to add it to our course bibliography this year, which means we provide on-line access to it (with the assistance of CLSI) for the course participants.  


QMS20_R is pretty faithful to Juran, which is both good and bad; good because it provides some insights into how the traditional model can be translated into medical laboratory language.  Where it lets down is that it is limited only to direct laboratory costs, which is really only part of the picture.


For example, in the community based out-patient setting, when a wrong thing happens and a patient has to be recalled, the direct costs include the time to call the patient, the time to draw the sample, the associated reagents and supplies, and the IT costs to create an amended report.  


But in the modern western world,  all that represents perhaps as low as 30 percent of the total costs because it does not include those costs borne by the patient including their time, and potentially work losses, and travel costs to the laboratory.  While all this may seem to be pretty inexpensive for an able, mobile retired person who lives within a short walk or easy bus ride to the laboratory, the costs are a lot higher when a person has to take off work, and drive down to the laboratory or take a cab.  (In my city, the hospitals charge $3.50 per half hour for parking! With even a normal wait and processing that’s about 45 minutes and at least $7.00 just for parking, and can get to $10-15 in a real hurry.)  And what happens if the person is a parent taking care of a child at home who has to find a sitter.  All these costs are borne by the patient and family.  Without trying too hard, this can accumulate to over $200 very quickly.  The laboratory may have to pay the costs of the repeat test, so they cannot bill for the actual testing, but imagine if the patient also submitted a bill for their out-of-pocket costs. 


IF the average out-of-pocket expenses were closer to $25 per event, a large laboratory would be responsible for about $27,000 worth of patient-borne expenses a year.  And that is a lot more than the laboratory would save by cutting back Quality Control by 50 percent or cutting out all proficiency testing.

And supposing the physician seeing the first result, and believes it to be true, and arranges for more tests, or a consultation or a procedure.  Fine if the person has full insurance coverage (not really) but again there are more out-of-pocket expenses that don’t get counted, unless this all leads to litigation.


And QMS20_R doesn’t take into account its own in-house expenses associated with stress or strain (mild injury) that can be associated with error.  Staff related stress and strain are compounding factors that can (and often do) lead to more errors and more costs.


So the document is a good step in the right direction, but continues to leave hidden uncounted costs.


But why raise these external costs if no one is asking or demanding the laboratory to cover them.  Those are costs that fall under the category “not my problem”.  But they are the laboratory’s problem if they don’t trigger a problem solving solution as opposed to a cost-cutting solution, like reducing QC or Quality Assessment.   That may save money but it only makes the problem worse, and the costs never go away.  


And this is why the Juran approach will never be completely appropriate for the medical laboratory setting.  The Juran model works in industry and services where at a certain point customer intolerance for poor service kicks in and the customer goes away, and the business leans or fails.  


In our insurance leveraged healthcare industry, left to our own devices, medical laboratories can live in the blissful zone of indifference.  The death knell to Quality is having an endless supply of new patients, with no obvious consequence for bad behaviour and not apparent benefit for good.  


More on this later.