Laboratory Quality: words or rhetoric?

Laboratory Quality: words or rhetoric?

This month the Infectious Diseases Society of America published a new article (A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2013 Recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)) in the journal Clinical Infectious Diseases. It is an impressive document and for those interested in laboratory medicine, and clinical microbiology and laboratory diagnosis to assist infectious diseases, it is an impressive document.  It is about 100 pages long and includes 250 references, so it would be fair to call it comprehensive. 

It was an impressive task to compile all this information and put it together in a single comprehensive manuscript.  The authors should be congratulated. 

Unfortunately, despite all these positives and kudos, it not only misses the bull’s eye, in my opinion it by-and-large misses the whole target. 

The shame of the matter, is that the authors are all very well know and well respected microbiologists in the clinical laboratory community; and they know what the target is, or at least should be.  They say right up front “Physicians need confidence that the results provided by the microbiology laboratory are accurate, significant, and clinically relevant. Anything less is below the community standard of care.” And they are bang-on.  I agree entirely. 

So what is their plan to ensure that laboratory results meet those criteria; their answer is that “all microbiology specimens be properly selected, collected, and transported to optimize analysis and interpretation.”  The problem is that this is just far enough off to be misleading and misguided. 

Don’t get me wrong, I think that collection and transport of clinical samples is important, indeed very important.  And if you want a document to help with clinical sample collection and transport, you can consider this manuscript, or better, look at the Canadian Standards Association document “Z316.7-12 - Primary sample collection facilities and medical laboratories - Patient safety and quality of care - Requirements for collecting, transporting, and storing samples”, which I think is eminently readable and applicable. 

Where we diverge from the value of the IDSA article, is that even if the sample is collected and transported properly, that does not ensure that it will be processed properly or accurately, or that the results reported in the clinical report will be significant or  clinically relevant.

While it is true that many, indeed most REPORTED laboratory errors are derived from the pre-examination phase and it is also true that testing accuracy and significance are affected by specimen quality, it is also true that testing, interpretation are influenced largely by laboratorian practice and competency as is the ability to generate a clinically relevant report.  We know that from data generated from our proficiency testing program over the last 10 years. 

In the table below, you can see performance of advanced laboratories (Blue), intermediate (Red), small (Silver) and very small (Green).  

Creating a manuscript that says all the problems are caused by improper collection and transport is an easy out.  “It’s not my problem, it’s not my fault.  Those guys who collected the sample did it wrong.”  “And if they don’t understand my report structure or my report content or my report jargon, that’s their fault too. “  “The problem isn’t me.  I know what I’m doing.  It’s all those other guys (i.e. you!) who are the problem.” “Trust me, trust me.” 

It speaks to the mindset of the authors when the word “Accreditation” is found in a 100 page (about 10,000 word) document only once, and this is in a footnote.  The word “proficiency” is similarly found only once, and not in the context of proficiency testing.  And the word “competency” is not found at all, nor is the phrase “quality management”. 

If clinicians are going to have the confidence that laboratory results are accurate, clinically relevant, and significant we need to be able to document in a public fashion that we laboratorians take these issues seriously and that we undertake the necessary steps to ensure through qualified external assessment that our leadership and sample management and competence and knowledge and proficiency are active and intact.   

PS: The October in Vancouver Conference for Medical Laboratory Quality is coming along nicely.  Hotel space is filling up well.  I suspect we will have more registrations than rooms at the convention rate.

For additional information see:  http://polqm.ca/conference_2013/conference_2013/conference_home.html

Quality Partners - Gap Analysis versus Gap Repair

The other day I received an email from a friend with whom I have worked in past on implementing quality practices.  He wrote in part:

A lot has changed at “the laboratory” and the staff in the lab need more than just documentation.   All through the mentorships, they seem to have been playing for time and now that I am here with them daily, they have realized that they have to try hard to change their behaviours and work more towards living quality and not just trying to write, read and sign SOPs.  It is amazing, some of the things I have found within one month of stay here. You will not believe that they have been participating in EQAs for the past five years but have never ever reviewed any of their returns for UNACCEPTABLE RESULTS.

In many countries including North America and Europe and Australia and New Zealand laboratories are required to participate in an accreditation program which provides some oversight to ensure that laboratories are doing what they are supposed to do to maintain some level of quality and competence. In other countries, national accreditation is available, but not required.  Laboratories that see a quality or business advantage participate on a voluntary basis.  In other countries there is no national accreditation, but laboratories can seek an international accreditation, from my experience mainly from United States or Australia or South Africa.  Generally the experience seems to be that laboratories with resources or connections seek accreditation, while the others do not. 

The accreditation process is not perfect.  It can generate many unintended consequences, most notably the tendency to brief moments of activity surrounding an impending visit followed by long sleep.  The other is the tendency to game (cheat) at quality control and quality assessment. 

But as the letter above so clearly demonstrates the absence of accreditation and the assumption of voluntary commitment does not work either.  The letter indicates some pretty concerning messages.  The laboratory has demonstrated to itself and to the PT provider that it can perform incompetent testing.  The laboratory has demonstrated the same fact over and over for (according to my colleague) for 5 years.  And it appears that the laboratory does nothing about it. It seems that putting out incorrect results is not a problem.  It seems that failure to support patient care is acceptable practice.  

Somewhere in the education and training and knowledge of the laboratorians at the laboratory there has been a key breakdown.  The point of the exercise is not to look for errors or opportunities to improve.  The point is to do something about it.

To be fair this is not the only laboratory that misses the point and continues with a pattern of failure.  It happens every where.  And you can see how it happens.  The whole chain from top to bottom is broken.  The reality is that in many places NOBODY cares… not the Ministry of Health, not the Hospital Superintendent and not  the Clinical staff and not the Laboratory administration. 

Personally I put the greatest blame on the laboratory directors.  It is probable or at least possible that no one in the ministry or the hospital or the clinicians have any idea about right results and wrong results or about proficiency testing as a quality indicator.  They have other things on their respective plates.  But the directors should at least be sufficiently knowledgeable about laboratory work to know when their laboratory is giving out wrong results.  

Actually in my experience the one group that does do something to address the problem is the group of clinicians.  They simply stop sending specimens.  What is the point.  They know from their own experience to not trust the results anyways.

Finding solutions can be a challenge.  The PT provider most likely is aware of who is failing and who is not.  Start off with an email or a phone call and find out what is happening or perhaps if anything is happening.  And see if some assistance can be provided within the finances and scopes of the organization and the laboratory. 

If there is no interest to work toward solutions, then the only reason that the PT provider can justify continuing to provide the service is strictly for the money. 

And that is immoral. 

At least that is my opinion.  

Ariely and Astion - bringing meaning back to the laboratory worker

I am reading “The Upside of Irrationality” by Dan Ariely (2010.  HarperCollins Publishers) and came upon a chapter that struck a chord.  It was one of those very satisfying moments. 

Ariely is a psychologist and behaviour economist; one of those guys who works in experimental design to address basic issues in behaviour.  In this one study he was interested in what motivates people to work diligently. 

The experiments involves asking folks to build some complex characters using the toy building blocks Legos or playing word games on paper.   The study design is essentially giving money for completing the task (either building something or completing the word game) giving more money for completing, but giving but progressively less money each time it is repeated.  The variable is whether the person sees some additional recognition.  In one scenario, the person’s building or word game is saved with they name, in another their work goes into a pile, and in the third, their work is shredded immediately. 

Turns out that folks will repeat the task multiple times, even though they are making relatively less money as they continue if they see the characters are connected to them by name or by preservation.  When their output is ignored destroyed, they do less repetitions, and follow the procedure with less accuracy.   People work more and more accurately when their work is not ignored or dismantled.  People work better when their work has meaning.   

When we put it that way, there is no surprise here.  But this begs the question about working in a modern medical laboratory.  One person receives a requisition and enters data into a computer, over and over.  Another takes the sample, now identified by a bar code and puts it into a tube or cuvette over and over.  Another pushes a button on a machine that makes the machine test the sample.  And another transcribes the machine result into report.  If workers name is collected, it is not for recognition, but rather who to blame when there is a problem.  This is a system that might make Henry Ford or Frederick Taylor happy (2 guys that built assembly lines) but it is tough to find a lot of meaningful recognition in this type of work.

In the microbiology laboratory, the technologist today receives a set of plates that have been incubating overnight, disconnected from the sample, disconnected from the requisition, disconnected from any clinical information.   Total disconnection. 

At our POLQM Quality Weekend Workshop, Mike Astion from Seattle was presenting on human resource issues in the medical laboratory and discussed this very scenario.  He was talking about laboratory workers being disconnected from their work… bored and making mistakes.  We need to connect the technologist back to the real live and living patient.  We need to connect the technologist with a reason for feeling like they are contributing to patient care.  We need to have meetings where the laboratory people actually meet and talk with the patients.  We need to make the laboratory people feel connected and meaningful. 

We need to ensure that laboratorians are clinically relevant.

There are all sorts of ways to make the reconnection.  In one laboratory that I have visited in Tanzania, they have put patient’s pictures on the walls.  Clinical technologist positions send the technologist out to participate in ward rounds.  Clinical-laboratory conferences with patients participating. 

These are all old ideas that were common practice in the 1960’s.  It is time to bring them back.

I love it when information from many sources all comes together.

Science? Hardly!

Most of MMLQR has been committed to the positives.  Where I have been critical I have been more general than specific.  This entry is different.

Western medical care prides itself on being generally science based, so called evidence based.  While there is a role for the so called art of care based on experience and feeling, the strength and power of medical care is predicated on the weight and influence of study and and analysis.  As "scientists" we learn our knowledge from our own study and from reading of studies by others.  This of course is based on the assumption that the material we are reading  is worth reading.

While simplistic, there is commonality between Scientific Method and Deming Quality.  One asks a question, creates an hypothesis, and establishes a method to collect and measure information (PLAN), then one does the measurements (DO) and evaluates the results (STUDY) and draws a conclusion and focuses on the next step of hypothesis (ACT).  You might think that Deming was some sort of scientist.  Having earned a Master's degree (U Colorado) and a PhD (Yale) n mathematics and physics supports that he was certainly inclined in that direction.

Unfortunately, much current (and past) medical information doesn’t bother with either science or quality.  For example, a few days ago I received a copy of a the Journal of Infection and Public Health (Volume 3, Issue 4, 2010) with an article about urinary tract infections in a neonatal intensive care unit.  The methodology of the study was to do a retrospective look at urine culture reports and distinguish infection into 3 categories: definite, possible and contamination, based solely on recovered bacterial count.  This is what we call nonsense.  There is so much wrong with this, it is hard to know where to start.  The data was collected before the hypothesis.  The data was not examined to get rid of confusers like prior antibiotics or other even more important  pre-examination and examination factors that would influence the measurement.  And the interpretations of the information collected were trivial and superficial, at best.  

I am not sure whom I am more annoyed with, the authors who decided to create a crude examination of information based upon test results that were never designed or intended to be the basis of critical examination, or the reviewers that looked at this crap and said that it was sufficiently interesting that it should be published, or the journal publisher who was so obviously desperate for something to print that they printed the article in some vain attempt to give themselves some credibility and sustainability.  That it was a from a Canadian institution in an international journal made it that much more embarrassing.

I have been around this block a long time, and I too have in the past written junk like this so that I could go to a meeting, or get an extra line on my cv.  But all this accomplishes is that it creates noise, and diminishes the quality of reading time.  And, as we are now ensconced in the 21st century, we should be learning from past mistakes, not emulating them.  

So qualitologists have an obligation.  Given a choice between structured cohesive manuscripts and junk, go for the former.  Given a choice between structured cohesive manuscripts and not contributing to literature, go for the latter.
Its kind of like a variation on the old proverb, better to submit nothing for publication and have people think you have nothing constructive to say, than to submit junk and have them know.

m

Lots of progress at www.POLQMWeekendWorkshop.ca

A brilliant Quality seminar.

This is a notice that will  be considerable interest to the microbiology community across Canada and in the US especially the North East, but should have special mega appeal to Medical Laboratory Qualitologists in the same regions. Maybe even bigger.

The clinical microbiology crowd is already aware of the annual Canadian Association for Clinical Microbiology and Infectious Diseases (CACMID) conjoint conference.  This meeting has been an annual event in one form or another since (I think) 1965.  It is the premier Canadian microbiology conference.  The Canadian Association for Medical Microbiologists and the Canadian Infectious Diseases Society (now collectively named AMMI-Canada) holds its meeting conjointly.
This year this conjoint meeting will be in Montreal from April 6-9, 2011 (visit http://www.ammi.ca/annual_conference/index.php)

Every year for the last 16 years we have hosted a Quality Seminar in conjunction with CACMID, usually on the first day (or pre-conference day).  This year it will be a 4-hour seminar on  April 6, 2011 starting at 1:00 PM.  The theme of the conference will be Communicating Quality.

I have to tell you that as good as all the seminars in this series  have been, I am especially proud of this one.

The meeting will have 4 presentations:
Michael Noble - Developing a comprehensive communication strategy for Quality.
Julie Coffey from Quality Management Program - Laboratory Services Ontario will present on on-line education in Quality.
Robert Michel the Editor of the Dark Report and the creator of the Dark Daily will present on developing a comprehensive Quality Communication Information Strategy
Sara Garcha of LifeLabs BC will present on Communications as an integral part of Quality Culture.

This seminar is a must see for anyone charged with developing and promoting a quality system in their own laboratory, or as is happening more and more, a network of laboratory sites.

The session is cheap ($80 Canadian), indeed under valued.
If you are involved in clinical microbiology you probably will come for the pre-conference seminar and stay for the whole meeting.
If you are interested in Quality, but maybe not from a microbiology perspective, I strongly recommend that you consider this meeting, even if it is only half a day.
At best you participate in a brilliant education seminar with knowledgeable excellent speaker-presenters  that will give you ideas that will change your quality practice for years to come.
At worst you attend an excellent meeting and get to have dinner in Montreal. 

It is difficult to see the downside.

You can register for the quality seminar on the CACMID website
https://notes.htgsports.com/HTGM.nsf/Reg?OpenForm&hoteleventid=&ParentUNID=6734DD638B69D28C852577A8004DA067&lang=EN

m

Resolutions 2011

I used to think that New Year’s resolutions were pretty much a waste of time. Most people that I know still do. I vow to be good; I resolve to quit eating; I resolve to quit smoking:   I resolve to get more exercise.  I resolve to stop being sarcastic. Yeah, yeah, and ...yeah.

But over the 5 or 6 years, the concept of resolutions started to make a little more sense. New Year's Resolutions are just a variation on the theme of setting Objectives and Goal.
I mentioned before that CMPT`s quality system has been certified to ISO9001: (2000 - 2008) since 2002. Every year in October we set quality and programmatic goals and objectives and then monitor to ensure that we meet our goals.  When we started we did this so that we would continue to get certified, but after a while we saw the value in the exercise, and did it for us... to keep CMPT on path and on track.  And it seems to actually be effective.

So it started to make sense that if we can do this positively and painlessly for a proficiency testing program, we should be able to do the same thing for the Program Office for Laboratory Quality Management, and for my teaching commitments, and also for the medical laboratory at which I worked as a medical director for Quality. And again, the experience reinforced itself by actually being productive. 

Go figure.  Those guys like Deming and Crosby actually knew what they were talking about.

And now that MMLQR goes though its first New Year,  it is time to start setting some objectives for it too.  Actually MMLQR has only been running for 6 months, but this is sort of like setting or re-setting an organization's fiscal or operational calendar.

Just to make sure we are on the same page, I use the term Objective to mean a large scale outcome that may take a number of steps to reach, and I use the term Goal to identify the individual steps.  To be credible the objectives should be achievable and the goals should be measurable.

So here are my goals and objectives for MMLQR for calendar year 2011

Objective 1:

MMLQR will be recognized as an active and credible and readable website to promote diversity of opinion and discussion for the full range of issues that surround quality management of medical laboratories.


Goal 1
To meet the measure of "recognized" I will promote MMLQR to support current readership and to encourage a broader audience.

Goal 2
To meet the measure of ``active``, I will generate at least one new entry each week.

Goal 3
To meet the measure of ``credible`` I will actively seek review and comment by others with long term interest in medical laboratory Qualitology.  This might be in the form of another shot at an electronic survey, or in the form of an external-internal audit.

Goal 4
To meet the measure of ``readable`` I will reduce the number of spelling and editing errors per entry.  (This one will be tough because I am terrible at proof-reading).

Goal 5
To meet the measure of ``diversity of opinion and discussion" I will invite and publish comments and commentary of differing opinion (as long as words like "jerk" and "pinhead" are not included) . 

Goal 6
To meet the measure of "full range of issues that surround quality management"  I will expand the topics covered including more commentary on politics and quality partners, as I see it.

So that is a good start with an achievable objective and a series of measurable goals.  MMLQR is a young start-up which has met reached a certain level of fragile stability (similar to how they describe the Canadian economy).  Going to the next step will take the discipline of setting some objectives and goals and PDSA.  We will see how I do by the end on the year.

See you in 2011.

m

Predictions in Qualitology - 2011

As the year slowly creeps to a close and the next year gallops forward, I start to wonder what 2011 will look like for medical laboratory quality.

1: Flavor of the decade?
It is unlikely that Quality is going off the agenda in the next while in health care.  Across Canada the media has decided to keep an eye on the laboratories, waiting for the bad thing to happen.  We are unlikely to disappoint. 
This will put increasing pressure on provincial governments and maybe (but unlikely) Ottawa. 
Organizations like the Royal College will have a hard time turning away.

The validity of Crosby will ring true in health: the costs of non-conformance, in NOT doing it right the first time, are too high.  I don't know if we will ever actually achieve zero tolerance for error, but 2011  will be a pressure point.

2: Jobs, Jobs, Jobs
As the world comes out of recession and folks again have money to spend, the jobs will return.  This will be true in both the private and the public sector.  Near the top of the list will be the positions postponed or sacrificed along the way.  People over machines.  Buying bigger and better analyzers is unlikely to be seen as the best way forward.  But institutions will still be cautious and a major priority will be effective use of money and more effective monitoring. 
And that will mean more interest for more quality team positions.
Add to this, increasing political pressures (as mentioned above) and there will be even more Quality positions.  Think of 2011 and 2012 as the equivalent of what SARS did for Infection Control.

3: Knowledge is King.
In Canada, we had our Royal College meeting and the importance of shared knowledge in Quality was seen as priority number ONE.  In the US the audience for quality is growing, as is the number of laboratories seeking supplemental accreditation.  The number of folks coming to our training programs is increasing from around the world.  So the message is clear in healthcare that more folks need more information, and we will see the sharers of the that knowledge in more demand.
Again as mentioned above, the wave of new positions will require a wave of new educational opportunities.
Universities and Colleges will become more actively engaged in Quality.

4: Conferences - maybe
Organizations are increasingly leery of  conferences as good vehicles for continuing education.  Airfares, hotels, meals are very expensive.  So how does this fit with Knowledge is King".

First the number of on-line courses and conferences and confabs will increase using a wider array of communication tools that will promote connectivity.  Video conferencing, collective conversation,creative use of networking software will be an increasing part of the on-line education experience.
Second, when conferences are held, they will attracting an audience will be tougher as folks get more selective.
The conferences that survive will be fewer but better.

Successful conferences will be the ones in the right place, and the right time, with the right information, and the right contacts. For example, Vancouver in June at the POLQM Quality Weekend Workshop (visit www.POLQMWeekendWorkshop.ca )


So I'm looking forward towards an exciting year coming up with lots to keep us all busy.
See you next year!

m

Preparing our next generation of leaders

I am preparing a number of new presentations for our Resident and Graduate Student Quality Seminar Series and took the opportunity to re-read Deming’s Out of the Crisis, written in 1982 to expand on the 14 Principles.  In chapter 2 Principles for Transformation of Western Management he writes “Support of top management is not sufficient.  It is not enough that top management commit themselves for life to quality and productivity.  They must know what is is that they have committed to – that is, what they must do.  The obligations can not be delegated.  Support is not enough; action is required. “

This is a core message that I am going to convey.  

Medical laboratories provide a broad variety of services including creation and provision of a menu of diagnostic tests, creation of a method for ordering tests (I hate that term: more on this later) and then providing a process for collection and transport.  The samples get accessioned and tested and results get generated and reported.   

Along the way some quality processes take place, including quality control and proficiency testing and sometimes accreditation.  Some projects, like the application of “Lean”, or a Lean variant of time and motion get initiated and sometimes actually competed. But we all know that problems still continue.  Over the last very few years we have seen pathologists misinterpreting and misreporting findings, faulty HIV testing, faulty tissue diagnostic tests, and pathologists with a pathological ineptness in writing reports.  We also have well documented sample contaminations in chemistry and microbiology.

In some laboratories we are starting to do more.  Quality management is starting to manifest some continual improvement processes (which is good) and even some error investigation (which is better).

So far I have told you nothing that you don’t know and that you have not heard before. 

But here’s what our residents need to know and understand.  That when push comes to shove all the above mentioned errors have a single primary root cause and it has little to do with technologist training or standard operating procedures, or competency assessment.  Our primary root cause of laboratory error is the consistent and persisted absence of personal active engagement by our medical laboratory directors in Management Review and change.  

 Quality is not about hiring a Quality Head, however named, and then delegating authority.  Management Review is not about being handed a bunch of manuals and annually signing them off, or about asking the Quality Guy how we are doing.

Our next generation of medical laboratory directors need to know that quality management is as much a part of their job as is reading pathology slides or signing our reports or dealing with human resources and budgets.  And it is not about number of slides read per hour worked or number of INRs ordered per week.  And it barely is about some artificial and artefactual measure of turnaround.   

They need to know there is a quality expectation, a quality vision.  Keeping laboratory staff focused on what matters is a critical function of the laboratory director . They need to know that satisfaction is not about making complaints go away, but is about comprehensive communication with hospital staff and patients.   

They need to know that quality is a science of planning, execution, measurement and response.  And they need to it is their job to make these things happen.

So it should be an interesting seminar series.

m

PS: I have a plan to see if we can monitor our impact on three scales: immediate, intermediate and at five years.  

PPS:   We have made some important changes to the Quality Weekend Workshop.  Dr. Denise Dudzinski is a bioethicist who recently published an article in NEJM on Disclosure Dilemma – Large-Scale Adverse Events.  I am looking forward to her presentation.

PPPS: I would really appreciate it if you can go back to the previous entry and fill in the survey.

Patience and Patients Safety.

I was reading my local newspaper and found a columnist discussing an article on Patient Safety and Hospital Error.  We can no longer be surprised that the things we do have become front and center in the cross-hairs of the media.  We have brought this on ourselves.  

The column reported on an article in a recent edition of the New England Journal of Medicine (how scary is it that a local paper columnist is reading articles in the NEJM!), which looked at the rates of “preventable harms” in 10 hospitals after 5 years of active process (2002 – 2007).  While there was a reduction (approximately 1% per 1000 patient days) the reduction was not statistically different, nor (my opinion) clinically significant, even if it was real.  This was true for each category from inconvenience to death.  This was despite active engagement in national and state patient safety training programs. The analysis was done by thorough and fair methodology with internal and external reviewers and appropriate reviewer comparisons.

The authors commented that harm from medical care remains high despite all the programs and the money being spent.  

 The study confirms reports from across the US and Europe about how little progress is being made.  The amount of evidence-based error reduction practices implemented so far has been modest.  All the things that can be done, including substantial improvement on handwashing (!), have not be implemented with any consistency or success.

A few thoughts. 

Systemic and personal behavior does not appear to be easy to change.  While there are folks within health care who are motivated for change, they are not having a lot of success, when measured by outcome.  Most of the money being spent on patient safety teams, training seminars, poster displays, and conferences is being wasted (unless your personal income comes from being on a team or charging for putting on training seminars).  Change is not happening.

My concern is that if healthcare management and healthcare unions wanted change, then change would happen.  I could suggest that there are other vested interests at play, but that would be unfair.  But if neither altruism nor fear of malpractice litigation is insufficient to drive change, then what does it take?

At some point the media will care enough and the public will care enough and the politicians will care enough and we will end up with a healthcare version of the Transport Security Administration and we will have our own version of an intrusive airport pat-down.  And folks will say, well it may not be fun, but it makes our lives more secure.  

For example, the regulators, and legislators always have lots of options, like perhaps a variation on pay-for-performance.  Rather than institutions getting a reimbursement bonus for good deeds, every year that they miss their goals, they lose 1%.  And insurance providers can start jacking up institution protection rates.  

“They” say that carrots work better than sticks, but sticks work.

From my vantage point, hopefully medical laboratories might be having some more success in error reduction because as much as we are a complex distributed activity, our activities are more focussed than hospital admissions.  Some centers have demonstrated some levels of reduced error, at least on a short term basis.  But we need to have an institution perform the longer term year-over-year study like the one above to observe if trends can be seen as improving.  I suspect that most are afraid to look.   

The media already cares, and the public is become more aware.  

Strike 2.

 m

PS.: The article is “Temporal Trends in Rates of Patient Harm Resulting from Medical Care” by CP Landrigan et al.  N Engl J Med 2010;363:2124-34.

Heresy?

 American Society for Quality has a number of  journals, and some excellent, and others pretty good.  One of the latter category, at least in my opinion, is the Journal for Quality and Participation.  Without wanting to be harsh, I tend to find articles, while generally interesting,  tending to be more  opinion than fact.  (The irony of me, an opinion oriented blog writer making this distinction is not lost!).

Nonetheless there were three interesting articles in the October 2010 edition that I received today.  One was “Improving Project Performance with Three Essential Pieces of Information” by Portnoy, and another “Creating a Self-Confident Workforce” by Denton.   The last one is  "Training on Trial” by Kirkpatrick and Kirkpatrick.  

I don’t intend to go into any (the journal is available at www.asq.org/pub/jap) in detail other than to say that the first article made the point that when designing a project briefing (the deliverable) it is useful to make it brief and unambiguous.  The point was that the more the number of words and the more jargon included, the more variable is the document's interpretation.  The training article was making the point that training can have a lot of challenges demonstrating that it actually provides a service that will address significant business results.  And the third article made the point that workers are more self-confident with less stress when they are empowered to make certain decisions on their own.

I can support all those points.

Which brings me to the heresy. 

At a laboratory where I was working, I often found myself in conversations that suggested that some of the standard operating procedures (SOPs) were so detailed and so “precise” that in my opinion, they were largely unfollowable.  Even with an adjoining process map they were unfollowable.  They were better when pictures were added in,  but especially better when pictures were used in place of words.  In the process of trying to make SOPs that were all encompassing, I felt we were laying the foundations for error.

And so I started to think that maybe it is not so important to tell microbiology technologists how they have to hold and streak a petri dish, but to let that happen on its own.  And defining precise colony counting methods was so rigid that it likely wasn’t followed anyways.  And trying to define all the combinations and permutations of bacterial growth was confusing.  

Now there are many procedures involving many pieces of highly precise equipment that do need precise instruction (I understand that) but if we pollute those instructions that are challenging to follow, I think we run the risk of some documents  that need attention and clarity getting lost in the shuffle.  

So my point is that SOP writers and trainers and supervisors need to take a closer look at the procedures that they create to make sure that they actually are useful for training, and more importantly allow the business purpose of the procedures to come through.  Its not only about the value stream, but also creating documents that give technologists the professional autonomy.  Smaller and selective documents, it  seems to me, make the procedure and much of the decision making process both more efficient and more effective.

And how heretical is that?

m