Customer Service - The Paradigm Shift in Laboratory Quality

Customer Service - The Paradigm Shift in Laboratory Quality

In the 18^th Century, Immanuel Kant writing in Critique of Pure Reason (1787) described the change in approach to scientific study as a “revolution of the way of thinking”.  In the 20^th century, Thomas Kuhn in his book The Structure of Scientific Revolutions (1962) advanced the phraseology to “paradigm shift”.  By whichever phrase we want to call it, today we are going through an new phase in thought and practice in Laboratory Quality, especially as it refers to customers and service, that is truly a significant shift.

Recently I hosted a conference in Vancouver on the topic of Quality Improvement, Knowing your Customers.  One of our speakers, Colleen Taylor, in a most creative way talked about the dual understanding of the word Patient.  In healthcare we use Patient to refer to one of our customer groups, the person who is the end-user of our products or services.  Equally “patient” describes our all-too-common approach to the end-user: “ You are tired of waiting?  Well we are all very important and very busy, and you just have to be PATIENT.  So just go sit there and we will get to you when we get to you.  Just sit there and be quiet, and you better be darn grateful when we get around to providing you with our time and services.”  

The rest of the world has figured out that that is no longer a winning strategy.  Increasingly customers have figured out there is always choice.  Hospitality, and retail, and banking and schools have figured it out; making an unhappy customer leads to an unhappy customer and a bunch of unhappy friends, and one day you look around and there are fewer and fewer people coming in your door.   And all of a sudden, your business is in trouble.  

Think it can’t happen to medical laboratories?  Point-of-Care Testing did not start in a vacuum.  Pharmacy based testing didn’t just happen.  Theranos, may have turned out to be a failure, but the reality was that Silicon Valley was responding to a perceived need, and there is every reason to believe that the next change will be far 

more successful.  

So at our conference we learned some truly important lessons. 

Hospitality industry can track millions of customer experiences, and can maintain complaints at a level of 3 per 10,000 (sigma 6.17).  They track and correct because they understand that every complaint that goes through the door unresolved gets increasingly expensive.

Tracking customer satisfaction in healthcare facilities can be done competently and comprehensively on a same day basis, and indeed on a same hour basis. 

Healthcare executive administrations are looking for service excellence solutions

International Organization for Standardization (ISO) is developing new standards and tools in service excellence under a new technical committee (ISO TC312 Excellence in Service).  

Some laboratories are developing some novel approaches for improving customer experiences

The approaches of “the customer is always right” and “the customer always comes first” are being replaced by “Your Customer have to come second because your staff have to come first.  Staff who are acknowledged and appreciated for their skills will take care of your customers needs in ways that are in both the short and long term successful”.   

We can shift staff attitudes and culture using thoughtful analysis using techniques like Organizational Culture Assessment Instrument (OCAI) and staff management skills and techniques.  

Small changes can have big impacts. Small changes regularly have huge impact.  

Starting now is ALWAYS better than starting later.

To be clear, other aspects of laboratory quality can not be forgotten about.  Areas like error awareness, error reduction, opportunities for improvement through audit and prevention and correction, continuing education, continual improvement throughout the pre- peri- post- and examination phases will not go away.  But their impact and success will be much enhanced through the dynamic of staff and customer satisfaction. 

For those interested in seeing some of the materials from our conference/workshop you can visit polqm.med.ubc.ca/conference 

   

Learning about Risk and Prevention through Continual Improvement

Learning about Risk and Prevention through Continual Improvement

Yesterday we had our 12^th external audit by our ISO certification body in 12 years.  You would think that by this time we would have the process down pat.  It should be a walk in the park.   Well this is sort of true.  In the early days we would look at audit day with a certain degree of anxiety and distress.  These days those negative concerns are gone, and in fact we look forward to the exercise because we still find opportunities for learning and opportunities for improvement.  

Some would say that now that ISO 17043 (Conformity assessment — General requirements for proficiency testing) exists there is no longer a place for assessment of proficiency testing programs to ISO 9001.  I can see the argument since ’43 is more specific, but to my mind there is no document more specific and exacting to quality management than 9001.  So while we will likely seek an external auditor that we have confidence can do a competent assessment to ’43, we will continue to stick with 9001.  Indeed, to my way of thinking, I suspect that when the smoke clears, we will likely find a way to do both.  

 

One thing that I appreciate about our current ISO 9001 assessment body (SAI Global) is that they provide us with a knowledgeable and experienced auditor with a lot of knowledge and skill in the laboratory area.  Several of his clients are in the laboratory arena.  He is knowledgeable about calibration and equipment and quality control, and our assessment covers these areas thoroughly.  In addition to our regular close look at our quality system and management review and customer satisfaction plus plus, we also get a solid review of critical laboratory expectations.  So in a sense we feel we currently are getting the best of both worlds right now.

 

So how did we do.  We were found to have no non-conformities.  We continue to meet all the requirements.  But we are not perfect.  Although we do two major internal audits each year, (one in February-March and one in July-August) and had the documentation available, when I wrote up my Management Review report, I forgot to add in an “Internal Audit” section.  We probably could have gotten away with that except we publish the MR review in our Annual Report (available on-line at www.CMPT.ca) and so the absence of an IA section was pretty obvious.  This was written as an “OFI-Opportunity For Improvement” rather than as a non-conformity.  I could go back and edit the MR review, but we agreed that the more appropriate approach would be to include the section in our next MR in our next Annual Report.  

 

The other thing that came up is a common problem, but I think we have found a good solution.  Like most organizations we are weak when it comes to having a documented list of Preventive Actions in our report.  It looks like we continue to be only re-active to problems rather than pro-active through prevention.  But in fact that is not true.  Our problem is one of recognition and value.  

 

We make changes and improvements all the time.  We changed our glass slide labels to a better material so that they would not fall off and not get covered with stain.  We changed our packaging to reduce the risks of leakage to a level beyond requirements.  We implemented our earthquake preparedness safety kit, and revised the labelling on some of our reagent bottles.  There have been probably 15-20 of these types of changes going on over the last year or two, and while we have thought of them as products improvements and safety requirements (which they are) they are also true Preventive Actions because each of them reduces a Risk of inconvenience to ourselves or our customers.  

 

 So now as we continue along our path of innovation and continual improvement we can also look at ourselves from a Risk and Preventive Action perspective.  And if that was all we learned from this year’s audit, it was well worth the cost.

 

As a PS note, some explanation may be necessary.  If we are so satisfied with our current assessment process, why would be even be thinking about including additional assessments?  The answer is that for some of our customers (clients) seeing the words “Accredited to ISO 17043” is becoming more important, and so I suspect our move to accommodate their concerns  will come to fruition fairly quickly. 

 

 

The Error Cost Dynamic

The Error Cost Dynamic

We have started our new season for our UBC Certificate Course in Laboratory Quality Management and I have to say that this year is perhaps the most animated, most adventuresome group to date.  Day 3 and there is already a lot of mingling and interaction, which is incredibly special in an on-line virtual classroom course. It truly feels like if I should not be surprised if I were to have a tap on the door or a call on the phone.  This is a good thing.

One of the questions that has ready come up is on the impact of communication, or lack thereof, on laboratory error.  This is a very interesting topic  because communication is so multidimensional; there is communication in the form of person to person chitchat or communication in the form of information sharing or communication in the form of instruction - guidance - requirement.  Regardless of which form we are talking about communication can be either very positive or very not-positive depending on the clarity, understanding and intent.  Said in a way that is clear and precise in-laboratory communication is very helpful.  Said in a way that is muddled and ambiguous and a whole lot of bad consequences ensue.

That is a long way to get to the topic of error.  The point I am struggling to get to (talk about poor communication skills) is that in Quality, concepts that are expressed with clarity and brevity lead to new insights and new understanding.  Concepts presented as subtle nuanced and complicated are a struggle and are often dismissed. 

For me, I think I have developed a helpful way to express the dynamic impact of errors and causes of error on the costs of poor quality.

All organizations experience daily work pressures, many of which are addressable and potentially controllable: noise, crowdedness, clutter, work volume, time pressures, stress and anxiety, miscommunication, accidents and injury, and finances.  

As daily pressures rise, the risk of error rises in the same time or compounding at a faster rate.  

As the risk of error migrates to being the actually of error, the impact of error becomes an additional source of daily pressure, sometime impacting on finance, but more often on stress, anxiety, accident and injury, and time pressures. 

Increasing error is a leading indicator of deteriorating Quality, contributing to management dissatisfaction, customer dissatisfaction, staff dissatisfaction, more remediation and increased cost and usually reduced revenue streams, all of which are can be measured and compiled as the rising costs of poor quality. 

Recognizing this dynamic, leads to an important conclusion; addressing daily pressures before they lead to problems is the easiest way to prevent error and reduce poor quality costs.  

One can appreciate the dynamic graphically as a series of gears all moving in concert. 

It seems to me that thinking about quality from this dynamic there are some useful valuable insights and conclusions, the first of which is that the easiest way to reduce error and cost is to reduce pressures that lead to mistakes.  Many of them would be addressed through an active Lean campaign (think especially about Sorting, Streamlining, Shining, and Standardization) which would go a long way towards reducing noise, crowdedness, clutter, and time pressures. My guess is that the impact this would have on an organization’s work culture would be so powerful, that the drive to sustain the improvements would come from within rather than requiring management motivation.

My second conclusion is that trying to implement a new Quality system without first addressing these pressures would not solve the quality problems; indeed it would make them worse.

I wonder if that is why some many organizations that try to implement Quality systems through ISO9001, and probably 17025 and 15189 fail.  It’s not that these are bad systems, but if you don’t create the culture and  time-space in which the Quality system can grow, you can be surprised when it doesn’t.