CVP - The Coronavirus Vanity Project.

In his 1984 book Quality Without Tears: The Art of Hassle-free Management, Philip Crosby wrote:  “Take everything that would not have to be done if everything were done right the first time and count that as the price of non-conformance.”   He referred to that as the Measurement Absolute of Quality.   

He went on to say that all too often these non-conformance costs could add to more than 10 fold the costs of “doing it right the first time”

In our annual Certificate course in Laboratory Quality Management participants work their way through the analysis of poor quality costs for common examples of a laboratory error.  The wastes involved often range between $6,000 to $12,000 for a simple error that could have  been prevented but ultimately resulted in 50 patients receiving some incorrect results over few hour period.  In a medical laboratory that is a lot of wasted resources.

It is a useful and enlightening exercise.

But perhaps we should apply the same exercise to the disaster that we can now call covid-19.  

Stepping back, a few days before the New Years celebrations and its associated massive country-wide travel, doctors in China identified a small cluster of people with pneumonia.  They decided that if this was going to be another SARS like episode they better do something early and so they decided to curtail any and all travel in or out of Hubei province where these pneumonias were found.  (This was a definitely high risk but probably appropriate decision based on what they knew at the time in a country that has the authoritarian power to make those kinds of decisions)  Using modern technology they recovered a piece of viral nucleic acid from the secretions of one of the patients, and then passed the information to high level laboratories around the world so that other countries could use that as the basis of a diagnostic test.  

That too was a good and responsible decision, but assumed that everyone would be able to use the material to recreate the same strand that could be used for uniform responsible world wide diagnostic testing. Unfortunately that didn't happen.

Instead it created the opportunity for some really unhelpful next steps… like mass screenings on tourist ships… like quarantining totally asymptomatic people for extended periods… like allowing media analysts to go out to the public airways with beyond irresponsible panic… like politicians jumping onboard using the Churchillian axiom  "Never let a good crisis go to waste".  Ego and opportunism… the most deadly combination of the modern era. 

With hindsight (what should have been foresight) it became universally clear very early on that based on a untried untested unverified experimental diagnostic assay that the vast majority of people who were being tested and found positive were asymptomatic or at most had the signs of a mild common cold.  (What a surprise, since coronavirus has been long recognized as a common virus of the common cold for decades).   

So did we use that information for the next level of decision making?  Nooooooo!  We just kept on going.  An exercise in futility and vanity.

Forget influenza; forget common colds that kill as many elderly and infirm as influenza, Let’s all focus on our new favorite virus.

Which brings me back to Philip Crosby and the costs of nonconformance and poor quality.  In our course we look at costs in terms of TEEM (Time, Effort, Energy and Money).   

Let me argue that if we had accepted after the first two weeks that this was NOT the once-in-a century crisis that it might have been and had decided to step down, how much TEEM would we have saved: Quarantining, lost time and income for asymptomatic people… N-95 masks and hazmat suits, curtailment of travel; disruption of enterprise; reallocation of resources from serious medical and laboratory science to a glorified diversion.  

I suspect that somewhere there is a graduate student who will be asked to take on the task of working out the total costs of the last few weeks, compared to the benefits (maybe a manuscript or a book or a t-shirt).  My guess is that the total poor quality costs will be way beyond millions, and perhaps beyond billions.  

Take everything that would not have to be done if everything were done right the first time and count that as the price of bad judgement.

At least that is my personal opinion and I am sticking to it!!!

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.

 

Quality and the Quality Conference

Quality oriented conferences have become prolific these days, even in the Medical Laboratory arena.  This actually makes a lot of sense because Quality has become a very relevant issue at almost every level.  It is a HOT topic.

There are so many aspects of Quality that touch the Laboratory arena include Costs, Clinical Relevancy, Patient Safety, Culture, Risk.  It has become near impossible to keep up with moving trends and recent advances if you are not connected to the Quality community.  

For those of you that visit this site from time to time, you may recall a post that I wrote about 9 months ago:  see http://www.medicallaboratoryquality.com/2014/07/quality-standardization-and-mh17.html  in which I argued the downsides of conference travel including cost, and risk.  Perhaps you may think that my now planning on hosting a meeting might seem a bit hypocritical.  

I would not agree.  Thinking in terms of Risk, one can look at conferences from both a occurrence/severity perspective and a risk/benefit perspective, and I can argue that if a meeting has high enough value of information and is held in a really nice and low risk environment and at a fair cost then the balance of factors leans strongly to the side of hosting and attending.  

So I will start from the positive high value side, or as Crosby would say it “Quality has to be defined as conformance to requirements”.  Will the meeting meet customer requirements?

In a short 2 and a half days, we will have speakers talking on Health-Quality-and the Law, on Safety as the Quality Imperative, on Modern Tools for the Modern Quality Manager, and on techniques to solidify the Culture of Quality.   It will be difficult to find a meeting that will provide a better array of topics.  Within those subjects we will talk about Teaching Quality to Adult Learners, reducing risk through Conflict Resolution, Establishing real time inventories of laboratory error and safety accidents and injuries,  We will look at calculating true costs of poor Quality (how Crosbyesque is that!) and determining risk in pre-and post examination processes.  

We will have presentations and roundtable discussions, and presenter contact time and the opportunities for posters and sponsor interactions.  All in all, this will be a high content conference.  This is exactly the structure that meets the Andragogy criteria for Adult Learning. 

In terms of the potential for bad outcomes by every measure they are very small.  The conference is being held in one of the most picturesque cities in North America (Vancouver BC) at a time with little risk for inclement weather, and essentially no risk for personal adversity.  Vancouver is an ideal city; big enough to be world class, but not so big that you get swamped and hit with major costs.  It is a major travel destination, with easy access from across Canada, the United States, Western Europe and Asia.   Thanks to the recent Olympics there is a truly beautiful and efficient airport, to be sure.  

 So it would be fair, reasonable and accurate to say with conviction that the potential for downside risk from either the occurrence or severity perspective is low-low-low.  

Some of you will want to know more and for those of you interested the preliminary website is available now at:  http://polqm.ca/conference_2015/home.html .

I look forward to meeting with some of you in Vancouver from October 28-30, 2015.  

More information will be available shortly. 

I will keep you informed.