GB/T32230: Quality Culture and the Medical Laboratory.

So I was browsing in this month’s Quality Progress (January 2019) and found an interesting article written by Ningning Jing about Quality Culture, a topic about which I have a lot of interest.  What caught my eye was that in 2015 a new guideline was created and subsequently published by China Standard Press entitled Chinese National Standard, GB/T32230-2015—Guidelines for Quality Culture Development in Enterprises.  I was unable to find an ISO equivalent, so I am unsure where or how the Standardization Administration of China (SAC) developed guideline.  As it turns out it is available in English, but it was fairly expensive. 

The guideline makes for some interesting reading.  It reminded me of how much medical laboratories have changed over the last 15 years, dating in my mind back to the original publication of ISO15189:2003 (Medical laboratories – the particular requirements for quality and competence).   

Laboratory life has changed a lot since those early days.  Despite the awareness of some of the efforts of W Edwards Deming and perhaps of Armand Feigenbaum and Total Quality Management in the 1980s, for the most part, quality in the medical laboratory was largely mechanical and technical.  The concepts of quality were mostly about accuracy and documentation, and very little about timeliness, or appropriateness, or clinical relevancy.  The quality dynamic was the laboratory, the physician customer and the specimen.

Quality principles as expressed in ISO15189:2003 made a material change because it introduced concepts of Quality Managers and patients and the needs and requirements of the staff.   In today’s medical laboratory, quality has expanded to address satisfaction, and interested parties and stakeholders and service excellence.  Modern laboratory quality is an essential component of every aspect of the total experience.

Today many almost every laboratory conference and education program and continuous improvement program for medical laboratorians will focus on some aspect of the essentialness of a Culture for Quality.

What many may not realize is that Quality Culture is not a new concept.  Joe Batten has been writing on the topic going back to 1992.   Back then Batten presented a definition of Culture that I still rely upon today [Culture: The pervasive philosophy, central values, beliefs, attitudes and practices of an organization, and the micro-elements that make things happen.] 

While I still have my old copy of Building a Total Quality Culture, I see it is no longer available even on Amazon, but I see there is a new edition (2014) available.

  

This new guideline defines quality culture as the “total of quality concepts and values, habits and behavior patterns, basic principles and systems as well as their material performance recognized by the enterprise and its staffs”.  With interest, ISO 9000:2015 provides a similar definition: “a culture that results in the behaviour, attitudes, activities and processes that deliver value through fulfilling the needs and expectations of customers and other relevant interested parties”  When either of these variation definitions is combined with the one used by Batten, back in 1992 you capture a clear picture of Quality Culture. 

The new guideline makes several points: (a)  the culture must be driven and directed from the top; (b) that without leadership, a quality culture is unlikely to happen.  And (c) that leadership by itself is insufficient and if the staff are not engaged then the process with fail.  (I am reminded of Feigenbaum who said that Management is responsible for 80 percent of Quality, with the organization sharing the responsibility of the 20 percent).  (d) the document reminds that Quality Culture is NOT a cookie-cutter operation.  Each organization is unique and their culture must have the freedom to reflect that.  And importantly (e ) building a Quality Culture is NOT a one-and-done activity; culture is a philosophy/attitude that must mature and change with experience.   

Importantly the new guideline urges that to ensure that the organization has implemented a truly effective program, it has to find a way to measure its impact, which begs the question, can one really measure an attitude?  Well the important answer is “yes, you can!” 

In our course on Laboratory Quality Management we talk about Quality Culture, and provide some ideas on how culture measurement can be done and more  to the point, illustrate how it is possible to assist culture realignment when the organization’s changing needs require. 

I have not yet taken the opportunity to read the guideline thoroughly, but so far I am pretty impressed.  I suspect that when the crafters of GB/T32230-2015 were thinking about “enterprises”,  medical laboratories were no where on their list.  But they have done us a valuable service. 

Do I think that the new version of ISO 15189: 202(?) will incorporate some elements of quality culture?  I would be pleasantly surprised if it did. 

But regardless, it is well worth the read.

The Culture Quality Interface

The Culture Quality interface

Culture and Quality has been a long-time interest of mine.  I have stated with total certainty that an organization needs to have a palpable Culture of Quality in order to succeed in Quality Improvement. 

I still believe that to be an absolute truth, although I have moved a little bit from the absoluteness of the statement.  Today I am more comfortable with the saying that having a Culture that supports Quality may or may not lead to significant improvements in Quality Improvement, but if the acceptance and interest in Quality is NOT there (i.e. if there is no Culture of Quality) there is absolutely no chance to creating any lasting Quality Improvements.  

Said another way, even if everyone sees the value and importance of Quality, improvements may not last because financial, or changing dynamics, or other interferences get in the way.  But with absolute certainty, if no one in the organization gives a damn, the likelihood of improvement is not only zero, the greatest expectation will be that more errors will occur, staff will be more indifferent and whatever level of Quality there is, will get worse.  It is stunning how often we see that in action. 

So understanding Culture is essential and integral to implementing Quality Improvement.  

With that in mind, the last few days have been really enlightening for me because I was able to change out of my teaching and investigation mode and became a student by taking a course in culture improvement.  The centerpiece of the course was exploring the Organizational Culture Assessment Instrument (OCAI) which can be used to define and characterize the competing values of culture types.

The course was given by Marcella Bremer who lives in The Netherlands and is a major player in the international community of Culture improvement. 

The course was just what I needed; away from the office and intrusions for 3 days and the opportunity to focus.   Most participants were consultants from across 5 continents wanting to explore and dabble in OCAI.  I also met a kindred spirit; a person working in another university setting and struggling with all the same issues that I also have to deal with, and maybe worse.  

Without going into too much detail, the developers of OCAI were deeply interested in the nature and personality of organizations (all organizations) and studied many cultural characteristics.  Through comparative analysis, they were able to weed down to 4 major personality influencers and types: 

Hierarchy

the processes that bring order and CONTROL to an organization such as standards and guidelines, top down management, process and procedure, quality control, accreditation etc.

Clan

The processes that bring collective COOPERATION to an organization such as staff engagement, kaizen, etc.

Adhocracy

The processes that bring CREATION to an organization such as research and development, new programs, new methods, new strategies, etc.

Market

The processes that lead to COMPETITION such as methods that increase market share such as market strategy, market growth, customer satisfaction.  (note:  in healthcare, there are elements of competition that exist such as wanting to find more patients, or more studies or more grants, but mostly what we are try to focus on is more and better satisfaction).

What is, or should be intuitively obvious, is that each of these elements is essential and the choice is not one of exclusion, but of balance.  Sometimes an organization’s improvement needs a little more top-down support.  Other times the opposite may be what needs to happen.

We spent little time talking abut the OCAI itself (it is after all only one management tool), and much more on what organizations can do if they believe there is room for culture adjustment and how the information within OCAI results can give some guidance.  What is pretty clear, is that (a) it is not as easy as snapping your fingers and (b) it can be a lot more straight forward and not as hopeless that you fear it might be.  I left with some definite ideas how I could make things happen.  

For me, this time away from the office was a total success; what could be better than getting to spend 3 days with people pretty much of like mind exploring new thoughts and new ideas.  

But as I said at the beginning, strengthening a laboratory’s collective culture and interest in Quality Improvement does not guarantee there will be success.  But doing nothing will assure that improvement efforts will not lead to success, and more importantly, will either remain static, or slide down the pipe to more error and failure. 

 

What a choice!!

Teaching Quality_Part 2

If we believe that communicating Quality is the cornerstone to implementing and developing a Culture of Quality, then we have to accept that those responsible to doing that communicating know what to do.  But with regret, that is what we call wishful thinking.  

I am almost certain that most Quality leaders have little to no training in effective teaching/communicating, and rely mostly on their previous experiences as a student (when they learned mainly from people with little training).  That, with regret sets us up for a potential problem.  

 So let’s look at this as a problem that needs to be solved.  Most people come to Quality later in their career rather than sooner.  It is an adult choice.  Most of their experience has come from being a laboratorian, perhaps a technologist or a pathologist, maybe a nurse.  But one thing is almost certain, few if any come to Laboratory Quality Management after being a teacher.  Most of us have little training in public speaking, much less teaching.  Indeed if there is any truth behind the stereotype of laboratory workers, many of us are not very comfortable in speaking in front of an audience. 

The result of this incompatibility is that either we tend to do the prerequisite teaching not particularly well, or worse, we find all sorts of ways to avoid it, or not even raise it as an issue.  And that is not good.

So there are a few things that we can do.  The first thing actually is not learning about content; rather it is about learning how to talk.  The content can wait.   For those that get tongue tied or stress out at the thought of talking in front of a bunch of people, consider taking an adult public speaking course or participating in evening acting classes at a local community centre or joining Toastmasters, or start practicing at home with family or in safe social settings.  Find a speaking coach.  Approach this in the same way as you would learning how to drive, or how to operate a new analyzer.  For most of us it won’t take long before we get the hang of it, maybe a month or two.  But if you are not comfortable with standing on your feet and talking out loud to others, communicating Quality will be a painful process, both for you and your audience.   

Another thing to do is look at andragogy (adult learning) and imbed some of the insights that others have garnered along the way.  Some of the classic ones are to be found in part 1 [see: http://www.medicallaboratoryquality.com/2015/01/teaching-quality-spoiler-alert-it-is.html ]

More recently I have been scoping our more of the andragogy literature, and found another excellent author (Roberta Silfen – Teaching the Adult Learner – 2011).

Here are some things that Dr. Silfen brings to the table:

1:  The Knowles principles are REALLY important.  Perhaps most important is that adults view their past experiences as universal truths.  They are very powerful and influence what they will gain from what they are learning today.  Challenging those past experiences can only be done with caution.  Adults want their past experiences to be respected and valued by others.  

2:   Given a choice between didactically presenting information and then asking if there are any questions, versus posing problem solving questions and then discussing the responses, adult learners prefer the latter.  

3: Adults learn better at their own pace than at someone else’s pace.  You have to be flexible.

4: Adults learning works best when teachers are comfortable in sometimes sitting back and letting others take the lead.  

These can be really tough.  For many of us (me, especially?) we love showing others what we know and love being the lead.  For those of us like that (again me, especially) the title of Part one is really important (Spoiler alert – it is NOT about you).  

To my mind, if building a Culture of Quality is important, then sharing the Quality message in a manner that invites your work colleagues to pick up the ideas to the point where they can apply them to their own work experience is absolutely critical.  We have two choices; doing that messaging well or doing it not so well.  One has a better chance of working than the other.  

Next time (Part 3) I will address the question about to present information in a variety of cost efficient and cost effective techniques.  Some are from my own experience, others are from Dr. Silfen.  

PS: Dr. Silfen’s book Teaching the Adult Learner is available on Amazon.com for a truly under-valued cost.