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.

Human Factors and Safety and Quality (?)

In 1986 Briggs Phillips published a small, probably near forgotten, but important study in laboratory safety (see in Laboratory Safety: Principles and Practices.  ASM Press 1986).  The author was able to identify two groups of people: one group of 33 who had experienced at least one laboratory accident in the last 2 years, and another group of 33 who had been accident free during the same 2 years.   The two groups were matched by job classification.    

The two groups were interviewed and surveyed for additional information.   

While not matched for the following characteristics, all including age, years of education, years on the job, weight, height and gender and marriage status were identical.  In addition, wearing glasses, medication use, showed no differences.  Also of interest, accidents outside the laboratory, and driving records were also equal.  

The factors that had significant differences were (A) smoking  (B) the number of accidents and injuries and infections acquired in the 2 years prior to the current 2 years (C) personal attitude towards safety (D) opinions of the safety awareness of their supervisors and co-workers, and (E) importance of training and communication versus personal experience.  In all these, the accident involved were more likely smokers (remember this was 25 years ago), had a long history of accidents,  believed that technique was more important than attitude, but thought that personal experience was more important than training.   

The accident free group were significantly more critical of the supervisors and significantly more critical of their co-workers safety consciousness, and believed that safety attitude and awareness were more important than having techniques and equipment.  

[If you are safety aware you will avoid getting into the high risk behaviour of rushing or allowing distraction.  If you are not safety aware, you are more likely to assume that equipment will allow you to go faster and increase risk.]

The message of the study points to importance of attitude and awareness in the avoidance of having a laboratory accident or injury.  

So why am I bringing up 25 year old studies?  Two reasons.

First, a recent study in ASQ’s Quality Management Journal V18, N:1, 2011 on factors associated with continuous  improvement in patient safety  by E. Naveh et al came to a similar finding of the relative importance of opinions on attitude and priority.

Secondly, and more importantly, what made the first study possible was that records were maintained on who had been involved in a laboratory accident or injury.  In many laboratories today, we have virtually no records of Quality accidents, and where we do have records,  the names of the people are commonly deleted.  So in many (most?) laboratories if we wanted to study the human characteristics associated with increased error, it would be impossible because we have no place to even begin.

Deming wisely called to “Drive out Fear” and I agree with that.  He also said that most error was systemic, and I agree with that too.  But Quality in the medical laboratory is a new field, and it is important that we study why errors occur.  Confidentiality is important, and so if avoidance of a sense of retribution.  But let’s not “throw the baby out with the bathwater”.  Continuous improvement requires having data to study.

That’s why they call it PDSA.

Communicating Quality

About 15 years ago I decided that if CMPT was going to progress we had to develop an electronic presence, so with the assistance of my son, we created www.CMPT.ca.  I was so pleased that I had made this huge jump into the future, or at least the very current present.   I had a web site.  It took about a month for me to realize that a website had to be fed new material on a regular basis, and gradually it started to take over as a major preoccupation.  Gradually, what started as a hobby became the full time work of a number of people.  The problem, of course, was that we had never budgeted for the expenses.  The message to self was that you need to make sure that your organization gets benefit from electronic presence because it is going to become time (and money) expensive.  

Well the world has changed since the early times.  Web presence has become common.  Today, folks can spend their whole work day and their social life in the web world.  Communication outreach is world wide and immediate.  But the old messages continue to be true.  To be effective, the electronic world consumes TEEM (time, effort, energy and money).

I state the obvious because progress in Quality in every organization, regardless of size needs communication.  In an earlier time, Deming, Crosby, Juran were committed to quality communication by way of books and lectures.  They were prolific communicators.  If they were working today, they would have been within the first wave to embrace the Internet because it would have expanded their outreach.  
Evidence this by the myriad of sites that promote and communicate quality; www.darkdaily.com. www.iso.org, www.csa.ca, www.qualitydigest.com, www.westgard.com, www.asq.org, and medlab-eqas.blogspot.com, just to name just the ones that I get to follow on some sort of regular basis.

But what is so interesting to me is that communicating quality has evolved so far from the organizational website.  Outside communication is now about the website and the vehicles that transport to the website, like the web-log (I have taken on an aversion to the “b” word) and social media like Twitter and Facebook, all of which have become destination sites with their own messages.  
Outside communication has on-line courses and on-line conferences, extending beyond information and on to knowledge.  And  Inside communication is about intranets, and organizational email blast outs.

This is not to say that the concept of holding a meeting so that people can meet is now obsolete.  Meeting in person has powerful effects that Skype or GotoMeeting or videoconferencing will never duplicate.  But many organizations are shying away because of obvious costs.

And that brings me to my message to self:

1: The laboratory cannot succeed without Quality and Quality cannot succeed without Communication.
 
2: Communication is critical valuable and at the same time can be hugely TEEM consumptive.
 
3: For Communication to be implemented it requires the same level of rigor of Quality implementation and management as every other laboratory essential.  It has to be planned, and be implemented with forethought.  The implementation requires study and opportunities for improvement acted upon.  Over and over.

4:Quality requires Communication and Communication requires Quality.

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

Quality Confab and Disconnection

I attended Robert Michel’s Quality Confab in San Antonio this week.  For those who do not know about the Confab, it is slowly become one of the sentinel Quality Meetings for those interested in medical laboratory quality.  (More on the other sentinel meeting shortly).  Lots of good speakers giving lots of good summary presentations.  Enough material for lots of folks to learn.  Enough material for lots of folks to discuss, ergo the title “confab”.  I gave a presentation about the challenges associated with examination phase error.  I will post the presentation on www.POLQM.ca.

But that is not what I want to talk about.  For me the most interesting and intriguing 10 minutes of the whole 2-day meeting, and perhaps for the year, was a brief discussion by Michael Astion (University of Washington) on the concept of Disconnection.

Michael is a long time leading Quality Guy, with a variety of insights on laboratory error, and as it turns out a lot of common sense concepts on Management theory and Human Resources.  In previous meetings he has talked vividly about human slips and foibles that contribute to error.  But this time he addressing error from a broader management perspective.  One point that jumped out for me was that one of the reasons that laboratory workers  make errors is because they have become disconnected from the clinical reality, and that being disconnected contributes to more focus on the self and less on work contribution.   

A solution for this is to reconnect and revitalize by bringing patients to the laboratory and the laboratory to the patient.

This sparked about whole slew of images for me. 

In many microbiology laboratories, not only is the technologist disconnected from the patient, they are disconnected from the specimen and even the requisition.  In some laboratories the technologist working on the culture doesn’t even get to see the patient gram stain.  For them the whole patient care experience is looking at some petri dishes.  Not only does this contribute to formulaic microbiology, it is also extremely difficult to sustain a sense of clinical perspective if you are completely eliminated from any vestige of the customer and patient care. 

The same is probably the case for chemistry and haematology technologists as well, although I suspect being involved in blood transfusions or smears with leukemic cells may snap folks back to something closer to the clinical realm.

A number of years ago there was a lot of discussion that there could be a lot of value in taking a technologist off the bench, and have them make ward rounds with clinical staff to assist with laboratory and testing issues.  The concept was essentially developing a laboratory equivalent to the clinical pharmacist.  By putting a laboratory person on the ward would be beneficial for the patients and clinical staff because they would gain insights from the laboratorian, and the laboratorians would benefit from the clinical exposure.  It was a great idea, but never seemed to take off.  I think it was just a too far ahead of its time.

So this notion of disconnection as a interference that could be reversed has been around for a while, and it is still an intriguing today.

On the other hand, laboratory folks are not the only workers stuck in the ME generation.  Someone once said that hospitals changed for the worse when  they stopped primarily being places where unwell people would go for care and attention, and started being places whose primary focus and function was to hire nurses.  There is lots of clinical staff who have all sorts of access to the patient care experience, and who still focus most of their time and effort working and worrying mainly about themselves. 

So count me intrigued by the concept of disconnection.  I have a lot more thinking and hopefully some reading on the topic.

More on the Confab shortly.

 

m

PS - With respect to the other sentinel meeting, eserve June 18-19, 2011 for the UBC Program Office Quality Weekend Workshop in Vancouver.