Quality and the Pre-examination delemma

In my last post I commented on our recent  Quality Seminar in which there were two papers on a new standard being developed to help laboratories improve their pre-examination procedures.   

The problems are well established.  The pre-examination phase of laboratory testing is a highly manual, person intensive group of procedures that address collecting, transport, accessioning and storing of patients’ samples.  The system is fraught with error, usually accounting for 70-80 percent of reported laboratory errors. If a laboratory wants to improve their overall performance and contribution to medical care they should focus on reducing their absolute numbers of laboratory error.

The new Canadian Standards Association standard (Z316.7 Primary sample collection facilities and medical laboratories – Requirements for requesting, collecting, transporting, and storing samples for patient safety and quality of care.) is going to be a valuable and informative guidance document.  

I suspect that most Canadian accreditation bodies will pick it up as a good accreditation document, and even if they don’t, laboratories will still find it an invaluable document to support their quality system.  It is broadly inclusive and rich with guidance.  If I have a criticism (and it is pretty minor), it is that some may find it almost too encyclopaedic.

On the other hand the informative annex designed for Microbiology is the opposite of encyclopaedic.  It is compact and more general than specific, but in an invaluable way.  Microbiology and tissue pathology are very different from Chemistry and Haematology because microbiology and pathology samples are rarely collected by laboratory trained and supervised personnel.  The annex makes it clear that that samples for each laboratory need to meet a specification  set (proper technique, correct container, accurate information, proper handling and transport) and if they are not met, the sample will likely be damaged and the quality of the sample impaired.  

The collector needs the information before collecting (afterwards is too late) and if they do not know the information for this specific laboratory (each laboratory is 
different) then check the correct manual or CONTACT  the laboratory BEFORE you collect the sample. 

Commonly microbiology samples are collected by nurses or physicians, and sometimes by the patient or their family.  The physicians and nurses that collect these samples are all professional, and caring, and knowledgeable in their field, but the reality is that few of them are informed about what to consider when collecting a sample for the laboratory.  Few actually look at a collection manual, and assume the way they learned it back in school is still the right way.  Some (not many) still work with“Just get it to the laboratory.  They’ll figure out what to do with it.” 

All too often we have not been clear enough about our message:  if you didn’t do it right, then you did it wrong and the laboratory can’t undo the damage.

The challenge to us is how to communicate the message.  We can write collection manuals, but when you consider how many pre-examination error occur, that does not appear to be particularly effective.  In some special facilities some of the information can be embedded in the laboratory information system, but again the information is usually seen after the collection when it is already in a wrong container, or in the refrigerator.  And none of this addresses the sample collection that goes on in all the family practice offices, and walk-in clinics, and homecare settings.  

The new standard makes it clear that as much as we have allowed the other people to collected our samples, we are responsible for the overall quality and we need to take more responsibility in ensuring that the pre-examination phase is done properly. 

All this brings us back to how we teach adult learners.  Adults learn what they understand is relevant to them.  They want it delivered clearly and concisely in a format that makes sense and in a manner that allows for communication and clarity.  

Experience tells us that writing memos or newsletters or posters are not sufficiently effective.  Holding workshops and seminars doesn’t seem to hold a lot of interest.  Non-motivated adults choose to not learn.  Positive motivation works better, but sometimes so does negative motivation.

If we are responsible for the creation of laboratory information, then at a certain point we may eventually have to become more aggressive in ensuring pre-examination requirements.   More hard lined.  Samples will not be accepted unless we can confirm they were collected in the proper fashion, and put in the appropriate containers and handled for transport in the appropriate fashion.  Fewer samples will be processed, but our confidence in the reliability of outcome for the ones that are will be higher.

In the coming era, soon if not now upon us, when reports go directly to patients with increasing expectation for accurate and meaningful results, then our choices are getting fewer.

So with apologies to Philip Crosby, welcome to the new version of DIRFT:  Do It Right Or Don’t Do It At All (DIRODDIAA).  

It would be enough to get Demining to roll over in his grave.   

   

Meet Dr. Watson

Michael Laposata is professor of pathology and medicine at Vanderbilt University School of Medicine in Nashville.  A number of years ago he coined the terms “pre-pre analytic” and “post-post analytic” to define the interface between the clinician and the laboratory.  One the one side, if the clinician orders the wrong test (pre-pre), then everything that follows is for not.  On the other side, if the clinical does not understand the result or misinterprets it (post-post), the same holds true. 

There are procedures that can be put into place to reduce error at these two critical points.  Electronic ordering systems can insert some specific questions that will direct the test orderer in one way or another.  And incorporation of advisory notes and cautionary notes and interpretive notes into the report can provide some assistance.  But to date neither of these systems is widely used in laboratory practice.  We tend to be comfortable staying within our self-imposed boundaries.

But it appears that the next generation of solution makers is just on the horizon, and its name is Watson.

For those who do not watch American game shows, IBM’s most recent super hero is a mega networked computer named Watson.  Watson is the son (or maybe the grandson of Deep Blue, the computer that beat the chess genius Garry Kasparov.  Watson is today’s best example of how far computers have moved towards faster-than-human artificial intelligence.  Basically one loads up Watson with about 200 million pages of information.  When asked a question it can process the information of about a million books per second and determine the best connected answer.  Watson is likely to provide recommendations for the right test at the right fashion at the right time, and give recommendations for the most appropriate interpretation.

In a head-to-head challenge with the 2 best humans ever to compete in the knowledge game show (Jeopardy), Watson was faster and over 98 percent correct.  In a two day competition, Watson “cleaned their human clocks”.

I raise this because the IBM team has decided that the next best target for Watson is to partner up with a medical insurance company to tackle the science and art of medical diagnosis and treatment.  The outcome is likely to be predictable.  Like the Olympians say “Higher – Faster – Stronger”.

It is the modern linear pattern.  In the early chaos, we find leaders, and in leaders we find body of knowledge authorities.  Doctors (as an example) became the repository of knowledge.  The internet changed all that with the democratization of knowledge so that everyone could believe that they could be an expert.  Watson goes the next step. 

I suspect that in a world with so much information, nobody can be a better expert than a supercomputer.  Watson will take the art out of diagnosis and fill in with lightening speed relational and probability analysis.  It will know and integrate what people forget. It will exclude personal bias and myth and “n-of-one” information. 

There are factors that make forming diagnoses more challenging than winning on Jeopardy.  Good clinicians are influenced by visual and tactile and olfactory clues that will not be available to Watson.  And depending on how one asks a question about symptoms, one can get a different response.  So I suspect that on a good day and in a one-off situation, the human diagnosticians will come out not too bad.

But on the long haul, we all tend to be burdened and distracted by so many side issues (hunger and heartburn, noises, smells, fatique, taxes, spousal tiffs, parking tickets) that Watson will do better.

Now what we will need is a machine that will improve the pre-examination phase, the next step along the way.

If Watson is here now, can HAL be far behind?

For a course in medical laboratory Quality with a Twist, visit www.POLQM.ca

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