The renaming of Quality Improvement?

 

I have had the opportunity to be actively involved with the American Society for Quality (ASQ).  I am the current Chair of the Healthcare Quality and Improvement Committee (HQIC).  I truly enjoy being  actively involved  because Healthcare Quality has become a personal passion.  Through HQIC I collaborate with like-minded people with a similar sense of passion. 

Last month the World Conference on Quality and Improvement was held in Philadelphia.  Unfortunately, I missed it because of another commitment.  Next year. 

But wait a second… in the last 3 sentences I used a phrase “Quality and Improvement” twice.  Prior to the last little while, I don’t think I have ever said or written Quality AND Improvement before.  I have talked and taught for years about Quality Improvement and Continual Quality Improvement and Continuous Quality Improvement, but never has the phrase Quality AND Improvement been part of that process.   Joseph Juran wrote volumes about Quality Improvement as did W. Edwards Deming, and Philip Crosby and while all of them were involved in ASQ they never used the interloping AND.

So where did it come from?

In 1947 the American Society for Quality Control (ASQC) was created as a union of some seven small organizations.   Each year they would hold an annual meeting (the ASQC Congress).

In 1997, on the 50^th anniversary of ASQC, the name of the organization was shorted to American Society for Quality (ASQ), I imagine because the organization appreciated that Quality had become more diverse and involved many more aspects than just Quality Control.

Along with the conference name change, the  meeting name similarly changed to Annual ASQ Congress.

Then eight years later in 2004, ASQ joined forces with several Quality organizations for other countries around the world, and they collectively decided there was value in merging all their congresses into a single world event which they called the World Congress on Quality AND Improvement;  and the interloping "AND" first appeared!

I wonder perhaps that was done to accommodate a common English translation for a conference including primary English and non-English speaking  countries.

In any event, jump forward anther 15 years to 2019, the ASQ goes through another modernizing name exercise.  Within the Healthcare Division there is a committee named Healthcare Technical Committee that needed a name revision.  They decided that a good name would  not be Healthcare Quality Improvement Committee (HQIC) but rather Healthcare Quality and Improvement Committee, still with the acronym HQIC.   

I don’t think any other committee in ASQ followed a similar path.   I did a global check of ASQ.org and found only one reference to an ASQ Committee with the phrase Quality and Improvement in its title, the aforementioned HQIC

Five years ago is not that long ago, however none of the people I have asked can remember why they opted for Quality AND Improvement.  Was there an ASQ organizational directive (now lost and forgotten) that recommended that all committees addressing Quality Improvement harmonize  their names with the conference name? 

So in the absence of a human memory, I decided to go the non-human route,  specifically  ChatGPT.  If AI doesn’t know the answer, then no answer exists.

So I asked the following… “What is the difference between ‘Quality Improvement’  and ‘Quality AND Improvement’? and in about 2 seconds, I got the following:

"Quality improvement" is a systematic, formal approach to the analysis of performance and efforts to improve it. In healthcare, for instance, it involves methodologies to improve care, patient outcomes, and other systems processes with an aim to reduce errors.

On the other hand, "quality and improvement" isn't a recognized term in the same sense but can be understood literally. It refers to the two distinct concepts of "quality" (the standard of something as measured against other things of a similar kind) and "improvement" (the act of making something better). This phrase might be used in a general context where one is talking about both the quality of something and the improvement of something, but they may not necessarily be related.

In my opinion this is an amazingly intuitive and nuanced response.  Scary that it comes from a machine.   Even if it is only the computations of a non-thinking machine, I don’t think it can be disregarded.  Somewhere in its algorithm  the machine recognized that Quality and Improvement are two separate processes that can function either together or  independently.  Just because an organization implements a Quality Improvement exercise doesn’t necessarily ensure there will be a measurable or meaningful improvement in the organization's  Quality. 

Seems to me there are two explanations for the interloping "AND"; either the folks back in that meeting in 2019 were truly visionary and  insightful, or it was a typographical error that never got caught. 

Or maybe they were just being smart alecs.

What I find interesting is that the term Quality and Improvement rings true in my ear, and I find the argument of recognizing the two activities as distinct compelling.  Maybe it is time for all references to Quality Improvement to adjust to the new AI standard.

I suspect Joseph and Edwards and Philip would enjoy the discussion.

Meeting Customer Threshold Needs in the Laboratory Proficiency Testing Cycle

 

This presentation is part 5 of a series highlighting 
Proficiency Testing as a Laboratory Quality Partner.

This series is put together by Dr. Michael A Noble BA MD FRCP the material founder and now retired chair of CMPT – Canadian (formerly Clinical) Microbiology Proficiency Testing Program.  It is based on his national and international experience and expertise in Proficiency Testing (PT/EQA).  Dr Noble continues on the advisory committee of CMPT and collaborates with other EQA programs including Oneworld Accuracy

 

Proficiency Testing (PT/EQA) is a Quality Partner, a program for laboratory Quality Assessment investigation and a foundational research base for learning about laboratory quality and laboratory error.  It is also a business with employees and customers and maybe even investors. 

The thing about businesses is that when they are organized correctly, they have a fair chance to succeed.  When they are organized poorly, especially about customer service, their chances of succeeding become much more limited, even if they feel protected as a required service. 

The reality is that when authorities and agencies receive enough complaints about poorly working programs, they can demand change, and programs can be dropped or replaced. 

Customer needs and satisfaction has been well studied in many businesses.  Noriaki Kano, an educator at the Tokyo University of Science was a consultant in quality management, and a pioneer in the arena of the customer satisfaction model.  Kano developed what is known as the Kano model, a structure that describes meeting customer needs in three stages, (a) threshold (or must-be), (b) linear (or progressive), and (c) customer delight.  For a more  information, you may want to visit: https://www.medicallaboratoryquality.com/2018/03/how-happy-are-your-customers-and-how.html

Without going into detail, I offer my interpretation based on years of satisfaction surveys and our very short list of complaints of how laboratory customers view proficiency testing programs and in particular what represents not meeting the needs and what approaches customer delight. (See below). 

Customer satisfaction is critically important in today’s post pandemic era, when businesses are struggling to hold on.  If a business is unable to meet the basic needs of threshold satisfaction, customers are apt to move on to another solution.

In PT/EQA basic threshold satisfaction means getting test samples to the laboratory on-time, intact, and providing challenges that the laboratories consider both relevant and fair.  If you tell the laboratory their samples will be arrive on Tuesday, they should arrive on Tuesday, and laboratories should get exactly what they ordered.  And they also expect and their samples should be intact, and not broken or leaking.   No surprises and no inconveniences.   

Break that commitment more than once, and your organization has lost face and reputation and maybe a customer.

That is why Production and  Distribution (Team 3) is so important.  If the samples are liquid, you need to ensure that the vials you use are sealed and leak-proof.  Packaging in most jurisdictions must meet specific regulations including absorbent material and sealed inner packaging to contain any leaks.  And packaging has to remain secure even if exposed to moisture or if dropped, and may have to be marked with visible warnings if they are deemed as being potentially dangerous. 

This is especially true if the contents could be classified as "dangerous goods".

Laboratories also expect the package to include specific instructions about handling and testing the samples and demand safety information in case there is a problem. Even if it seems that they don't read either of them, leaving them out is done at your peril.

Shippers have to be arranged well in advance and their waybill lists need to be completed accurately.  And when the shipper tells you they will be there at 2PM in order to ensure your shipment will get shipped on-time, you better have everything prepared and ready to go well before 2PM.  And never get the shipping address wrong.

If there are special instructions about where the package should be delivered and who is to be notified, that information must be available and apparent, or the package will get lost. 

If these tasks seem basic, they indeed are, but if they are ignored, the risk of reputational and maybe even liability damage rises, and there is no one to blame, except yourself.   

What may not seem apparent, these steps require close attention to detail.  Putting these tasks in the hands of workers that don’t have that level of knowledge and focus and discipline puts your organization at risk.  There  probably are people in your team that skills of exacting nature and abilities.  This is their place to shine.  It is called matching tasks with talents, an important step in Employee Engagement.

Bluntly put, if your organization can’t get this right, you probably are in the wrong business. 

In the next offering we will talk about achieving better and best customer satisfaction in PT/EQA.

 

 

 

 

RCA and Gnosis

Recently I was in a conversation with a standards development person, and an interesting (and new to me) turn of phrase was used.  ISO9001:2015 was called an “agnostic” standard by which my colleague meant that it would be generally applicable to every business or organization regardless of sector.   To me, agnostic has a very different meaning, a “don’t know, don’t care” attitude towards religion.

At first I thought that referring to a standard as agnostic was borrowing from religious terminology rather pedantic, but upon reflection I realized that referring to a standard as agnostic is a high compliment. In its purist form agnostic is derived from early Greek; “a” meaning “without” and “gnosis” meaning “esoteric knowledge” or “dogma”.  I can’t think of a better way to refer to a standard describing it as being “without dogma”. 

The Quality movement has tried to the extent possible to be agnostic and even scientific.  There is effort to stay away from devolving into its own belief system or esoterica or dogma.  In many instances it has been successful; in other places, to my mind, not so much. 

The other day I was reading in ASQ’s November issue of Quality Progress, and came around to an article by Matthew Barsalou entitled “A Better Way” in which he means a better approach to performing Root Cause Analysis  (RCA).  With no disrespect for Mr. Barsalou intended, in my mind, I find it difficult to put the words “Better Way” and “Root Cause Analysis” in the same sentence.  

I cannot think of anything more the opposite of “agnostic” than the concept of root cause analysis (RCA).  To my mind RCA is the very poster child of dogma in Quality. 

In the medical laboratory, it is an absolute that the investigation of nonconformities requires a Root Cause Analysis.  Accreditation bodies spend all sorts of time expecting laboratories to have RCAs for every proficiency testing error, every audit deficiency, and every complaint.  That is a requirement in ISO15189:2012 (medical laboratories – requirements for quality and competence) and also in ISO17043:2010 (Conformity assessment -- General requirements for proficiency testing).   

While I don’t have my copy of ISO/IEC ISO/IEC 17025:2005 (General requirements for the competence of testing and calibration laboratories) close at hand, I am almost certain it is in there as well. 

To their credit, the crafters (ISO TC176) of ISO9001:2015 (and its previous iterations) did not use that phrase; instead it simply says to “review, analyze, and determine the cause, and the determine if similar nonconformities exist or could exist”.  (Personally I would prefer a small but critical variation – “determine the possible or probable cause…).

RCA assumes that if you know that a bad thing has happened, a knowledgeable person can trace back to the point of origin which indicates the root of the evil outcome.  It’s like Stephen Hawking’s tracing back to the origins of time.  RCA is totally dependent on the assumption of traceable knowledge. Putting that level of faith in RCA flies directly in the face of important concepts like, Mathematical Chaos Theory, Knightian Risk, and Risk Management and the whole science of uncertainty.  

Chaos Theory is the mathematical model that informs that every cause leads to an effect, and every effect has a cause.  Causes and effects are non-linear, in that small cause may have big effect, or not.  Once causes occur the ripples that result can be altered, buffered, changed before the effect manifests, and the greater the time interval between the cause and effect, the more likely alterations occur.  And finally the “effect” you see may not be the significant effect. 

 That does not mean that we can just shrug our shoulders and soldier on.   We can and should do a look back and see if there is a possible or probable error that could account for our problem.  Sometimes it comes down to maybe a slip or a distraction, or perhaps an error in the procedure.  More often than not, it is little more than a supposition, unless there has been two or three events (boo hiss!) when at least you can look for common factors.  You can try to layer in another piece of swiss cheese (think James Reason).   

And then monitor to see if the problem stops happening.

So let me argue, that the time has come that we can follow the lead of the crafters in TC176 and get rid of the phrase “Root Cause”.  We can look and we can investigate and sometimes we will find a possible or probable cause.  

Just so long as we don’t make the transition from investigation to blame.  

Quality is about a lot of things, but laying blame is not one of them.

But maybe that’s just my own Dogma.

Note: a critical spelling error was found, and amended.  My apologies to any who might have been offended.