The Distributed Costs of Poor Laboratory Quality

 

 https://cost-impact.netlify.app

 I have written about Costs of Poor Quality before (see: Tuesday, March 3, 2020CVP - The Coronavirus Vanity Project -or- Sunday, March 6, 2016 Another look at costing Quality-2016 -or- Saturday, June 7, 2014 Taking Charge - Taking Responsibility ) It is a favourite topic of mine.
While first introduced by Joseph Juran, it was best defined by Philip Crosby as the Measurement of Quality. “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.” 

 Crosby made the point that all too often these non-conformance costs could add to more than 10 fold the costs of “doing it right the first time”. My guess is that he didn’t just pick that number 10-fold of the air; my guess it was probably based on a ton of calculation, which must have been a megaton of work considering the state of computers (by reference that was the year that I bought my first Commodore 64 with its amazing 64K of RAM).
Today we can take a better measure of the Costs of Quality and Costs of Poor Quality. My estimate is that today the Costs of Poor Quality can run up to 100-1000 times the cost of doing it right the first time round.

When thinking about Quality Costs any organization,  it becomes apparent that the Quality Costs are core or nuclear, but Poor Quality Costs are expansive, maybe explosive. Quality Costs can all be captured as a series of single line items in the laboratory’s budget. It is much harder to capture Poor Quality Costs because they not only affect the laboratory through extra reagent costs, extra staff work time, and repair and maintenance costs, but they also extent outside the laboratory hitting the budgets and pocketbooks of our customers. Think about these as the Distributed Costs of Poor Laboratory Quality. 

When a clinician is notified about an incorrect result, they will need to go into their files, find the patient, contact them and explain the problem and may have them go back to the laboratory for another test. They will need an additional note in the chart. That all takes time out of their day, maybe 20 minutes to an hour for each patient (more if contact requires a few phone calls) for which they probably cannot bill.
For the patient, their time and patience are consumed; they were notified and informed a test result may be in error causing stress and probably annoyance. They may need to have a retest; maybe they will need to get a sitter, or leave work early, or drive to the laboratory and park, all of which is money out of their pocket. Maybe they will lose work time and maybe lose income. Maybe they have already purchased medications based on the wrong information. Pretty sure the pharmacist is not going to take the pills back.
And what if the problem was a microbiological problem that got public health attention (an errant COVID-19 test, or stool pathogen test). The chase-down and corrections can consume many hours.
Worse, if the problem had some bad outcomes and lawyers got involved, there are going to be facility costs that could run into the thousands, if not millions of dollars.

And what if the error was not picked up right away and more than one patient was involved. Maybe it was 5, or maybe 10. I was involved in the investigation of one that involved over 100 patients.

So what starts as a simple “oops” can sometimes within the blink of an eye evolve into a very big deal. Capturing these distributed costs can be an important part of your awareness and corrective action process. Taking ownership may be a bitter pill to swallow, , but learning about these distributed costs has to be a part of the nonconformance / OFI investigation, which certainly is an accreditation requirement, and far more importantly and Quality requirement. 

If you want to visualize how much these distributed costs can climb, I have a tool that calculate the estimated costs and give you a graphic depiction in dollars and minutes. Let me know if you think it helpful.

 https://cost-impact.netlify.app

Quality and Social Networking

Quality and Social Networking

Paul Borawski asks an interesting question about the use of Social Networking by Quality Managers [see: http://asq.org/blog/2013/07/which-social-networks-do-quality-professionals-use/ ] 

I have to tell you that every time I hear the term “social network” I think of West Side Story and the song Gee Officer Krupke  that includes the line:  “Hey, I got a social disease…”  I don’t know if Stephen Sondheim appreciated that he was writing for the ages, but I think he pretty much nailed it with the line “It’s not I'm antisocial, I'm only anti-work”. 

Social networking, in all its manifestations is more about anti-Quality and about pro-Quality.  It’s about wasting time, and letting your ego get ahead of the thinking part of your brain.  It has more to do with addiction and self pleasure (dare I say the “M” word?) than about constructive activity. 

Is there anything really productive about Facebook or Linked-in?  Not very much.  Lots of pictures, lots of writing, lots of trivia and fun, and lots of minutes and hours consumed.  No wonder so many companies and organizations block access.

But the social network programs are part of our world now and some of it, used sparingly, can actually verge to the edge of being productive. 

Take Twitter for example.  Whatawastatime.  Pretty much a total self amusement for narcissists who think that folks should care about what they ate for dinner.  But in certain situations Twitter can be a powerful notice provider when there is a crisis.  For the Quality team, 140 characters is pretty much all you need to let folks know to look in the manual for a notice of document change, or to check the office white board for a procedure notice.  Yes, you can do that all by sending a group email but it is easier to send with Twitter and a lot easier to receive, provided that reading Tweets is reserved for when you are NOT doing critical activities. 

And how about Blogs? Again, pretty marginal.  For some, 700 words is about what they need to put together a cohesive cogent argument.  Blogs can be a structure to substitute for self-published manuscripts.  Readers need to be really careful and really selective because of the absence of a professional or peer reviewer of editor, but occasionally the information can be, if not useful, at least interesting.  For me, I have always been a diary writer; I think better when my hands are busy.  So for me, my blog is as much personal as it is public.  But I do understand that some folks see blogs as strong manifestation of self-absorption. 

As a provider of education courses, I personally find You Tube as a powerful tool for sharing video information with course participants, and there are tons of really good examples on You Tube of video procedures.   In the “olden days” creating video meant going to a studio and paying a whole wack of money to put together a series of teaching clips.  Today you can do the same thing for free and in less time, making it possible to provide regular video updates.  If there is a downside to the  ease of use is the temptation to generate clips that are too casual.  Take the time to create work with polish. 

Where will we be as time goes by?  Who knows.  Over the short term probably we will see more of the same.  But with the internet the one thing that is certain is that there will be change and innovation and new ways to while away the time.

PS:  Our Vancouver conference on Medical Laboratory Quality is shaping up really well.  Vancouver is a great place to be in October.  I look forward to meeting your there.  For more information, visit  [http://polqm.ca/conference_2013/conference_2013/conference_home.html ]

Another Successful Quality Seminar

Another Successful Quality Seminar

In Canada we have a variety of medical laboratorian organizations whose primary function is to bring people together for an annual meeting.  For microbiology technologists, scientists, and physicians the predominant organization is known as the Canadian Association for Clinical Microbiology and Infectious Disease, which is abbreviated as CACMID.  To some the word CACMID brings to mind hacking and gagging, not in a polite way.  The organization has been around and active since 1974.

In 1994, I proposed to create a side seminar to highlight the interests and activities of Canadian microbiology oriented Proficiency Testing programs.  It turned out to be pleasantly successful, and there was a thought that we should do it again.  Well we did, again and again, and yesterday we did it again, for the 20^th time.  

With the probable exception of the annual conference of the American Society for Quality, I would not be surprised if our 20 year run is the longest run of conferences dedicated solely to Quality in any industry.  If someone knows of another series or other series, I would be interested in hearing.

Over the years both the hosting organization and the Quality seminar meeting has evolved.  Now there are two hosting organizations CACMID and AMMI-Canada (the Canadian Society for Infectious Diseases and Medical Microbiology).  The Quality seminar has moved from its focus exclusively microbiology and PT.  Over the years we have high-lighted accreditation, standards development, Quality education, and suppliers; in essence  we have covered the spectrum of Quality and the collective group of Quality Partners.  

This year was another evolution as we focused on a variety of laboratory Quality tools.  One speaker was a clinical chemist who gave a very interesting discussion of Six Sigma calculations and how they can be used to describe and monitor error in the medical laboratory, not only with respect to quantitative assays but also for qualitative ones.  In the medical laboratory we see six sigma as a valuable shorthand that can reduce very complex numbers to very small and simple numbers.  This is very analogous to pH as a measure of hydrogen concentration or logarithms for that reduce 1,000,000,000 down to 10⁹.  Already we hear laboratory folks talking about having an error rate around 4 (meaning an error rate around 0.5%) so we know that the shorthand is taking hold.

The second talk was one to which I am very committed.  In North America jurisdictions are falling over themselves consolidating many laboratories into 1 mega-laboratory; very financially efficient, but maybe questionable on effectiveness.  An adage in healthcare has long been “closer to home” meaning that the facility near you knows you as a person while the mega-lab doesn’t know much other than you as a number and a vial of blood.  Our second speaker was talking about implementing Quality into a laboratory in a small town hospital.  It we can keep these smaller facilities up-to-date and up-to-Quality, we extend and enrich their value far greater than shipping samples down the road to the big house.

The third presentation was on another subject that I enjoy; implementing internal audits in new formats that increase interest and attention and focus and knowledge.  It moves audits from the section called “mundane and boring” to “interesting and fun”.  Sara (the presenter) did a great job of conveying enthusiasm.

The fourth presentation was on a better way to look at Risk as it applies to decision making in the medical laboratory.  I have previously written in this blog about Risk and Uncertainty and Severity-Occurrence as a value monitoring tool.  This was my first time to do a live presentation on the subject of Risk.  I was pleased at how well it went, but it still has opportunities and potential for improvement.

For those interested we have posted 3 of the 4 presentations at www.POLQM.ca for public 

viewing.  

 One of the presentations is going through a review, because the spectre of copyright infringement has been raised.  I suspect it is more speculation than fact, but we are checking it out rather than facing off problems.  It likely will appear next week. 

So with another successful meeting under our belt, some decisions are being made about what happens next.  Personally I have to do a motivation check after every seminar these days.  The process of getting new and fresh speakers is getting tougher.  But at the moment, I am pleased with 20, but now we are thinking of shooting for 25. 

Time will tell.

BC Quality Forum 2012

I had the opportunity to attend an interesting conference earlier this week.  It was the British Columbia Quality Forum, hosted and supported by the British Columbia Patient Safety and Quality Council.  It was an interesting meeting with lots of positives, and maybe, as we say in the Quality arena some room for improvement.

We can start with the positives.  This was primarily a local crowd from my home province.  There must have been the better part of 500 people attending.  When you consider that in British Columbia in total there are about 4 million people and in clinical health care there are maybe 50 thousand workers, having a group of 500 come out to a 2-day conference on Quality represents a pretty substantial level of interest..

Most of the attendees were nurses or hospital or ministry related bureaucrats and administrators.  A few physicians.  I think I was the only person from the laboratory world.  So you can see there was a strongly clinical bent in the crowd. 

Watching what happens as a new movement starts to catch a lot of attention and enthusiasm can be a lot like watching a novice rider sitting atop a galloping horse; arms and legs all akimbo, holding on to the reins, trying to stay in control but very much just trying to stay atop.  There was a large scatter of projects, most of them (in my opinion) basic and trivial, but with all sorts of enthusiasm and a far too much jargon talk about “PDSAing” and Kaizen and Just Culture.  The over-riding sense is lots of trial and lots more error; all the finger prints of faddism.

One presentation stands out as the poster child of enthusiasm without substance.  A pediatric hospital saw a need to develop a new pathway to alert the team when a child was seen to be taking a “turn for the worse”.  That’s a good idea.  So after many versions and revisions (PDSAing) the document was released for use.  After two years they looked at the number of bad events there had been and saw a substantial drop the first year, but a return the next.  They would like to point to the use of their protocol as the base for success, but as they pointed out, many staff didn’t like to use the document, most of the new staff were not trained on how to use it, and none of the doctors knew anything about it.  So having learned this what had they done about it?  Well not much, but they had plans.  So while there was some good intention and lots of audience and self-congratulation on a task so well done, when it came down to the crunch, the real point of the exercise had been missed.  Having recognized a need, there had been a Plan to create a solution, and an implementation (Do) and an examination on how it was working (Study) but no follow through; all this revision and revising of the form, but no tangible steps to implement improvement. 

If that sounds negative and pessimistic and petty, that would be a poor and unfair choice of words on my part because on balance I have more cautionary enthusiasm than discouragement.  Having been involved in a LOT of conference at every level from institutional to international, I have seen many weak presentations.  From that perspective, this presentation is a fairly typical example of a neophyte group grappling to experiment with something new.  

I have been working in the Quality arena now for near 30 years, and it is great to see that clinically oriented healthcare is both aware and constructively starting to catch on.  If I have a concern, it would be that superficial dappling that uses up TEEM resources without tangible will result in disappointment and if it becomes a flash it will quickly become a burned-out fad.

Memo to self: By its history, development and quantitative nature,  the medical laboratory is much further along the path to Quality implementation than clinical service, but typical of the introvert nature of laboratorians there was virtually no presence.  It is consistent with the absence of laboratory presentations at the annual conference on resident education.  Not participating in these Education and Quality forums is a poor decision.  If you don’t get engaged in the community, you can’t be disappoint when it doesn’t appreciate your accomplishments.).  

Next year, if the BC Patient Safety and Quality Council decides to put on a forum again, I am going to ensure there are at least 10 laboratory presentations.  My group will do four. 

Now all I have to do is convince some of my colleagues to submit the other six.