Reading Quality Tea-Leaves in Laboratory Medicine Residency Training.

Reading Quality Tea-Leaves in Laboratory Medicine Residency Training.

I have put on a Quality Management Seminar Series for Medical Laboratory Residents three times since 2007.  As far as I am aware it is the only Quality Seminar series for Laboratory Residents in the Country.  I have written about this before [see: http://www.medicallaboratoryquality.com/2011/02/resident-quality-seminars-as-adult.html].

Each time the series has covered the spectrum of Quality topics over a period of 7-8 hours over 3 or 4 days.  We include topics like historical perspective, standards, error, Quality tools, Management Review and Leadership.  It is not intended to be definitive course, but it is a start towards awareness.  Some of the residents have started taking our 20 week course to get a much fuller Quality experience.  I think that is a good thing, and I trust we will find that they think it is a good thing as well.  

In the first session, I was a neophyte on putting on courses, and missed the opportunity to get much pre seminar or post seminar information.  I fixed that the next series and improved the process again this time.  Either we belief in Quality Improvement or we don’t.  

There is one question that I have asked repeatedly, which is:

In your opinion, is the information in the Quality Seminar Series most apt to:

A: Your experiences as a resident in laboratory medicine

B: Your end-of-residency examinations

C: Your future career as a pathologist

D: None of the above.

Since we started I have seen each year that the most common response is always (C ) your future career as a pathologist, and that makes sense to me. 

But to me, the most interesting results are that over the period the (A) option has increased each year and the (B) option has decreased, and no one has ever used the (D) option.

Now to be fair, we get to ask the question every two years, and to date it has been answered only 3 times, and the total sample of responders each year is small; so I know that trying to interpret these results is a lot like reading tea-leaves and it would be a BIG mistake to put too much stock in this, BUT…

I see the trend of increasing awareness of the value of Quality as part of the general pathology and laboratory medicine residency (training period) as both real and positive. 

 

Here’s why.  A quick visit to PubMed [http://www.ncbi.nlm.nih.gov/pubmed/] the search engine for scanning articles in the US National Library of Medicine found over 120 articles where the phrases “Pathology and Laboratory Medicine” AND “Quality Management” OR “Quality Improvement” were found.  If I changed “pathology and laboratory medicine” to “laboratory testing” the number jumps to 15,634.  If I use just the term “six sigma” I find another list of some 1,295.  What that means is that any resident (trainee) who is regularly reading journal literature is seeing these words on a regular basis as part of the accepted peer-review literature.

Second, residents are commonly on the outlook for short term projects in which they can get involved.  Quality Improvement initiatives such as Internal Audits or Quality Indicator studies fit well with that.  

Third, some residents are becoming more aware of structured Quality Assessment including Proficiency Testing and Accreditation.  Some are even getting the opportunity to participate in site visits.

And fourth, many of the old pathologists who neither knew or cared about all that stuff have been retiring and are being replaced with younger staff who know and understand the value that Quality programs can add to the dynamic laboratory.  Getting rid of deadwood is always a good thing.  

Lastly, in my experience, people interested in pathology and laboratory medicine are not well known for being shy or particularly “politically correct”.  If they think something is a waste of time, there will usually be at least one person who will let you know.  That none of them have chosen this opportunity to point out that the Quality stuff is junk by choosing the option D, suggests that positive awareness is underway. And that is a good thing.

We will see what happens when we run the course again in 2014.

Constructive outrage about Education

In my previous entry I mentioned my mini-survey on Linked in about issues the group of laboratory professionals considered as “burning”.  The following is one of the responses:

“Continuing education on the topics of Lean/Process Improvement and Effective Management/Leadership. Med techs receive no training in these two important areas during their college courses, and this causes many laboratories to be less efficient and more dysfunctional than they need to be. Better management + improved processes = laboratories that are superb in every way!”

Since the survey was designed to be anonymous, I know nothing about the writer of the comment, other than the person is a laboratory professional that connects to Linked in.  While they might know of me, there is no purpose or advantage for them to be stroking my ego.  I therefore take the comment at face value.  That being said, I am very supportive of the sentiment being expressed.

Education providers are an interesting group.  On the one side, their personal interest side, educators tend to be a group prone to being progressive and promotional.  As a general rule, if you want to know what is current thought, talk to a teacher.  On the other side, the teaching professional side, they tend to be dreadful stick-in-the-muds.  When it comes to the content of their teaching, the rule of thumb is “change nothing”.  The process to change curriculum in many (most) universities and colleges is made difficult beyond difficult.  There are departmental committees, faculty committees, senate committees.  Everyone needs to have the opportunity to discuss and debate forever.

When it comes to Quality, with the exception of business schools and Engineering, you might think that the concepts were never developed.  (Most Business school curricula will have a course which includes Frederick Winslow Taylor, Water Shewhart, and William Edwards Deming, and most Engineering schools will have curricula on ISO 9000.) 

But in Medical Laboratory Technologist programs, there has been essentially little progress beyond Levey and Jenning, with perhaps the inclusion of the rules of James Westgard, which essentially are all about how to use and interpret Levey-Jenning charts.  Quality in these programs means Quality Control.  Period.  End Stop. 

That also is true when it comes to training programs for Pathology and Laboratory Medicine Residency programs.  And in my experience the same is true in medical science oriented graduate studies programs. 

So we continue to have laboratorians with absence of understanding of critical issues like how to reduce error, how to evaluate risk, how to reduce poor quality costs, and how to implement effective change.  As a colleague said today, their working strategy for change and improvement is IDEA - SHOOT - AIM!

There are programs that fill the void, mainly on a Continuing Education level.  For example there are courses available through the American Society for Quality, and Clinical Laboratory Manager Association (CLMA) and the Michener Institute (Toronto) and of course, my course The Certificate Course in Laboratory Quality Management through the University of British Columbia (see www.POLQM.ca).  And I am sure there are lots others, but they all have the same common characteristics; they are voluntary and they are provided as post-graduate continuing education. 

One can wonder why this programmatic void exists.  In my opinion it is a mix of disinterest, absence of imagination and visioning, and above all, inertia, all the hallmarks of stagnation.  And that is just sad.

And so to the anonymous responder to the survey.  Congratulations for speaking up here.  Now, take that same idea forward to your laboratory and organization and college or university.  Take it forward with constructive outrage. 

Demand change.

And in the meantime, contact me at www.POLQM.ca  

PS:  I have had a few more responses to my survey (http://www.surveymonkey.com/s/BurningIssuesB).  The ranking of burning issues remains the same, with stronger values.  Feel free to participate over the next few days.

An important meeting for this year.

 

www.POLQMWeekendWorkshop.ca

Quality Education: what's it good for?

We are putting together a Master’s in Laboratory Quality Management which we expect will be available both in an on-line option and an on-site option.  The on-line will primarily be for folks who are working and intend to continue to work.  The on-site will be for folks who want to take some time away and spend some time doing primary research in medical laboratory quality.  I will continue to write on the subject as the program becomes ready for prime-time.

In the process of putting the proposal together, we did a survey of the folks who participated in the UBC Certificate Course.  Rather than invite and re-invite folks to respond to the survey we made the decision to take the responders from the first pass.  Both approaches can be equally useful, as long as you take methodology  into consideration as you interpret the results.

So after 5 days we gathered about 25 percent of course attenders.  The distribution of folks from across British Columbia and across Canada, and from outside Canada were essentially the same as the total group.  In addition the responders  equally included participants from the early years, the middle years, and the recent years, and few from the current group.   As we did not put any pressure on this group we can interpret this as a reasonably representative group.

Of interest to us was that about 90% belief there is a market for people with a Master’s degree today, and that the same percentage see that the market will be much stronger over the next 5-10 years.  That is what I believe too.

One finding that interested me, and disappointed me at the same time, was that only about 65% of responders currently are holding positions involved directly  in Quality.  We didn’t ask how many had held quality positions but had changed jobs, in large part because that was not the primary point of the survey  But what was interesting was that folks who had taken the course but were not actively engaged in Quality positions still believed there are opportunities out there, and that the market will continue to get stronger.

Which all got me to thinking; there are all sorts of positions for people interested in and trained in Quality.  The most obvious position is as part of a quality team or a part of laboratory  management.  But there are lots of other places as well.  There are positions with all the quality partners, like the proficiency testing group and the accreditation bodies.  There are positions within public or civil service, especially within the Ministries (or Departments) of Health and the health authorities, where knowledge of laboratory quality is important.  There are positions with service and equipment and reagent suppliers who need to be aware of validation, verification, stability, and measurement uncertainty.  And there are consultant positions, especially as we in Canada move more and more towards official inquiries for laboratory error.  And importantly there are increasing opportunities within education with the schools of technology, as well as the medical schools.

Bottom line appears to be that Quality in health and in particular the medical laboratory is a growth opportunity; today and tomorrow, and from the folks who responded to our survey, for the next 5-10 years plus.

Resident Quality Seminars as Adult Education

A few weeks ago I wrote (See “Communicating Quality and the Principles of Adult Education - January 30th 2011) that adults learn what they want, and  how they want and accept the knowledge if it makes sense and is consistent with what we already know.  The educator needed to be seen to be organized and pragmatic and relevant and interesting.  If adults are motivated they learn better.  

So with this in mind, can I make any objective comments about my own teaching capabilities?

I got back the results from my Resident Seminar Series.  
 
Background 
To summarize, I put on a seminar series for anatomic and general pathology residents.  The series begins the week after New Years and my sessions start at 08:00 AM.  A draw to the academic half day program is that they get a free breakfast when they attend.  
Before I start the seminar series  I create an anonymous on-line survey that includes a series of 10 questions on quality facts, along with some demographic information.  I then present 7 hours of seminars over 4 sessions and give 1 hour to a guest presenter, and after that asked the group to respond to a second on-line survey which asked the same questions as before and added some additional comments on the series based on a 7 point Likert ranked scale with a maximum value of 6.0

Attendance
The pre-seminar survey had 25 responders.  
On average there were 29-31 attenders to the seminar series.  Nearly everyone attended all 4 sessions.
The post-seminar survey had 14 responders.

Findings
So my first point.  Adult learners do what they want and respond to surveys if there is something on the table.  After the series we were able to get 14 responders (despite repeated requests).  Not getting a better response rate in the post-survey was annoying, but it is what is is.  

My second point:  There was improvement in the responses to all the fact based questions.  There was significant improvement (yates corrected p<0.05) in 2 questions.

My third point:  The responders found the information relevant to their career (5.5/6.0)  informative (5.36/6.0), relevant to their residency (5.29/6/0), and relevant to preparation for examinations (5.07/6.0)  The weakest response was when the group found the information interesting (5.0/6.0).  

Interpretation.  
Overall I can this a success.  Not an overwhelming success, but a success none the less.  

What was encouraging was that after the series, one resident  approached the hospital quality manager to get engaged in a project, and one resident approached me on a similar topic.

The increase in knowledge performance was ojectively positive and in part significantly so.  And there is a powerful opinion and recognition that knowing something about quality is important in a laboratory career.

Discussion and Conclusion
The objective measures point to the seminar series as a measurable success with opportunities for improvement.

Teaching my on;line course is the ideal adult education situation.  The participants seek us out because they want the information.  There is money on the table.  They feel free to participate actively.
With residents, they are present because they feel required to be there, even if they don’t care.  At worst they still get a free breakfast.  There is no money on the table.  They feel free to drop out if they are not being entertained.   

Note to myself:  
Look forward to doing the seminar series again, maybe next year, more likely in 2 years.  
Make some changes to beef up interest.  
And importantly don’t take the weak response rate too personally.  If they really thought the series stunk they probably would have taken full advantage to let me know.  

PS:
The information will be presented more completely and formally during the POLQM Quality Weekend Workshop in June.  There will be an education breakout session.

Communicating Quality and the Principles of Adult Education

In recent while, I have been engaged in the active promotion of  medical laboratory quality in a variety of forums, including writing this web-log, providing an on-line course, hosting single-site lunch time education,  hosting the resident seminar series, and organizing and participating in workshops and conferences.  All of them have provided me with the opportunity to consolidate my own philosophy towards Quality.  

There is a lot of differences between all these activities; some have been held in Canada and others are international, some are one-off events while others short-term multiple events, and others yet are long multiple events, some of them are at no-charge to the participants while others are at substantial cost. Some of the participants want to be participating while others they are there because they feel compelled for one reason or another.  It would be easy to say that the only thing they have in common is a common topic, but there is something of far greater commonality; all the participants are adults.

Teaching adults is a special event because adults learn in their own special way.  There is tons written on adult learning.   For a quick summary you can visit Principles of Adult Learning at the University of Hawaii site.  

There are lots of reasons that people attend courses.  For learning, the most successful reasons are when they believe there is something in it for them; it is a topic of interest or there is an opportunity for career advancement.  Sometimes it is less about knowledge, and more about the social aspects; is a way to meet and connect with others, or is better than just being bored.  These folks may not be focused on learning, but they might connect.  Sometimes folks attend solely because they have to; it is a requirement and attendance is being taken.  This never turns out well.

Adults are autonomous and self-directed, and learn on top of their accumulated knowledge and life experiences, which means we learn what we want and how we want and accept the knowledge if it makes sense and is consistent with what we already know.  And we learn if we see the purpose to the information and especially it is meets our own goals.  And we are practical and pragmatic learners; if the information is not organized and timely then we turn-off. 

Adults tend to learn best if motivated, especially if we can link the information to what we do as a matter of competence or promotion, or job enrichment.  (Some say we learn better if there is money on the line.)  

For the educator, this means that the successful ones make the information relevant to what people do, is consistent with what they already know and link the knowledge to competence and enrichment.  Keep the information organized and timely and interesting.  For me, I have been involved as an adult educator for over 30 years.  When I think back to what I was like when I started, I can say with confidence that I am a lot better today than I was back then.  And one of these days I may actually get it right.  

One of the most successful educators I know has a formula.  He has 3 points to make (4 points a maximum).  He makes his points and reinforces them with stories and humor.  When he has delivered his points and told his stories, he stops.  I’m pretty good at the selecting 3-4 points and the telling stories.  I am pretty weak at the humor, and tend talk until I run out of time, rather that knowing when to stop.

Memo to self:  with widely divergent groups, some folks are there because they want to be there; others are not.  Remember the motivation; point of why knowing about Quality is an important   component of competency and enrichment, and can have an impact on promotion.  Be organized and know when to stop talking.  After than, the rest is largely out of your control, so don't worry about it.

m

PS: I am accumulating the post seminar series data now.  Will share the results soon.

PPS:  Big changes at www.POLQMWeekendWorkshop.ca  Lots of NEW information.