Customer Satisfaction and the Medical Laboratory - again

Let me state from the get-go that in my opinion, the jump-start in medical laboratory Quality around the world in the last 10 years can be directly attributed to the International Organization for Standardization and its creation of its landmark standard ISO15189, requirements for quality and competence. 

Many countries had dabbled with medical laboratory accreditation since the 1970’s most of their documents were created by cherry picking good ideas from a broad variety of processes, some from credible organizations, others developed from local opinion makers.  Some countries, like the United States created federal legislation on minimum requirements, and others, like Australia adapted other documents, such as Guide 25 which became ISO17025.  But the reality was that issues of Quality monitoring, and Quality improvement remained by and large a combination of minimal Quality Control and Lip Service. 

With the increasing awareness of the dangers imposed by healthcare (IOM’s To Err is Human) and a voluntary standard ISO15189:2003 many medical laboratories around the world started to focus on implementing Quality Management Systems. 

It has been an impressive change in mind-set.  That is not to say that the task is done and now we can go on to the next thing.  In my opinion medical laboratory Quality still has a long way to go. 

Take for example the principle of Satisfaction.  This is not a new concept.  Japanese engineers, having benefited from giants like Deming and Juran and wrote early about customer expectations and “customer driven” Quality.  Crosby reinforced and popularized the recognition of Quality as meeting requirements. 

Business learned that waiting upon receipt of complaints was a poor way of assessing satisfaction; much more active approaches are needed to garner information.  Many have taken to doing customer satisfaction surveys, often by internet.  Unfortunately many are poorly designed and don’t create much useful information, but I have written about that before.

ISO15189:2012 talks about customers and complaints and suggestions, but the word “satisfaction” does not appear in the document.  It does not suggest or imply that surveys can or should be done, which is interesting since the concept of surveys was included in the previous versions.  There are so many steps along the way that can through simple and inexpensive measures improve service and efficiency from the specimen ordering form, through the process of sample collection, and transport to accessioning and on through reporting.  They require some attention to detail, but they would reduce the risk of error that result in delayed results or worse. 

Most docs and patients don’t bother to complain because it is not worth the bother.  That is common everywhere.  Many organizations have realized that most people do not complain, and that when one is received that represents perhaps 10 others that were felt but not entered.  Actively pursuing information to learn how laboratory workers are functioning, through the eyes of the users is a valuable way to gather information.  (Note: not the only way; direct observation through internal audit is also invaluable)

So entering into a third iteration of the document and stepping further back from actively pursuing information, in my opinion is a step backwards. 

In Canada, where nearly all healthcare is public, the absence of an active process to define opinion is really lacking.  One might interpret this as “who cares”.  Government is very interested in reducing costs, and I suspect strongly believes that asking opinions of how to meet “customer driven” requirements would increase the costs, not lower them.  But from Juran a long time ago it was clear that small improvements can result in substantial decreases in total costs associated with poor quality.

(As a side note, recently I was a customer of our health care system.  Most of the experience was excellent, but there were also significant problems that could and should be addressed.  If I want to bring these to people’s attention, I would be required to write a formal letter.  I am not averse to writing, but I have to decide if it is worth the energy.)

The private sector of health care in Canada, the US, and the Caribbean are embracing 15189 more aggressively than the public sector; I suspect that is because they see the financial and business advantage that Quality and Satisfaction can bring.  I trust that these organizations have the smarts to recognize that defining and meeting customer driven requirements is where Quality should begin, and not where it should end. 

ISO15189:2012 is a valuable part of the Quality movement, but the crafters need to focus on  gathering better information if they want laboratory Quality to get to the next step..

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.

Resolutions 2011

I used to think that New Year’s resolutions were pretty much a waste of time. Most people that I know still do. I vow to be good; I resolve to quit eating; I resolve to quit smoking:   I resolve to get more exercise.  I resolve to stop being sarcastic. Yeah, yeah, and ...yeah.

But over the 5 or 6 years, the concept of resolutions started to make a little more sense. New Year's Resolutions are just a variation on the theme of setting Objectives and Goal.
I mentioned before that CMPT`s quality system has been certified to ISO9001: (2000 - 2008) since 2002. Every year in October we set quality and programmatic goals and objectives and then monitor to ensure that we meet our goals.  When we started we did this so that we would continue to get certified, but after a while we saw the value in the exercise, and did it for us... to keep CMPT on path and on track.  And it seems to actually be effective.

So it started to make sense that if we can do this positively and painlessly for a proficiency testing program, we should be able to do the same thing for the Program Office for Laboratory Quality Management, and for my teaching commitments, and also for the medical laboratory at which I worked as a medical director for Quality. And again, the experience reinforced itself by actually being productive. 

Go figure.  Those guys like Deming and Crosby actually knew what they were talking about.

And now that MMLQR goes though its first New Year,  it is time to start setting some objectives for it too.  Actually MMLQR has only been running for 6 months, but this is sort of like setting or re-setting an organization's fiscal or operational calendar.

Just to make sure we are on the same page, I use the term Objective to mean a large scale outcome that may take a number of steps to reach, and I use the term Goal to identify the individual steps.  To be credible the objectives should be achievable and the goals should be measurable.

So here are my goals and objectives for MMLQR for calendar year 2011

Objective 1:

MMLQR will be recognized as an active and credible and readable website to promote diversity of opinion and discussion for the full range of issues that surround quality management of medical laboratories.


Goal 1
To meet the measure of "recognized" I will promote MMLQR to support current readership and to encourage a broader audience.

Goal 2
To meet the measure of ``active``, I will generate at least one new entry each week.

Goal 3
To meet the measure of ``credible`` I will actively seek review and comment by others with long term interest in medical laboratory Qualitology.  This might be in the form of another shot at an electronic survey, or in the form of an external-internal audit.

Goal 4
To meet the measure of ``readable`` I will reduce the number of spelling and editing errors per entry.  (This one will be tough because I am terrible at proof-reading).

Goal 5
To meet the measure of ``diversity of opinion and discussion" I will invite and publish comments and commentary of differing opinion (as long as words like "jerk" and "pinhead" are not included) . 

Goal 6
To meet the measure of "full range of issues that surround quality management"  I will expand the topics covered including more commentary on politics and quality partners, as I see it.

So that is a good start with an achievable objective and a series of measurable goals.  MMLQR is a young start-up which has met reached a certain level of fragile stability (similar to how they describe the Canadian economy).  Going to the next step will take the discipline of setting some objectives and goals and PDSA.  We will see how I do by the end on the year.

See you in 2011.

m

Message to self

Let me start by saying that I do a lot of surveys. To date my account has 82 surveys completed and an additional 3 currently active.  I survey students regularly during courses, and annually we do at least one customer satisfaction survey for CMPT.  I have done surveys for the International Organization for Standardization (ISO) and for International Laboratory Accreditation Cooperation (ILAC).  Over the years I have become adept at creating surveys that address the issues that I want addressed.

Last week's survey was my first experiment of linking a survey to a discussion website like MMLQR.  I would not call it a totally successful experiment. 

When I look at the reported results, first I noted that we are attracting a variety of laboratory Quality professionals from Canada and internationally.  There are some positive trends.  Based on a 6-point Likert scale, this site was ranked either as Excellent or Good by near everyone with regard to variety of topics, relevance, clarity, accessibility, and refreshment.  There were no "poor" or "unacceptable" responses.  The same was true for the Overall assessment.

So this is all good, Yes?
Well it provides documentation that supports impressions based on the progressively increasing readership, and it confirms that the people that I am interested in engaging in conversation aer finding the site.  But based upon the number of tracked page views, it looks like less than 4 percent of people connecting to MMLQR have responded to the survey.

With the information that I can garner, I don't know how many people opened the survey but chose to anwer no questions, but I assume that that is a very small number

So there is a problem, but a generalisable problem.  Almost all the surveys I have done in the past have been to a closed or faily closed population, where I could go back to the group and try again and again.  This is a survey to an open population.  In that regard it is similar to attempting to do a satisfaction survey of people exiting a laboratory patient service centre, or of physicians that use laboratory services.  
In all these situations, one can generate a denominator of how many potential responses there could have been.  The challenge is how does one increase the numerator without generating bias, both positive and negative.

In the laboratory setting, one might try creating focus groups as definable groups, but one has to create incentives to garner participation.  This is potentially expensive and would only be applicable if one risked confidentiality breaches.  One could combine focus groups with electronic surveying, but still one would have to have identifiers to work with.
In this setting, I have no access to identifiers, and no obvious inducements that might entice a response.

So it is back to the drawing board with some questions to be asked, like who do I want to attract to the survey, and how can I entice them to participate, and what is a sufficient cluster, and what kinds of questions will capture the information that I want.  And maybe to affirm why I want to generate the information.

It's kind of like my own PDSA

If I come up with some answers I will try again.
In the meantime if you are in the 4%, many thanks for participating.

In the meantime, I am going to take a few days off and come up with my predictions and resolutions for a happy and Quality 2011.

For those of you who celebrate the day, Merry Christmas.

m