The Quality Carry-over

The Quality Carry-over

Others have written on this topic, and I have alluded to it previously as well.  Quality is an interesting arena in which one can work because once you have bought into the philosophy it tends to spill over into other work and non-work areas of your life.

You might say that other professions do this as well.  Physicians and nurses often find hobbies related to health information, such as becoming health historians or health artists, or becoming health information apps developers.  Chefs often become sophisticated foodies, searching out the perfect tomato or traveling to the out most regions to savour the perfect dumpling.  Metal workers become sculptors.  Profession becomes hobby.

But Quality is different.  True, Qualitologists often find themselves creating their own personal OFI lists, and finding ways to maintain personal records and receipts in a way that would paralyze a “normal person”.  Quality Carry-over goes beyond that because the qualitologist starts seeing the “flaws” in the world around them and then starts to try to do something about them.  This is not profession becoming hobby; it is profession become obsession. 

An example.  Over the last while I have had some health issues that have required me to stop being a physician and start becoming a patient.    And that is rarely a good thing because as a general rule we are not very compliant patients.  We suffer from “I know better”.

But there are some areas in which we do know better.  Over a short hospitalization I was seen by 3 medical specialists and probably 8 nurses and 5 technologists.  All of them had tests to record and reports to write, so that you would imagine that there would be a lot of information generated.  But when I visited the out patient clinic, none of the records or reports (NONE) was available.  In addition, none of the information was conveyed to my family doctor (NONE !) even though I was informed that he would be responsible for my follow-up.  My prescription was written by one physician who informed me that I should go to my family physician for refills which I would take for an extended period, but no one told him was I was supposed to be taking.  And finally while in the clinic I found that there is another fellow with my same first name but with different last name, different age, different birthday, and they still managed to get the two of us and our records mixed up.  Worst off, his wife and my wife happen to be good friends, so the issues started to become a breach of personal confidentiality.

I suspect that many people would be miffed, and some would probably get angry.  In some countries, not Canada, we might even be getting close to the law-suit level of discontent.  But I didn't go there.  Instead, I wrote a memo to the person that I perceived as the one most likely to “get it”.  I understand that this is the system in which she normally works and probably sees  as problematic but normal and don’t see any way around it. 

I mentioned that as a healthcare savvy person I was going to be able to manoeuvre through this mess, even if it meant writing my own prescriptions and refills.  But for many of their patients this would be chaos, and the risk of a bad event would be substantial.  I suspect they happen all the time, but they just get lost and missed in the shuffle.

I mentioned to her about occurrence awareness and management, and how to organize an Opportunities for Improvement (OFI) list, and offered my assistance in helping their group develop a strategy and goals for quality improvement.

To date there is no answer.  I will wait a while and re-contact her.  If that doesn't work, I can always kick it upstairs until I get a response.

PT Bonus Opportunities: would your laboratory benefit?

PT Bonus Opportunities: would your laboratory benefit?

Frequently we talk about the benefits of Proficiency Testing as a method for the detection of systemic error in laboratory testing, especially as part of the examination phase.  Once you accept that Proficiency Testing challenges have been thoroughly quality controlled and are highly reliable, then it becomes, as my old calculus professor used to say, intuitively obvious that the greatest probable cause of deviation between a clinical laboratory’s result and the PT program’s result is some form of problem within the clinical laboratory.  It likely is a slip or distraction by someone in the laboratory’s testing chain, but it may reflect a larger systemic error that is otherwise is being not recognized or is under-appreciated.  Discarding deviations in PT performance can be lost opportunities for improvement.

But recently we had two interesting results come to light that reinforce that systemic error in the testing pathway detectable with proficiency testing materials can come from all sorts of places. 

As per our normal routine, our PT coordinator was checking the laboratories that had not yet sent in their results 48 hours before the due date, and found one such laboratory and contacted them.  [As an aside we can provide that extra level of service because we are a small program.  Large programs with thousands of participants could never provide that extra assistance.]

The laboratory checked their records and came back on the phone and said that the problem was on our end, because the laboratory had never received our samples in the first place.  We were the problem.  So a check was made through the courier service and what was found was that the samples had been delivered on time as committed, and that the delivery way-bill had been signed off within the laboratory.  A call-back was made and sure enough, the box was sitting in the refrigerator where they had been placed, un-opened.

The story has two messages.  First, if this happened with our package, this could have been a one-off by someone who simply forgot (call that a human slip) or perhaps this happens more commonly than the laboratory is aware (call that a system error).  Second, our system informs the laboratory on the day the package goes out.  If there is going to be a problem it would be captured within 48 (max 72) hours.  If someone had called us and checked, the box would have been found immediately.  That this didn’t happen either means that a distraction resulted in the call not being made, or that the laboratory has an inventory-control problem which needs checking. 

Either way the point is that even without being tested, this PT shipment has resulted in detection of two problems (is it OK to call them errors?) that the laboratory now has the opportunity to check-out.  Either they were a chain of simple human foible, or they were a manifestation of failures in the delivery handling and monitoring procedures. 

A second story is similar, but starts not from us contacting the laboratory, but the laboratory contacting us with an apology for a 5 day delay in submitting results.  Apparently, there usually was a Quality technologist whose job it was to submit  PT challenges reports, but that person had recently retired and no one had yet been appointed and so the job was “slipping through the cracks”. 

We understand that people do retire; that is called “business as usual”.  But if the PT reports are not being submitted, are there other tasks that are not getting done.  If quality control testing is being delayed, and reagent defects are not being identified, then how many hours are going to be lost having to remediate erroneous test reports?  Or worse, what if quality control testing isn’t being done at all?

My point is that PT samples are more than just a material to challenge the examination phase of laboratory testing.  They are known and traceable and regularly received materials that can be used to monitor every aspect of the laboratory cycle.  Usually everything works as it should, and sometimes it does not.  It is when things do not go well that these “safe” opportunities arise for checking for system error. 

Opportunity accepted or opportunity ignored?