Overthinking Quality

I took a little time to do some journal reading over the holiday break and found an interesting short article in the December 2012 edition of ASQ’s Quality Progress.  I want to thank all the authors who contribute and the editors that regularly put together a good read, even if I don’t always agree.

In this particular story, the author, a Master Black Belt in Lean Six Sigma is in a store where there is a huge amount of last minute shopping going on and all of a sudden the retail computer system fails thereby causing all credit card transactions to freeze.  Needless to say the mass of customers goes through the normal and predictable hostile reaction which pretty soon gets ugly.

The author standing helplessly and hopelessly second in line with a single small item in his hand, scans his knowledge and experience and Quality expertise, and comes to the conclusion that the best solution is to allow those people who are prepared to pay cash to come to the front, make their cash transaction and move on.  

That should be the end of the story, right?  Unfortunately is it not.  First he discusses this with his partner (aka wife, spouse), who does what partners tend to do, and informs him that his idea is nuts and is never going to happen.  Maybe this is a relationship between two Master Black Belts, because for reasons unclear, he decides to agree and then yammers on about how he was just being selfish and not thinking of all the other people like the information technology (IT) folks who are internal customers and might have a problem with cash transactions and a loss of tracking data.  I had had enough.

The reality is that he was right in the first place.  Had the store had a strategy of providing their customers with a variety of ways to pay for goods (cash, credit, debit, cheques) while the inconvenient crash probably would have occurred anyways,  a sizable portion of the crowd would have kept moving and the unruly mob would be been contained.  Some folks who were primarily intending to use plastic probably would have gone back to the old fashioned way of paying with cash.  While there would be some with major purchases who would have been upset, they could have been calmed down perhaps with some free juice or maybe a promise of a small discount when the register was again working.   Some folks would have been angry, some likely would have given up and walked out (swearing never to return!), but for most folks the whole mess would have been a non-event.  This would have taken some of the pressure off the IT technologist who was tasked with getting the mess back up and running.  The bottom line would have been instead of 100 percent of folks inconvenienced and angry, the truly perturbed probably would have been reduced by 80-90 percent, maybe even more.  

To me the answer was easy.  So why did author feel compelled to overthink it, and make a simple problem complicated.  What happened to KIS(S) (Personally I have never thought that adding the word “stupid” to the end of “Keep it Simple” was much of an enhancement!).  And more importantly what happened to all his Lean training and expertise.  

In the medical laboratory we sometimes have an analogous situation when the laboratory information system computer has a problem.  In that situation, it is really easy to focus on who is the customer,  what is the problem and what is the solution.  The point of the laboratory is to generate accurate information in a timely fashion so that clinical decisions can be made.  The tests continue to be performed, the information is gathered perhaps by pencil or maybe an off-line computer, faxes and telephones convey the information until the computer is up and running again.  Yes it means some extra work and cooperation and pulling together, but that is all part of the laboratory’s culture of Quality and culture of Community.  

In many respects this story addresses the true core of the Quality movement.  Quality Management reminds you of who your customer is and Risk Management and Preventive Action strategies highlight where bad things may happen that can have a negative impact on that customer.  Lean principles show the path to simple and direct solutions, and Culture development keeps your staff pulling together for mutual benefit of customers and organization success, and personal and collective  job satisfaction.  

Message to the author, not everything your partner says is a pearl.  You were right and your partner was wrong.

Risk Benefit analysis in the Medical Laboratory

A few years back I was involved in the writing of an ISO technical specification on the role of Risk Management in the medical laboratory.  The thesis of the TS was that managing Risk interfaced with Quality Management principally through Preventive Action.  By examining for potential events before they occur, adverse events can be prevented or at least contained.  I still think that is true.  Although the revision of the document will point out a much broader view of what constitutes Risk in the medical laboratory, the core of the link will be through preventive action.

One of the major tools that is used in Risk Assessment is an Occurrence – Outcome grid, where a potential event is either qualitatively or semi-quantitatively assessed from never occurring (0)  through to always occurring (100) .  The contrasting concern assesses outcome from never significant (0)   through to potentially fatal (100).  The point of the exercise is to determine the controls and the degree of risk aversion or avoidance or tolerance need to be considered and applied with regard to the event. This sort of tool can be used in a variety of situations that could potentially have an adverse effect on the patient, the clinicians, the staff, the laboratory or the community.

An important characteristic and perspective of that approach is its singular view that outcome falls on a negative gradation, which starts at neutral (no impact) and goes to bad and then to worse.

 

But as I read and think about risk and the medical laboratory I see one variance between the traditional view of medical laboratory risk and risk literature.  In risk theory and in its applications to finance, to innovation, and to discovery, there is an also a positive side to risk, which is on the risk-reward side.

 

Consider in the world of gambling and investment.  One looks at potential outcome as either leading to profit or loss, and weighs the balance of circumstance and evidence and comes to a decision.  Either the potential benefit is worth putting money on the line or it is not, and through to a certain point, the greater the potential benefit, then the more that the person is prepared to risk.  At a certain point either the opportunity for benefit is either so low or the likelihood of major success is so small that the exceeding a level of risk is no longer rational or appropriate.  Consider the common phrase: if a deal seems too good to be true, then it probably is. 

And so I have to ask, is there a place in the medical laboratory where Risk and Quality come together where the potential positive side of Risk and Benefit comes to play?  It seems intuitive that the right answer is clearly “no”.

 

Many would agree that over the last many years hospitals have had policies that say that the only level of acceptable risk is risk aversion, where there is absolutely no tolerance for any level of risk.  An outcome, even with a frequency of 1:10,000,000 is unacceptable.  That clearly has not been a workable or financially viable policy.

 

What makes more sense is to make a measured, objective calculation of tolerable risk where patients are protected, perhaps to an arbitrary risk of perhaps 1:1,000,000. 

But to get back to the question at hand, the health care system, and the laboratory in specific cannot and must not make risk-reward decisions that provide benefit to the hospital or the laboratory or the laboratorians that may put patients at risk of harm which would include the risk of faulty diagnosis.

Similarly in a public pay health care system, one should similarly argue that the hospital should not be making decisions that put public money at risk for loss if the benefits accrue only to the health community.  We see that often enough in the news when people get caught.  The newspaper calls that abuse of public office, and people sometimes can go to jail.  (In Canada we have seen a really good example of this in area of building Electronic Medical Records systems.)

But let me argue that there are situations, such as implementing green energy systems, or error tracking systems, or high efficiency operating rooms to allow for more laparoscopic or other accepted minimal invasive surgical techniques that have the potential of resulting in better or improved service. 

Given an option I prefer this to be part of the private care system when the owners and decision makers carry the liability of poor outcome, but the reality is that at a certain point in the public system, there needs to still be an institution that has to go first. 

I think that the point that I am trying to make is that in my experience, many institutions make arguments more by impression than by calculation of measured risk.  Measuring risk in most situations is an exercise to reduce error and negative outcome.  But sometimes, risk can be a positive concept where the point of the laboratory and the institution can benefit from positive reward.   

A standard on medical laboratory risk needs to recognize and address both sides of the topic, 

Duchess Kate and the Quality OFI

My friend and colleague Shelia Woodcock wrote to me yesterday about the recent news event that surrounds Kate Middleton, Duchess of Cambridge, the King Edward VII Hospital, and a morning radio station performer.  

For those that do not follow such events, Kate is married to Prince William, the son of Charles and Diana (It is significant to remember that Diana was killed in part trying to flee British paparazzi).  Duchess Kate was hospitalized for a private matter and the morning radio show performer (MRSP) from Australia contacted the hospital pretending to be Charles (the father-in-law) and was able to get to a nurse, who unknowingly was hoaxed into sharing some private information about Kate on the radio show.  A short time later the nurse was found dead, apparently from a suicide.

Sheila pointed out that there are many villains in this whole sordid ugly story, but at its Quality core, there is a major policy issue.  Seemingly this MRSP was able to pass from one person to another over the phone until he finally reached the nurse who chatted on.  So where in all this is the King Edward VII Hospital privacy policy, and if it exists, how come so many people ignored it?  Had the policy been in place, the MRSP would have been blocked out, the nurse would not have been contacted, and would not have talked and perhaps would be alive today.  So as much as the MRSP was a rudely intrusive self-entitled waste-of-time, the King Edward VII Hospital was incompetent and derelict in enforcing its own critical policies.

First off, let me suggest that if there is a family that is the very model of decorum, it would be the Royals.  The likelihood that they would have barged their way against a policy designed to protect them would be nil.  So being intimidated is not an excuse; and being accommodating was inappropriate.  

So the real story hear is that the hospital was inept, and the staff ignored a critical policy.  Had the hospital been more diligent with respect to policy and process, this whole event never should have occurred.

Perhaps this suggests an approach that all privacy based organizations should consider.  I think of it as very Deming.  If you create a critical policy, on some sort of regularly intermittent basis (that means ever 3-4 months), someone should do an internal audit to see if the policy is being followed.  They pretend to be a person calling in for patient information.  If they are blocked from achieving information, we will call that being proficient; if they are successful in garnering private information we call that having opportunities for improvement.  

The institution would monitor and track performance and capture potential breaches early. 

That would be a really good example of combining Quality Indicators and Risk Management to ensure Continual Improvement.  And by-and-large would cost virtually nothing.

But having gone there, my CMPT background and naturally entrepreneurial imagination, took me one step further.  Perhaps one could even create a business opportunity and develop a program for testing adherence to privacy policies; we could call it Privacy Proficiency Testing.  Consider the opportunities; in Canada we have about 1000 laboratories, probably 20,000(?) banks, 40,000(?) schools, and 50,000 doctor’s offices.  The imagination boggles at the possibilities.

Put in that light the MRSP who started this whole ugly mess was not really a rudely intrusive self-entitled waste-of-time; he was really a public-spirited  free-service external audit provider whose goal was to see if they Princess’s privacy was truly secure.  

Or maybe he was both.

Thanks Sheila.

Influential Voices - Arguing for Quality worth

Paul Borawski, the CEO of ASQ poses an interesting question in his A View from the Q about how best to inform your employer of the worth of Quality Team members to the organization, with a view to raising your salary [see http://asq.org/blog/2012/12/2012-salary-survey-whats-your-cause-for-a-raise/ ].   This is not a common topic on MMLQR, in fact this is my first time that I have ventured into the domain of personal value, worth and compensation.  But it is an adult question about an adult topic, so having thought about it, I think it is I do have an opinion.

Let me start by plagiarizing an advertisement that I used to see regularly in an airplane magazine.  It was one of those ads that sticks in your head, even when you don’t remember what product or service they were selling. 

“You don’t get what you deserve, your get what you negotiate.”

I raise this in the sense that I don’t see “worth” as a referential Quality term.  It is too amorphous, too vague, too relative to be a measurable metric.  On the other side negotiated values qualify as measurable, definable, independent values.

 That being said, this is a very difficult time to being in negotiation mode in healthcare in Canada.  Most provinces are finding that healthcare is either just at, or over the 50 percent level of provincial budgets.  Ministries are not particularly open to negotiation.  If you plan to venture forward bring your A game.

With that in mind, two weeks ago I was talking to ministry representatives about the hidden horror called “Costs of Poor Quality”.  Every medical laboratory administrator know to the penny what they pay for proficiency testing and accreditation and quality control, but none have a clue about their failure costs except in the occasional major disaster with hundreds of patient recalls.  In medical laboratories, the combined silent leakage related to error can range between 10 and 16 percent of annual budget.  Many laboratories are still at the point where small incremental changes in Prevention and Appraisal Costs will have substantial impact on Failure Costs expenditures.  So when I proposed that given the authority to implement some basic procedures I could effect a 3 percent savings through reduced Failure Costs, it was not an unreasonable expectation.  The project would take a relatively short time to implement and a few years to document. 

Considering a mega million dollar budgets that the province pays for medical laboratories, I would like to think I have given them something to think about.  Time will tell.

Back to the main point, identify the organization’s weakest point which can be fixed through Quality initiatives and bring that to the table as a starting point for negotiation.  It should be a powerful tool.   

Or maybe not.