Quality and the Pre-examination delemma

In my last post I commented on our recent  Quality Seminar in which there were two papers on a new standard being developed to help laboratories improve their pre-examination procedures.   

The problems are well established.  The pre-examination phase of laboratory testing is a highly manual, person intensive group of procedures that address collecting, transport, accessioning and storing of patients’ samples.  The system is fraught with error, usually accounting for 70-80 percent of reported laboratory errors. If a laboratory wants to improve their overall performance and contribution to medical care they should focus on reducing their absolute numbers of laboratory error.

The new Canadian Standards Association standard (Z316.7 Primary sample collection facilities and medical laboratories – Requirements for requesting, collecting, transporting, and storing samples for patient safety and quality of care.) is going to be a valuable and informative guidance document.  

I suspect that most Canadian accreditation bodies will pick it up as a good accreditation document, and even if they don’t, laboratories will still find it an invaluable document to support their quality system.  It is broadly inclusive and rich with guidance.  If I have a criticism (and it is pretty minor), it is that some may find it almost too encyclopaedic.

On the other hand the informative annex designed for Microbiology is the opposite of encyclopaedic.  It is compact and more general than specific, but in an invaluable way.  Microbiology and tissue pathology are very different from Chemistry and Haematology because microbiology and pathology samples are rarely collected by laboratory trained and supervised personnel.  The annex makes it clear that that samples for each laboratory need to meet a specification  set (proper technique, correct container, accurate information, proper handling and transport) and if they are not met, the sample will likely be damaged and the quality of the sample impaired.  

The collector needs the information before collecting (afterwards is too late) and if they do not know the information for this specific laboratory (each laboratory is 
different) then check the correct manual or CONTACT  the laboratory BEFORE you collect the sample. 

Commonly microbiology samples are collected by nurses or physicians, and sometimes by the patient or their family.  The physicians and nurses that collect these samples are all professional, and caring, and knowledgeable in their field, but the reality is that few of them are informed about what to consider when collecting a sample for the laboratory.  Few actually look at a collection manual, and assume the way they learned it back in school is still the right way.  Some (not many) still work with“Just get it to the laboratory.  They’ll figure out what to do with it.” 

All too often we have not been clear enough about our message:  if you didn’t do it right, then you did it wrong and the laboratory can’t undo the damage.

The challenge to us is how to communicate the message.  We can write collection manuals, but when you consider how many pre-examination error occur, that does not appear to be particularly effective.  In some special facilities some of the information can be embedded in the laboratory information system, but again the information is usually seen after the collection when it is already in a wrong container, or in the refrigerator.  And none of this addresses the sample collection that goes on in all the family practice offices, and walk-in clinics, and homecare settings.  

The new standard makes it clear that as much as we have allowed the other people to collected our samples, we are responsible for the overall quality and we need to take more responsibility in ensuring that the pre-examination phase is done properly. 

All this brings us back to how we teach adult learners.  Adults learn what they understand is relevant to them.  They want it delivered clearly and concisely in a format that makes sense and in a manner that allows for communication and clarity.  

Experience tells us that writing memos or newsletters or posters are not sufficiently effective.  Holding workshops and seminars doesn’t seem to hold a lot of interest.  Non-motivated adults choose to not learn.  Positive motivation works better, but sometimes so does negative motivation.

If we are responsible for the creation of laboratory information, then at a certain point we may eventually have to become more aggressive in ensuring pre-examination requirements.   More hard lined.  Samples will not be accepted unless we can confirm they were collected in the proper fashion, and put in the appropriate containers and handled for transport in the appropriate fashion.  Fewer samples will be processed, but our confidence in the reliability of outcome for the ones that are will be higher.

In the coming era, soon if not now upon us, when reports go directly to patients with increasing expectation for accurate and meaningful results, then our choices are getting fewer.

So with apologies to Philip Crosby, welcome to the new version of DIRFT:  Do It Right Or Don’t Do It At All (DIRODDIAA).  

It would be enough to get Demining to roll over in his grave.