The State of North America
Laboratory Quality 2015
Earlier this week I was
invited to participate in the 2015 edition of Robert Michel’s and Dark Daily’s
annual Laboratory Quality Confab held in New Orleans. I was the third speaker in a symposium on the
challenges facing US laboratories. The
lead speaker was Ellen Gabler, a journalist with the Milwaukee Journal Sentinel
who had written a number of articles on the questionable quality of what the
Commission on Medicaid and Medicare Services (CMS) and the Clinical Laboratory
Improvement Act (CLIA) refer to as unwaived tests, i.e. tests that are so easy
to perform correctly they require no quality assessment, and on the state of
laboratory inspection (accreditation). [in
a nutshell… big glaring problems abound with both].
The next speaker was Elissa Passiment, the Executive
Vice President for the American Society for Clinical Laboratory Science and
importantly the head (former) of the Clinical Laboratory Improvement Advisory
Committee (CLIAC), the body that reviews activities associated with CLIA and
reports to Congress. Elissa talked about
the challenges that CLIA has posed, and continues to pose to US
laboratories. And as she put it CLIA has
become a driver to the bottom rather than an inspiration to excellence (Those
aren’t quite Elissa’s words, but certainly the sentiment!).
I talked about Quality
Partners (a favorite subject of mine) [see: http://www.medicallaboratoryquality.com/2014/12/competition-and-quality-partner-dynamic.html ] , emphasising both their strengths and weaknesses
and how laboratories need to progress through the development of Quality
Progress Plans, basically a page out of the newly published crown document of
organizational quality, ISO9001:2015.
I thought the symposium went
well, although my guess is that it was way over the heads of most of the
audience. While I give them all points
for wanting to be at a laboratory quality conference, for 80 percent of the
audience this was their first time attending.
More importantly, and without putting too much importance on show of
hand displays during conference presentations,
when I asked how many worked in laboratories where they regularly
performed internal audits or if they maintained an Opportunities For Improvement
list, for both questions I got about a 10-15 percent response. So their notions about quality are not really
yet on the foundations of quality improvement.
Of interest to me, following
my presentation, Robert Michel asked me in front of the audience with
microphone in hand, how I felt about Canada being a country with provincial
control over laboratory quality and would we do better if we had CLIA.
My response was that it is a
tragedy that in Canada our federal government has never engaged in a process,
voluntary or mandatory to insist on an across-the-country approach to laboratory
Quality, leaving a true hodgepodge mess.
But on the other hand I thank my lucky stars that we do not have to put
up with the tired and obsolete mess that the US Congress has made with
CLIA.
If there is a true and singular
tragedy it is that in 1967 the US Congress create a ground breaking approach
through the creation of a quality concept, but over time, with the introduction
of lobby power over quality power, and political expedience over any interest
in patient care, CLIA has fallen from being a force for quality to one of the
exact and very opposite. CLIA today almost
guarantees Quality-by-luck rather than Quality-by-design.
Even a quick look at CLIA
rules today points to the absence of quality assessment for the vast majority
of tests, the absence of any semblance of clinical appropriateness
requirements, test acceptability tolerances that one could drive a Mack truck
through, and a series of silly regulations about who you can and cannot talk
too, or how many times you can or cannot test a proficiency testing sample as
if any of that is monitorable or has anything to do with Quality.
What it speaks to is how poor regulations lead to gaming rather than improvement.
Tired, broken, lack of innovation. Not at ringing endorsement.
Given the choice, between
Canadian hodgepodge and American tired-obsolete, I think if I really needed to have a laboratory
test performed today, I would have far greater confidence on the accuracy, quality,
and interpretability of the test performed in a Canadian laboratory.
Today we have a new
government in Canada with a 4-5 year majority mandate (in other countries we
would call that a benevolent dictatorship), and perhaps a new opportunity for a
new beginning. Perhaps this is the right
new time to start communicating with my federal government contacts.
