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How straight is the road to QI?

While the relentless push toward quality in the clinical laboratory has won many advocates, a few skeptics remain, according to findings of a survey on quality improvement conducted by MLO in late 1991. Consider four comments:

"Our QA program with CQI [continuous quality improvement] has given us the opportunity to have an increased dialog with the medical staff and other patient care departments in resolving patient care issues," says the lab manager at a small not-for-profit hospital in Oregon. (Hospital size as used here is defined in the first part of this article.)

Quality assurance "puts problems in black and white, where you can see what needs to be done to correct them," says the chief technologist at an independent lab in South Carolina. "If a problem is not written down, you might think of it once in a while, but it might not be followed up."

From a less sanguine perspective, the microbiology supervisor at a midsize public hospital in Delaware expresses concern about "paperwork and the time and staff required to do it. We always had a QA program. Although it didn't have an official name, we found problems and tried to solve them. Now we're swamped with paperwork, documentation, and meetings. People who don't know beans about the lab are looking over our shoulders and telling us what to do."

Attention to QA detail takes time, worries the manager of the laboratory at a small not-for-profit Montana hospital: "We had our CAP inspection last week and the inspector thought our QA program was just great. I think it's a lot more work than it's worth. The quality of service would not be reduced one bit if QA disappeared."

* Skin deep. "I'm not surprised at the study results, which show that labs aren't as far along in QA as they should be," says Lucia M. Berte, M.A., MT(ASCP), director of laboratory quality assurance at Elmhurst (Ill.) Memorial Hospital. "Considering that laboratory QA efforts have been out there for three or four years, I'm a little disheartened. There is a tendency to be reactive and not proactive." One advantage of instituting total quality management (TQM), Berte says, is to encourage people "to take a step back from the error and look into the process that made that error occur."

Daniel M. Baer, M.D., chief of pathology at Veterans Affairs Medical Center in Portland, Ore., considers the reactive mode inevitable. "The idea of TQM is to shift the focus from errors to opportunities for improvement," Baer notes. "Unfortunately, theory hasn't caught up with practice yet. It's much easier to set up a standard and then look for deviations from that standard. That's pretty much the current state of the art." Errors and incidents share another attribute: They can be counted.

* Looking too long. A typical way to deal with errors identified through QA is to study the problem and counsel the technologist who made the mistake. That too is an error, says Paul Bachner, M.D., chairman of pathology and laboratory medicine at United Hospital Medical Center, Port Chester, N.Y. "I get a sense that there is reluctance on the part of management and administration to completely believe the signal they're getting" from QA monitors, he says. Managers "identify the problem but deal with it by continuing to look at it. Does that mean the problem is not important enough to require taking action?"

The problem that is being ignored, Bachner feels, is contained within the system. He suggests following the precepts of TQM: "You define a goal, look to see what the level of performance is, then try to improve the level of performance by redesigning the system. That's better than assuming there's something wrong with people and then counseling them or sending them nasty memos. The basic philosophy is that most problems are systems-based, not people-based."

The most helpful improvement to be realized from quality assurance is in "moving toward the TQM approach--away from the 'bad apple' approach to the process approach," says a survey respondent who is administrative director of the laboratory at a midsize hospital in Utah.

* Resistance. However beneficial the change, some opposition may be unavoidable. MLO asked respondents how employees' reluctance to tackle QI had been dealt with. Here are some of their replies:

[paragraph] Coercion. "So far, the main thrust is to ram [QA] down their throats," says the blood bank supervisor at a midsize public hospital in California.

[paragraph] Patience. "With masterly neglect. Waiting long enough makes QA procedures seem routine. No one recalls when they did not exist," says the manager of a satellite lab at a small not-for-profit hospital in Michigan.

[paragraph] Communication. The manager of a lab at a midsize not-for-profit hospital in Washington State takes a more aggressive approach. Her monthly report to staff on current QA results "includes data collected, follow-up, action to be taken, and problems resolved. Staff awareness of an actual problem resolved by QA gives them incentive to participate in the program actively," she says.

Another tack is "pointing out successes," says the technical supervisor of a midsize not-for-profit hospital lab in California. Her solution includes "increased involvement of staff, no blaming, and staff suggestions for [QA] studies and solutions to problems."

Giving all levels of employees more responsibility for QA is helpful, finds the lab education coordinator at a large not-for-profit hospital in California: "We let everyone choose indicators and suggest ideas for good ones."

[paragraph] Collaboration. "Continued education and monitoring of QA on a bimonthly basis" works for the chemistry supervisor at a large not-for-profit hospital in Missouri. "One-to-one communication between lab and physicians and between lab and nursing" is also vital, the supervisor notes.

"Clinical directors had to be convinced that indicators were meaningful only if they were developed in collaboration with the medical staff" of a large not-for-profit hospital in Louisiana, says the administrative director of its laboratory. "They originally tended to use indicators that made their areas look good, rather than indicators necessary to solve problems and improve service."

* Medical staff. Communication with the medical staff is a vital issue that often could be handled more adeptly. Witness the following answers to the survey question, "Please name the single greatest problem remaining to be solved in your lab regarding QA":

[paragraph] Stats. "Responding to true Stats from physicians" is a problem for the central laboratory coordinator at a large not-for-profit Tennessee hospital where Stat orders represent 40% of the laboratory workload. The assistant supervisor of clinical chemistry at a midsize not-for-profit hospital in Mississippi decries "the abusive use of Stats by physicians merely for their time convenience, not for life-or-death situations--for example, all tests ordered Stat just before the lunch hour!"

[paragraph] Appropriateness. "Doctors need to stick with the standards they have agreed are appropriate when audits indicate a lack of compliance," says the manager of the laboratory at a small not-for-profit hospital in Indiana. "More input may be needed when standards are initially set."

Inappropriate test orders trouble the manager of an HMO referral laboratory in California, who says, "We can identify problems, but resolving them is difficult without the willing participation of medical staff."

* Nursing staff. Poor communication with nurses vex respondents to the MLO survey. "Getting nursing to document QC results when they perform blood glucose testing" is a concern of the lab manager at a small not-for-profit hospital in Nebraska. For the chief medical technologist at a small proprietary hospital in California, the problem is "educating the nursing staff to collect, transport, and label specimens and to fill out [test] requisitions correctly."

"Most errors are [made by] nursing, even though they blame the lab," complains the microbiology supervisor at a midsize not-for-profit Texas hospital. "They remember the [lab's] one bad [action] and not the 100 good [ones]." This supervisor adds that her single greatest QA problem is "nursing acceptance and compliance" of quality assurance standards.

* Contradictions. Laboratorians "complain about nurses' creating patient wristband identification problems," says Lucia Berte, "but 38% of labs responding to the survey haven't even instituted that as a quality indicator.

"You hear a lot of talk about inappropriate blood orders--urine cultures performed on specimens with negative chemical and microscopic tests," she adds. "Why go through the expense of a urine culture when screening tests indicate there are no bacteria present in the urine? Yet 56% of labs say they're not looking at that very important monitor of the appropriateness of test orders. They're complaining, but not doing."

Dr. Baer points to common misinterpretation of the JCAHO requirement "that the quality and appropriateness of pathology and medical laboratory service must be monitored and evaluated. The rule was interpreted by some to mean it was the lab's responsibility to do something about the appropriateness of test orders. That was not what the Joint Commission said, however. They said it was a medical staff function. My feeling is that most places have found the issue of appropriateness a very, very difficult one to deal with. Ideally, the pathologist and the clinician decide what to do and the clinician set up a mechanism to police the decision. But I don't know of any institution that has successfully faced the challenge.

"It's really difficult to set up criteria for determining what's appropriate and what isn't," Dr. Baer adds. "It requires a thorough review of the patient's chart, and you can't do it statistically. It must be done on a case-by-case basis, which is very time-consuming. In general, it's hard to get a group of clinicians to review a case and agree on what was appropriate or not."

* Satisfaction. Berte notes that 41% of respondents' labs do not conduct user satisfaction surveys. Of those that do, only 46% include the medical staff. She asks: "How does the lab ever find out what other people think its problems are? Only 27% of labs ask the nursing staff for their opinion, yet nurses are the group that has the biggest interaction with the lab. My feeling is that if we asked nurses what they thought of the lab, the answer wouldn't be very good. The reason we don't ask is that we don't want to know."

Even when communication between the lab and its users is clear, positive results do not automatically ensue. "Initially, QA provided better communication between the lab and the medical staff," says the director of the lab at a midsize public hospital in Georgia. "Now this does not exist" because QA efforts have been reduced to "turf guarding" and "the 'Gotcha!' game," he observes.

* Good experiences. Fortunately, negative thinking is not the rule. Most respondents' experiences with QA have been positive.

[paragraph] TAT. "Our emergency department and pediatric facility have dropped their demands for Stat labs due to our TAT monitoring and improved TATs," says the laboratory education specialist at a large not-for-profit hospital in Florida.

[paragraph] Paps. "Improvement of the quality of cytology Pap specimens from 54% adequacy in 1988 to 90% in 1991" is the gain proudly cited by the laboratory education coordinator at a midsize not-for-profit hospital in Ohio.

[paragraph] TDM. A serious problem in the collection of TDM specimens was found "and is being addressed hospitalwide," says the education/QA coordinator of a midsize not-for-profit hospital in Georgia.

[paragraph] Contamination rate. "The rate of contamination in the drawing of blood cultures has improved greatly," notes the assistant lab manager of a small not-for-profit hospital in Arizona. "This is especially noticeable in the newest phlebotomists."

The satellite lab section chief of a large not-for-profit hospital in Tennessee reported that her lab's blood culture contamination rate dropped from 6%-7% to 2% in two years of QA monitoring.

[paragraph] Orders. Since the advent of QA, "we receive orders sooner" than before, says the chemistry supervisor of a small not-for-profit hospital in North Dakota. "In the past we would receive body fluids and bloods specimens before the orders."

[paragraph] ID. The hematology/chemistry supervisor of a large not-for-profit hospital in North Carolina cites "the recognition of potentially life-threatening incidents and finding better ways of handling them" as a QA problem identified and solved. To prevent "a mislabeled specimen or the wrong patient being stuck, we now have a hand-held computer that we take to the patient's bedside. We 'light pen' the patient's bracelet. Correct identification labels are then generated."

The lab manager of a midsize not-for-profit hospital in Arizona says, "We have greatly improved the continual problem of patients without armbands. Once we identified the problem as related to QA, it went from several per day to one to three per week."

* Better patient care. Quality improvement helps lab workers keep sight of the bottom line of lab service: patient care. "Lab employees see follow-through that analyzes a problem and attempts to solve it--evidence that the hospital cares and is trying to improve the quality of care," says the director of laboratory services at a small not-for-profit hospital in California.

To serve patients better, prepare for a transition from QA to TQM/CQI, advises MLO Editorial Advisory Board member Luci Berte of Elmhurst (Ill.) Memorial Hospital. "Technologists and their leaders should start becoming familiar and comfortable with TQM/CQI terminology and definitions. They should begin using quality improvement tools: flowcharts, fishbone charts, and Pareto diagrams.

"I would also encourage laboratorians and their leaders to read literature on quality improvement. There's a lot to do before 1994, when the JCAHO will mandate TQM/CQI. The way to get it done is to start educational programs and to read about QI as a standard part of laboratory practice."
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Copyright 1992 Gale, Cengage Learning. All rights reserved.

Article Details
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Title Annotation:Readers' Strategies for Quality Improvement, part 2; quality improvement
Author:Jahn, Mike
Publication:Medical Laboratory Observer
Article Type:Cover Story
Date:Mar 1, 1992
Previous Article:Making the grade on the long road to QI.
Next Article:A QA plan to monitor charted lab results.

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