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Japanese QC techniques merit our attention.

Japanese QC techniques merit our attention

Japanese manufacturers have their U.S. competitors on the run. Even diehard American patriots now admit that many products from the Far East work better and cost less. This edge has led organizations here, including hospitals and laboratories in the service area, to eye Japanese management techniques. Are we performing as well as we can, or do the Japanese have something to teach us?

We probably don't need to import any ideas on the cost front. DRGs have reduced the average U.S. hospital bill and forced health care facilities to trim their budgets. But how about quality? Are our quality assurance methods sufficiently comprehensive or even appropriate? Are we satisfied simply because we meet the requirements of the Joint Commission on Accreditation of Hospitals and other regulatory agencies? Do we think it's enough to perform statistical quality control and test unknown specimens? The Japanese don't.

The typical Japanese quality assurance program has six components1: 1) meeting customer requirements, 2) total (companywide) QC, 3) statistical QC, 4) training, 5) quality circles, and 6) management support and understanding. We seem to be doing fine with statistical QC, but let's consider the other components.

Meeting customer requirements. Customer satisfaction is one of the most important aspects of Japanese quality control. In fact, it is the final determinant of quality achievement.1

Laboratories have three classes of customers--the physicians who order the tests, the patients who receive the services, and the parties that pay the bills. Each group views service quality from a different perspective.

Most physicians are less interested in the coefficient of error of laboratory results than in the range of tests offered, turnaround time, and ease of obtaining reports. A physician who can get a toxicological study done at 3 a.m. Sunday thinks the service is great. But an anesthesiologist who has to wait for blood components will say the lab stinks.

How many of us know the average time a physician's office nurse spends on hold when calling for a laboratory result? Do our personnel go out of their way to be helpful? Do we audit the lab's telephone courtesy?

From a patient's point of view, quality control is largely how presentable, skillful, and attentive our phlebotomists appear.2,3 We receive low marks if a patient misses a hot breakfast because the blood collection is late, if a phlebotomist doesn't respond to questions, or if we let inexperienced "stickers' turn arms into pincushions. We should get patient and nursing feedback on the performance of these highly visible employees.

Are patients our prime consideration in staffing practices? Do we assign experienced employees to night and weekend shifts when work demands are greatest and supervision is minimal? Would we ourselves want to be admitted to the hospital on a holiday?

Does a student facing final exams in the morning have to sit in our emergency room two or three hours in the middle of the night, waiting for the result of a mononucleosis test? Will the test even be done that night? Does an anxious parent have to wait 24 hours for the result of a throat culture when the Urgicenter down the pike offers an immediate dlide test?

Finally, there's quality as a payer perceives it. Outpatients who pay from their own pockets soon learn that prices vary markedly from laboratory to laboratory and that higher charges don't guarantee better service. Thirdparty payers care little about quality, but fiscal stringency does not necessarily bring on lower quality. The danger is that we may focus too closely on cost control and overlook quality assurance.

Total quality control. In Japanese firms, total quality control embraces all aspects of production and all employees.1 TQC has several dimensions in the laboratory. The first relates to each step of laboratory usage--beginning with the physician who requests a service and ending with the physician who interprets the results. Flowcharts are useful for ferreting out potential sources of error in each step. Computerized data handling has eliminated many of the problems that show up in these charts, but many remain.

Educating physicians in the selection and interpretation of tests and profiles is more important than ever. In addition, as nursing staffs are cut back, we have to guard against increasing problems with collection, labeling, and delivery of specimens. TQC also should involve everyone in the laboratory, from the director to the glassware washers and filing clerks.

And what is our responsibility for laboratory testing done outside the main lab? That's a vital issue, considering the proliferation of bedside testing, satellite labs, and physicians' office labs.

Training. Japanese managers regard training as one of the most important components of their system. Massive practical instruction is an ongoing process. A Japanese employee in a progressive organization receives an average of 50 days' on-the-job and classroom training each year.1

It's true that technical and professional educational programs have been one of America's strengths. But many of these programs face uncertain futures, and others need to be revised.4

Training laboratory supervisors and pathologists in managerial skills has not been our strong suit. Another area where some laboratories are deficient is continuing education for part-timers or employees who work off-hour shifts. Maximum effectiveness is achieved when training is individualized, so as to narrow the specific development, obsolescence, and commitment gaps of each employee.5

Quality circles. Here is an example of how hard it is to transplant managerial strategies. Quality circles are one of the most successful elements of the Japanese system. But a survey of American companies that implemented the concept showed only a 28 per cent success rate.1 Many reasons have been postulated for the high proportion of American failures. Possible explanations include lack of preparation, poor support from unions and/or management, selecting weak quality circle leaders, and general loss of interest.1

There's good reason to doubt the universal applicability of quality circles in the U.S. They are probably not needed in organizations that facilitate upward communication and reward innovativeness. On the other hand, organizations with tunnel vision, cutting off input from employees, are not likely to nurture quality circles. Before trying circles or other quick-fix gimmicks, we should strive for general supervisory excellence.

Management support. Management's support and commitment are prime characteristics of Japanese quality control.1 Unfortunately, quality improvement programs usually lack immediate payoffs, and American organizations tend to invest in activities that present short-run advantages --especially quick profit.

Hospitals are more bottomline-oriented than ever before. Return-on-investment attitudes are forcing quality improvement investments into the background, and those leaders who try to maintain a sound balance risk being replaced. In Japan, return on investment is not the main criterion of managerial performance, so managers there can make quality assurance a top priority.

Obviously, without support at the top, our attempts to improve the quality of American products and services will be limited. It's time for employers and managers to stop blaming their workers and take a hard look at how these employees are led. American workers are intelligent, and they direct their effort where they think their bosses want it directed. Paying lip service to quality control while demanding greater productivity will not inspire workers to take pride in their product or service.

So what's to be done? Laboratory managers have no direct control over top management, whose support is essential for QC excellence. However, in many instances, quality improvement can be shown to be cost-effective-- and that may persuade top management. In health care, with lives at stake and a litigious clientele, we can make a stronger case than organizations in many other fields for preserving and strengthening our quality assurance programs.

Instead of formulating quality control practices according to the prescriptions of JCAH and CAP, we should review our programs and policies from a broader per-spective. The needs of our customers --patients, physicians, and payers, in that order--should be considered in each quality control component. I recommend assigning a senior member of the laboratory staff to be a customer advocate. This person would represent the needs of patients and physicians at all laboratory staff meetings and in the formulation of quality control policies and audits.

Finally, we must strive to make all of our personnel conscious of the need for better service. Just as everyone in the clinical laboratory is involved in safety, so should everyone be involved in quality assurance.

1. Lee, S., and Ebrahimpour, M. An analysis of Japanese quality control systems: Implications for American manufacturing firms. SAM Advanced Management Journal 50: 24-31, Spring 1985.

2. Peglar, M.; Snider, J.; and Gordon, J. A paychological approach to better phlebotomy. MLO 16: 83-90, September 1984.

3. Robinson, G.S. Techs, tots, and fingersticks --without tears. MLO 15: 104-112, April 1983.

4. Barros, A. It's time for zero-based lab education planning. MLO 16: 21-23, August 1984.

5. Umiker W. O. The three gaps that threaten laboratory survival. To be published in MLO.
COPYRIGHT 1986 Nelson Publishing
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Copyright 1986 Gale, Cengage Learning. All rights reserved.

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Title Annotation:medical laboratories; quality control
Author:Umiker, William O.
Publication:Medical Laboratory Observer
Date:Jan 1, 1986
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