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Quality management: watchword for the '90s.

The '70s will be remembered as the decade of im- proved technology and increased support for health care. The '80s will be noted as the decade when cost became a critical factor in health care. And the '90s will be characterized as a period when quality ascended as the leading issue.

Yes, technology will continue to expand, and cost will be an important factor, but quality will predominate in this triad. The Joint Commission on Accredi- tation of Healthcare Organizations has acknowledged the importance of outcome indicators of quality care. Many hospitals are beginning to use quality of care as a key marketing tool.

Our department of pathology and laboratory medicine has embarked on a total quality effort for all activities. We approach each task by an-

swering the following questions: Who are our customers? What do they require? How can we deliver what they need? Are we succeeding in this effort? If not, what can we do differently?

We are committed to meeting our customers' needs. This is done through an ongoing program of quality management, a program we call "caring for quality. "

William E. Zierden, a professor of business at the University of Virginia, offers a very explicit defini-

tion of quality: "Meeting the customer's requirements for a product or service. The general goal in every case is to meet the requirements on time, the first time, with no errors or defects. "

Management expert Pe- ter Drucker notes: "A product or service is quality not because it is hard to make or extremely technical or complicated, but only if it is of use to the customer and gives the customer value." Both

Zierden and Drucker agree on defining quality in terms of the customer. For a clinical laboratory, this is usually the clinician user, but it can also be a patient, a hospital administrator, or an outside client using the laboratory. Second, we

ascertain what the customer wants, which is not necessarily what the customer needs.

Finally, in order to determine how well the laboratory is doing, we must have performance indicators. It is critical to be able to measure quality as well as manage it. If you can't measure it, you can't manage it.

Quality assurance, which ev-

eryone talks about these days, is like a warm puppy: fuzzy and soft. Those characteristics are desirable in a pet, but when used to describe a concept, they denote something difficult to grasp and implement. We have to be clear, not fuzzy, about the meaning of quality assurance and the other "quality" words, including quality management: * Quality care meets the expectations and the needs of health care consumers-patients, doctors, and payers. For example, a patient undergoing surgery expects to have postoperative pain minimized, and quality care can achieve that. * Quality control is a technique that is used to detect and correct errors before they result in a defective product or service. It involves proficiency testing and daily assaying of controls and is

often referred to as the back end of quality. * Quality assurance is a program that monitors and evaluates the service provided to insure that both process and product conform to the expectations or standards. It involves auditing, interfacing with laboratory users, training, writing procedure manuals, and instrument calibration and is often referred to as the front end of quality. * Quality management means managing for quality rather than for productivity-placing quality first in importance among management activities and in decision making.

The best-known advocate of quality management is W. Edwards Deming, an American statistician credited with helping Japanese industry to rebuild and to excel in the international market. Deming stresses that improved quality leads to improved productivity by eliminating rework-the need to do something over because it was done wrong the first time and the quality was unsatisfactory.

The Japanese experience demonstrates that doing something right the first time will result in greater efficiency and better-satisfied customers. For example, correct and timely administration of pain medication results in greater patient satisfaction than incorrect or delayed medication, and no time is wasted on identifying, documenting, and righting an error.

Improved productivity leads to lower costs because eliminating rework saves time and materials. Lower costs, in turn, set up a price advantage and a competitive position, thus permitting the orga-

nization to stay in business and provide jobs. According to Deming, quality means jobs in today's competitive market, and the unemployment in some American industries is an indictment of past management practices.

All of these quality terms are information-driven. To respond to customer needs, to implement quality controls, and to understand how to improve quality, we must be able to measure quality performance.

The role of quality assurance within hospital departments is to assist in this process of defining and measuring quality performance. Quality assurance activities should give management the information it needs to improve quality care and quality service.

Many argue that it is impossible to do justice to cost and to invest in better quality; the two goals seem inconsistent. That is not true! By spending more money on quality up front, we can save much more money down the road.

Presents various qual-

ity-related expenses divided into two categories-the cost of conformance and the cost of nonconformance with quality requirements.

In the conformance category are prevention and appraisal costs. Prevention costs are incurred preventing defects; activities toward that end include training, calibration, and maintenance. If employees are trained well and instruments calibrated properly and maintained satisfac-

torily, the laboratory should run smoothly and produce accurate results.

Appraisal costs are expenses that are incurred to measure and control quality through inspection, testing, and auditing. These expenses relate to the operation of internal and external control pro- grams-or back-end quality control versus front-end quality assurance.

If prevention and appraisal activities are not performed adequately, problems soon develop. These are called failures, and they

bring on nonconformance costs.

Internal failures are situations picked up within the laboratory and are unknown to the customer. They include the cost of reworking and/or discarding an entire batch of test results or an individual specimen due to some element of improper processing that led to an erroneous result. With internal failures, you must reanalyze out-of-control runs and troubleshoot the analytical process.

External failure is the most serious consequence of poor quality. The costs are related to follow-up on physician or patient inquiries about lab results that do not help to solve the patient care problem. Correcting erroneous data and investigations of unusable results fall into this category. The most

significant external failure cost is the loss of revenue when the clinician decides to no longer use the laboratory.

Poor quality leads to waste,

customer returns, rework, inspection costs, rejects, additional quality control expenses, and retesting. Investing in quality at the front end-in the prevention phase of quality management-saves money down the line and will eventually reduce total costs. Thus the goals of cost containment and quality management are consistent.

Keys to improving quality. The first is leadership. The head of the department or organization must believe in the benefits of quality management. Companies that have been successful in quality management have leaders who endorse quality explicitly. Ford Motor is an example. The president of Ford underscores quality as Ford's number one job.

Second, management must be committed and participate in the quality process. Experience in industry has led to what is known as the 85/15 rule: 85 per cent of the problems can only be solved by management; only the remaining 15 per cent can be solved by workers. Quality is primarily a

management problem. Most improvements require changing the system or process, which means changing the way things are done-and only management has that power.

Third, there must be an explicit plan for quality management, defining quality goals and explaining step by step how they will be accomplished.

Unfortunately, many organizations refuse to allocate the resources necessary to carry out their quality plan. Quality management in such cases exists only in theory. Japanese workers spend up to 20 per cent of their time attending quality circle meetings and continuing education courses, but such activities have been curtailed in the U. S. under the reign of cost containment. That deci- sion is very shortsighted and will lead to long-term failures.

Once management understands quality and is committed to improving it, the message must go out to managers at all levels, including front-line supervisors, and to workers. The plan and goals of quality management must be communicated to all staff members, and they all must buy into the organization's quality program.

Teamwork and sharing of responsibility are critical. Managers and supervisors must delegate authority to all workers in the department as necessary. Often this is contrary to the usual way of doing things.

With teamwork and employee participation in identifying and resolving problems, quality becomes everyone's job. Because this usually requires major changes in management style and

organizational culture, implementation of quality management takes a long time-typically three to five years.

All individuals contributing to the total program should be recognized, through such means as a diploma or service pin. Our hospital has a Recognition of Service Excellence (ROSE) program, and employees who receive a ROSE certificate truly know they are appreciated.

Finally, one must be persistent.

Many organizations find it easy to begin a quality program and then allow it to falter. It is critical to keep the spirit alive and to practice quality management on a regular basis.

That's what we do at our 1,100- bed hospital, where a quality management program was adopted two years ago. Dr. James Westgard, acting as facilitator and consultant to the department of pathology and laboratory medicine, introduced the program to management staff members at a three-day seminar in September 1987. We learned the definition of quality (meeting the customer's

requirements) and the importance of defining our customers and their needs. We were exposed to the concept of quality cost, the cost of conformance, and the consequences and cost of nonconformance or poor quality.

Then, so all could agree on a common purpose, we adopted the following departmental mission statement on quality:

"We are committed to listen to our customers' requirements, to establish appropriate performance

standards, and to meet or exceed these specifications consistently. "

Having learned about quality in various industries, we proceeded after the seminar to determine which quality factors applied to the laboratory setting. Essentially, we answered this question:

What does a clinician user need from the lab?

We also developed quality indicators, because (as we have already pointed out) if you can't measure quality, you can't manage it. One useful indicator is the frequency of incident reports. For the most part, these are generated

when test reporting is substantially delayed, specimens are mixed up, and results are obviously incorrect.

We review test results monthly against goals of zero recollects, zero incorrect reporting of results, and consistent on-time delivery of test results.

Phlebotomy turnaround time is documented. One recent morning, for example, 15 phlebotomists collected 475 of 481 patient specimens by 7 a.m., for a 98.8 per cent completion rate.

We also monitor turnaround time for chemistry glucose. On another morning, the laboratory had to collect and run glucose tests on 158 specimens. We met the established cutoff by completing 98.1 per cent of the results before 7 a.m.

How much quality is enough? How can we define the acceptable limits of quality? Industrywide consensus is more suited for setting analytical performance limits, acceptable limits for turnaround time, and the frequency of incident reports. Locally defined

limits (at the institution or community level) are more appropriate for evaluating the adequacy of test menus, the quality of lab reports, and the quality of laboratory consultation.

Our department uses team management and quality circlies to support quality project teams. These teams have developed internal and external laboratory newsletters and are working on backup requisition forms, improving turnaround time for spinal fluid specimens, blood inventory management, improving chart availability of surgical pathology reports, ways to make sure shared urine specimens do not go astray, and interdepartmental training.

What is the cost-benefit relationship in a quality improvement program for clinical laboratory services? First, the total cost of quality may actually decrease. A laboratory that meets quality requirements has fewer reruns and complaints, and this saves money. Second, meeting quality requirements satisfies clinician users of the laboratory, giving the lab a greater competitive edge and

providing job security for the senior staff. Finally, meeting quality requirements leads to better and more efficient patient care. This decreases the average length of stay and total medical costs and gives the hospital a competitive advantage.

Quality was once interpreted as conforming to professional standards. Today it means satisfying customer expectations. We consider our customers' requirements and strive to meet them consistently.

Who cares if we turn out quality work? Clinicians care; hospital administrators care; and, most of all, we care. Although cost containment remains an important goal, we subscribe to the following motto: Quality is remembered long after the price is forgotten!"
COPYRIGHT 1989 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1989 Gale, Cengage Learning. All rights reserved.

Article Details
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Title Annotation:medical laboratories' quality control
Author:Statland, Bernard E.
Publication:Medical Laboratory Observer
Date:Jul 1, 1989
Previous Article:The past as prologue: a look at the last 20 years.
Next Article:The impact of the new technology.

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