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Patient Safety Focus: Collected Wisdom on Patient Safety

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 Collected Wisdom on Patient Safety

By Michael Astion, MD, PhD, Bonnie Messinger, Peggy Ahlin, MT (ASCP), and James Hernandez, MD
Editors, Patient Safety Focus

Since 2004, we have conducted more than 25 interviews with various leaders in the patient safety movement, both inside and outside of the laboratory industry. These interviews have been published in a variety of forms or used to collect information about best practices for our own quality improvement efforts. In addition, we have had the opportunity over the last 20 years to visit more than 100 labs and talk with the people who work there, many of whom have valuable experiences and opinions related to improving quality.

Many of the most helpful comments we have received in the course of these activities remain unpublished, either because we were requested to keep them off-the-record, or because these remarks were heard in a context that had nothing to do with publishing them. In this piece, we put some of these comments to paper without identifying the sources. We hope readers of Patient Safety Focus will find some gems of wisdom in this collection.

Leadership

“Mediocre leaders connect every single thing to patient safety. Surgical huddles, checklists, measurement of key quality metrics, hand washing, lab automation, and statistical quality control are all part of patient safety. New furniture, pretty flooring, decorative fountains, more access to better coffee, and even tastier cafeteria food are all nice, but should not be linked to patient safety. Not everything that leads to beauty and flavor leads to patient safety.”

“It is not helpful to declare a crisis around every quality problem. Most labs have serious challenges, but they are not in critical condition. Continuous process improvement is a better model than crisis management. Tampering is worse than doing nothing. In the real world, changing something—anything—so we can say we ‘did something’ is an even weaker intervention than ‘reviewed with staff’.”

“I am skeptical when upper management is disconnected and employing consultants for every quality improvement effort. Consultants, when they have deep domain knowledge, are useful for some high-risk projects when there is insufficient local expertise. Most quality improvement projects can be accomplished by people within your institution. Minimally, give your people some quality improvement training and let them have a chance to solve problems. Trained workers with context are often more successful at improvement than experts. On the other hand, the only ‘expert’ is the one that doesn’t work for you. Fresh ideas can be injected with less pain if they come from a charismatic stranger.”

“Some lab medical directors state that quality process improvements, including Lean and Six Sigma, are faddish or not applicable to healthcare. I couldn’t disagree more. We use the DMAIC process to tie Lean and Six Sigma together in our system—Define, Measure, Analyze, Improve and then Control. Our efforts stress knowledge and formal training in use of these tools. Employees at all levels are encouraged to pursue levels of training in quality process improvements, from bronze level to silver level and green belt to black belt. Most importantly, I believe that all leaders should have some advanced training in Lean/Six Sigma. We are witnessing the nascent evolution of the science of healthcare delivery systems. Healthcare thinking is woefully behind other arenas in using formal process improvement tools, which is a shame, since these tools are already being used in our laboratories or are quite intuitive. Plus, in the laboratories, we are data-driven and natural analytical systems-thinkers.”

“The hardest work in improving quality and safety is not learning the tools. It is leading change in the laboratories. It is convincing others that the status quo is not good enough. Questioning can be quite powerful. Are we willing to have our statistics in this area published in the local newspaper?”

“Training in change management, teamwork, and conflict resolution can be very good investments. There truly is nothing soft about the soft skills. Leading change is not for sissies.”

Communication

“One of the most important things you can do to improve quality is to listen to your staff. In highly functional units, staff will provide valuable information about serious quality problems and ideas for fixing them. Even in poorly performing units, listening to staff is crucial. It is more challenging in this setting, because the information often has a poorer signal-to-noise ratio. By this, I mean you are going to get a mix of accurate and inaccurate information. By using measurements, observation, and more focused staff interviews, the accurate information can be distinguished from the inaccurate information. The accurate information provided by dysfunctional units is just as useful as that provided by the most highly competent unit.”

“It is good to remind your coworkers that the patient is in the vial. It is better to refer to lab specimens as patients rather than specimens.”

Measurement

“People’s perceptions are their realities. It is amazing to me that two equal groups can do the exact same work and one group considers themselves overworked and exhausted and the other group views the workload as modest and easily completed. The only way to find out if a perception is objectively true is to measure. For example, consider the example where staff perceives they are overworked. You can determine if this is true by measuring that work in many ways using techniques like videotaping, tallying the work, and doing time motion studies. Those measurements can be compared and contrasted with peer laboratories.”

“You have to get rid of hand waving and emotion and start measuring. Otherwise quality improvement will be determined by who complains loudest. If you want to know which errors to work on, measure error rates and how frequently specific classes of errors seriously harm patients. This is a better approach to quality improvement than loudness.”

Work Environment

“Work culture is local. Within the same lab, you can have work units that are highly productive and focused on patient safety, and other units that are centered on themselves.”

“Consider making your workplace more formal. It may be true that a few workplaces improve quality and productivity by eliminating dress codes, letting people bring their dogs to work, providing indoor putting greens, and supplying unlimited soda and popcorn. But I think these workplaces are the exception to the rule. It is a stretch, and defies commonsense, to think that any of these things will improve patient safety. It is reasonable to expect that a serious atmosphere, which is not unnecessarily severe, will lead to a serious approach to quality improvement.”

“It is not a good sign for quality if staff members are calling the medical director “dude” or vice versa.”

“It is good not to confuse friendly with formal—medical directors can be friendly and formal at the same time. I discourage the use of having others call me by my first name; it lets them know that even though our hierarchy is relatively flat, it is not as flat as North Dakota. Someone has to make the difficult and final decisions.”

Quality Improvement and Morale

“Continuous quality improvement need not be painful. In fact, there is no better way to boost morale than to report improving QI metrics to the employees who made it happen. It is good to advertise the QI accomplishments of staff. People love to see their name in lights on a marquee; advertising is a great motivator. This is better than cake and ice cream socials and small gifts favored by some administrators. These things quickly lose their power and end up becoming expectations.”

“Besides improving the quality and safety of our laboratories, implementing QI projects in our laboratories over the last five years has improved safety for both patients and our employees. Listening to frontline workers is called listening to the ‘voice of the customer’ in the quality terminology. We have witnessed employee morale improve as they embrace and implement QI projects.”


What is better for morale: Cake and ice cream socials or providing feedback about successful QI?

Quality Tools

“It’s more important to find the best method for making the improvement at hand than to select one method, transform the organization, and then make every improvement effort fit the method. Any opportunity that can’t be solved using the selected method goes unresolved, because no one knows what to do with it. You may have to come up to speed really fast on a new method, even attend some training, but it’s worth the cost and effort.”

“If you do not have multiple and the right tools in your arsenal you may not ask the right questions in order to identify and solve a problem.”

“It is a general rule of thumb that the more sticky notes there are on an instrument, the worse that instrument is performing. The in vitro diagnostics industry designs instruments to work without sticky notes.”

“Technology will not fix every patient safety problem in the lab. It is not a good idea to automate a bad process. Americans are enamored with technology fixes. There is a role for technology, but improving patient safety in the lab is primarily about continuous process improvements and building safer cultures.”


Sponsored by ARUP Laboratories, Inc.
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