Counting the Costs of Poor Quality

Transcription

1 Counting the Costs of Poor Quality Michael A Noble MD FRCPC Chair Clinical Microbiology Proficiency Testing Chair Program Office for Laboratory Quality Management University of British Columbia

2 By way of introduction Michael Noble Medical Microbiologist and Internal Medicine by training Laboratory physician by profession Medical Qualitologist by evolution and avocation Qualitology The body of knowledge pertaining to Quality. Standards development Research and Development Education Application

3 Foundations of Quality Quality is not a new body of knowledge Modern Industrial Quality is traced by to 1890s Frederick Taylor Henry Ford Walter Shewhart W. Edwards Deming Joseph Juran Philip Crosby Armand Feigenbaum Masaaki Imai Taiachi Ohno Robert Galvin

4 Modern Quality in Health Modern medical laboratory interest developed between Levey and Jennings (Quality Control) Belk and Sunderman (PT) R. C. Bartlett (Microbiology) But Healthcare in North America was shocked into awareness in 1999 with the publication of To Err is Human by the Institute of Medicine (IOM).

5 Healthcare s Biggest Challenges

6 The Equivalence of Faulty Forces Costs drive Error and Poor Quality. Error drives Costs and Poor Quality. Poor Quality drives both Cost and Error

7 Medical Laboratory Error Error is the single greatest risk to medical laboratories: Patient Care Work Flow Financial stability Worker satisfaction Credibility Investigation Litigation Regulation

8 Medical Laboratory Error Error is uncommon 1:3000 to 1:5000 samples (But in Canada there are about 100M samples annually) Most error is cause by human error from slips and distractions Most recorded errors occur before any work is actually performed on the sample opre-examination 80% oexamination 5% opost-examination 15%

9 The Most Common Causes of Medical Laboratory Error Slips, Distractions, Personal Judgements

10 The Most Common Causes of Slips, Distractions, and Personal Judgement Error System Factors Work Distribution and Time Constraints Noise Crowding Confused instruction Personal Factors Rushing Attitude Physical and Mental Stress Medical Para-medical factors

11 Costs of Poor Quality Financial Costs of Quality have been a central topic of discussion since 1950

12 Six Decades of Useful References 12

13 Joseph Juran and Traditional Accounting Calculation for Costs of Poor Quality Prevention Costs Standards Equipment Supplies Training Continuing Education Implementing Quality Management Appraisal Costs Quality Control PT/EQA Accreditation Failure Costs Internal Failure Recognition Remediation Correction Prevention External Failure Recall Remediation Repeat Correction Prevention Litigation

14 Costs of Quality Prevention Appraisal Internal External

15 Calculus of Costs of Quality SMALL increases to Prevention-Appraisal costs results in BIG decreases in Failure costs Reduced Failure costs will reduce Total Costs Excessive increases in Prevention-Appraisal costs can drive up Total Costs

16 Traditional Costs of Poor Quality Kevin O Leary Canadian Hyper-Rich TV Personality

17 Challenges with the Traditional Model Poor Quality is NOT just about money. Not all costs are financial. Defining all costs as financial diminishes impact. Non financial costs can drive Error. Other Costs to consider Time Costs Patient Costs Reputational Costs Staff Costs

18 Some errors take longer to repair than others Pre-examination patient demographic error 25 Pre-examination labeling error 40 Examination mechanical 116 Examination mechanical (retesting required) Minutes 140 Patient recall for retest 200 AVERAGE ERROR 130

19 Medical Laboratory Error excluding complaints, quality, finance, HR, IT Errors per DAY Demographic Labelling Examination mechanical (20+ patients) Examination mechanical - retesting Patient recall Minutes Lost per DAY AVERAGE DAY CPQ TIME LOST 1040

20 Percent FTE Consumption for Error All Errors per day Minutes Lost 10 FTE 30 FTE 100 FTE 250 FTE

21 Medical History A 67 year old woman of Indian descent complains to her family that she is not feeling well. She is unable to describe her illness other than pain and abdominal discomfort. Family assumes it is probably her common recurrent constipation. (Note: a common characteristic associated with culture, age, and gender, is vagueness in verbal description of symptoms).

22 The Story Continues Following 3 days of continued complaint of discomfort, the woman visits a family practice clinic. Further history and physical examination is examination does not shed any light of possible cause. The doctor orders blood tests to check liver, heart, kidneys and urinalysis. All blood results return normal. Urine result delayed. Doctor supports a diagnosis of gas and constipation and instructs her to take laxatives.

23 Three days later The daughter-in-law finds her mother tearful, and saying that she is going to die. She continues to have discomfort. Now has a fever. Son takes her to ER. The emergency physician suspects some abdominal discomfort but gets little more information than the previous physician. He orders: Blood Tests WBC up slightly, Chest X-Ray, Abdominal X-Ray no suggestion of ileus Patient returns to home.

24 Two days later The woman is quite unwell, crying, fevered, with marked back-pain. Return to the ER. The attending physician suspects kidney disease, and orders: Urinalysis, Urine culture, MRI, and more blood tests. Admits to hospital.

25 The next day The attending physician receives a telephone call from the family doctor. The urinalysis from 6 days had been mislabeled and lost, but now recovered. Strongly suggestive of infection. 4+ leucocyte esterase 4+ nitrates. 3+ RBCs

26 By this time Infection now involving kidneys. Elder woman now requires 14 days of hospitalization and intravenous antibiotics. Found to have kidney stone that requires surgery. Discharged from hospital following surgery, but with marked fatigue and disability.

27 Message Had the urinalysis been processed same day and would have followed with culture. All results available, including antibiotic susceptibilities in 48 hours.

28 Poor Quality has its Consequences Mishandled urine sample 2 minutes. Consequences Patient s sustained infection Two ER Visits Hospitalization Multiple tests Intravenous antibiotics Kidney stone and surgery Post hospital debility.

29 Consequential Costs Patient s sustained infection Immeasurable Two ER Visits $2,000 Hospitalization $70,000 Multiple tests $5,000 Intravenous antibiotics $3,000 Kidney stone surgery $12,000 Post hospital debility. Potential Liability Costs Immeasurable Immeasurable

30 Reputational Costs: Medical Errors can result in unwanted attention In Canada over the last 10 years we have had medical laboratory error leading to public enquiry in 5 provinces.

31 The impact on your reputation of having to say you are sorry Priceless???

32 Another example In a business, Person A is top management and Person B is a line worker. Person A is paid $150 per hour while Person B is paid $25 per hour. An accident happens. If Person A is unavailable for 8 hours, the organization continues to operate. Cost to the organization is $1200. If Person B is unavailable for 8 hours, the organization stops, but the cost to the organization is only $200.

33 So

34 TEEM Costs TIME EFFOR T ENERG Y MONEY The amount of time lost counted in minutes The amount of physical effort and potential injury that is experienced. The amount of mental stress and anxiety that is experienced. The amount of money that is expended or lost as impact of cost and error.

35 Look for the Warning Signs TEEM Impacts are Present if you look. If you miss them the FIRST time you will invariably get a SECOND opportunity.

36 TEEM Compounding Impacts STRESS ENERGY ANXIETY Slips Distraction s Errors Accidents STRAIN EFF0RT PAIN

37 TEEM SCALES EFFORT Making your heartbeat and 1 breath faster 2 Exertion to Sweating 3 Restlessness 4 Fatique 5 Tightening your muscles Loss of coordination for 6 intricate movement 6 Trembling / Shaking 7 Muscle ache 8 Pain 10 Injury 20 Long term disability ENERGY 1 Anxiousness / Moodiness 2 Restlessness 3 Inability to concentrate 4 Quick temper 5 Loss of objectivity 6 Problems with memory 7 Poor Judgement 8 Sense of being overwhelmed 10 Requires Day Leave 20 Medication (drugs/alcohol) 25 Requires Stress Leave

38 TEEM SCALES TIME minutes minutes 3 31=60 minutes minutes minutes person days % work staff days % work staff days 40 > 25% work staff days 100 Shut down MONEY 3 Minor operating costs 10 Significant impacton operating costs 15 Significant impact on revenue stream percent new deficit 40 > 5 percent new deficit 100 Financial Closure

39 Composite TEEM Scores Money Energy Effort Time 10 0 Period 1 Period 2 Period 3 Period 4

40 The New Cost/Error Dynamic TEEM Factors MAGNIFY Costs and Errors AND Poor Quality

41 In summary Quality, Costs, and Laboratory Error are intertwined with each feeding growth of the others. Poor Quality impacts on Costs for Patients, Staff, Reputation TEEM Factors Magnify the problems that manifest cost and error and poor Quality Multi-dimentional (TEEM) costs CAN be measured and Monitored.

42 In conclusion Poor Quality, Costs, and Error are inexorably linked. Poor Quality, Costs, and Error are Measurable and Monitorable Addressing Poor Quality, Costs and Error is of benefit to ALL.

43 BEAT the TEEM

44 Thank you For more information on Quality and Cost and Error Making Medical Lab Quality Relevant Consider the UBC Certificate Course in Laboratory Quality Management. This Presentation is available at

45 The New ERROR Dynamic COSTS TEEM FACTOR S POOR QUALITY