The Pathologist as a Quality Manager

Henry Travers, M.D.Governor

College of American Pathologists

Attending Pathologist and Medical Director of the

Blood BankAvera McKennan Hospital

Sioux Falls, SD

Physician’s Laboratory, Ltd.

Pete.travers@mckennan.org

What is a Quality Manager?

Someone at a management level in an organization who has responsibility for

quality

What is a manager?

There are a number of ways to explain what a manager is, but the easiest is probably through what a manager does.

•Makes decisions

•Communicates decisions

•Follows up on decisions

•Motivates

•Organizes

Differences Between Physicians and Managers

Physicians Managers

•Doers•1:1 Problem solving•Reactive•Immediate response•Deciders•Autonomous•Independent•Patient advocate•Independent professional

•Designers•1:N Problem solving•Proactive•Long time span before results•Delegators•Collaborators•Participative•Organizational advocate•Interdependent professional

Why be a quality manager?

“Serious and widespread quality problems exist throughout American Medicine. Current efforts to improve will not succeed unless we undertake a major, systematic effort to overhaul how we deliver health care services, educate and train clinicians, and assess and improve quality.”

-Institute of Medicine National Roundtable on Health Quality, 1999

Assumptions about Quality

The gap between the quality that we could create and that which we do create is large

Addressing this gap requires a transforming redesign of the patient-system interface

A culture clash between clinicians and managers constitutes a major impediment to this transformation

Establishing quality as a business strategy offers the most promising approach to healing this culture clash

How do you manage quality?

First, you have to have an understanding

of what quality is.

A general definition of quality will be unsatisfactory to at least some segment of any population interested in quality.

So what is quality?

•Quality is a part of a description of the end product of processes•Quality is also part of a description of products of intermediate processes•Quality can be quantitatively or qualitatively expressed•Quality can be improved•Quality in any given process may be defined differently by different observers•Quality may be subject to cost-benefit analysis

OK, so all kidding aside,what is quality, really?

Quality is a descriptive term for a “product” incorporating both the customers’ satisfaction with the “product” and the fitness of the “product” to accomplish the function for which it was designed.

Leadership

“One might go so far as to say that a unique function of ‘leadership’ as contrasted with ‘management’ or ‘administration’ is the creation and management of culture.”

-Edgar Schein, Organizational Culture and Leadership

Quality and Culture-I

Culture is a pattern of shared assumptions:

•Learned by group members

•Taught to new group members

•About the “correct” way to perceive, think about, feel and act in all aspects of daily work life

•In order to solve problems of survival

Quality and Culture-II

Elements of Culture:

•Artifacts: Visible, hearable, feelable manifestations of underlying assumptions (e.g. dress codes, behavioral patterns)

•Shared Values: Espoused reasons why things should be as they are (e.g. goal statements, value statements, codes of ethics)

•Shared Basic Assumptions: Invisible, but surfacable reasons why group members perceive, think and feel (e.g. assumptions about mission,

relationships, etc)

Quality and Culture-III

•People are less aware of assumptions than artifacts

•The power of culture lies in the assumptions

•Observable conflict occurs at the level of artifact

•The “disconnect” is at the level of assumptions

•Shared values are the bridge

The Craft to Systems Evolution

Our challenge as clinical and managerial professionals: Collaborating in such a manner as to incorporate and preserve the best of medicine’s craft heritage to the emergent, inevitably more systems-based health care environment

At the core this means protecting, even enhancing the sanctity of the patient’s experience

Craft and Systems Quality

1. Focus

2. Mastery

3. Training

Individual

Process

Entire Process

Whole process,

many years

Population

Outcome

Specific aspects

For particular

part in process,

understand whole

Aspect Craft Systems

Changing Cultures

•Adopt a new system vision

•Identify assumptions and values in the old system that must be changed and those that must be preserved

•Link cultural changes to strategic objectives

•Involve persons in the change

•Align economic incentives with the new vision

•Lead change, don’t manage it

Commitment vs. Interest

There’s a difference between interest and commitment. When you’re interested in doing something, you do it only when it’s convenient. When you’re committed to something, you accept no excuses…only results.

Commitment to Quality

• Commitment is replacing interest

• Everyone working with you must be committed and aligned with the philosophy of quality

• If you can’t say why you made your institution a better place, you should not expect tenure there

• The culture of quality helps define outcomes

Quality Truisms-I (From Ben Lytle, CEO, Anthem, 1999)

•Healthcare quality is much worse than we can prove•Many physicians argue that quality cannot be measured, but

they’re wrong•The public believes that managed care controls costs at the

sacrifice of quality, but they’re wrong•Expect the media, consumer and employer focus on quality to

intensify•Expect quality to be the number one issue in healthcare within 5

years

Quality Truisms-II (From Ben Lytle, CEO, Anthem, 1999)

•Expect quality-based licensing by government

•Expect disclosure of quality data by providers

•Focus on disease management and quality if you want to be here in 5 years

•In the long run, better management of disease is the key

Roles of the Pathologist in Quality Management

1. Laboratory Director

•Establishes the goals of quality in the laboratory

•Organizes personnel to accomplish goals

•Analyzes information

•Draws conclusions

•Implements action

Roles of the Pathologist in Quality Management

2. Member of the Medical Staff

•Serves on medical staff committees

(e.g. transfusion review)

•Applies expertise to medical staff quality review

•Perceived “neutrality”

•Avoids “enforcement” function

Roles of the Pathologist in Quality Management

3. Liaison with the public

•Perceived objectivity

•Scientific method applied to quality

•Central figure in patient deaths

•Expertise in quality analysis

The Pathologist’s Roles as a Quality Manager are not Limited to the Laboratory

•Quality is a system concern

•Pathologists must educate administrators and their fellow physicians about quality

•There is no ultimate quality “destination”

•Quality activities will result in conflict unless there is a cultural change that integrates quality as an underlying

assumption

Approaches to Quality Management

•Quality is inherent: we’re all professionals here

•Quality is an onerous administrative requirement: we’ll do only what we have to to comply

•“Gotcha”

•Quality as a delegated responsibility

•Quality as part of the culture

Principles of Establishing Quality Goals

•Common processes (e.g. serum/plasma glucose)

Improvement affects large number of people

•Processes where the “cost” of an error is high

Death, disability, prolonged stay, delayed diagnosis

•Processes which have already caused problems•Processes for which ideas for improvement are available and workable•Processes over which you have control

The degree to which you have control will determine success

Continuous Quality Improvement

CQI

Do what you’re doing a little better

This works in a stable environment, but

In a revolutionary environment,

CQI may not be an appropriate model

CQI in a Revolutionary Environment

Point of Care Testing

Test methods may use new paradigms of quality control

The object is to provide results in real time

Begin with the desired outcome and work backward through processes

Outcomes

• The ultimate measure

• Elusive

• A few are agreed on: e.g. death

• The most functional are ones that are the result of a process

• The most commonly measured in a laboratory is turn-around-time

Turn-Around-Time (TAT)

Intermediate processes

Test ordering

Specimen collection

Accessioning

Test performance

Result reporting

Turn-Around-Time (TAT)

Related Considerations

Clinical need

Provider expectations

Service limitations (e.g. time of day; personnel)

Patient location (in-patient; out-patient)

Case Study

A renal transplant surgeon schedules tacrolimus assays at 8:00 AM. to coincide with his rounds. He makes daily treatment decisions based upon the assay results. He is told by “a lab tech” that the TAT for this test is one hour.

At 9:15 AM you receive a call from the surgeon’s nurse demanding to know where the morning’s results are.

Case Study Questions

1. Is this a quality issue?

2. Do you have a quality problem?

3. What should you tell the nurse?

4. What should you do first (i.e. when you get off the phone with the surgeon’s nurse)?

5. What do you do next?

6. Should you include events such as this in discussions of quality with laboratory staff?

Case Study Answers

1. Is this a quality issue?

Yes

2. Do you have a quality problem?

Maybe, maybe not.

3. What should you tell the nurse?

Determine the facts from the nurse’s point of view. Write them down. Explain that you will investigate within X minutes. Ask for a phone number where you can reach him/her. Be polite.

Case Study Answers

Digression:

The primary issue regarding lab results is to get them to the decision maker when they are needed. This means that your obligation is to the physician. However, physician work habits often make use of extenders. While you will have to speak to the surgeon about this issue, it may cloud the whole process of review, needlessly antagonize a fellow healthcare worker, and make further interaction more difficult if you do not acknowledge the nurse’s place in this event.

Case Study Answers

4. What should you do next?

Find out if the result is available. If so, have it called to the patient’s location at once. Then collect information on when the test was ordered; when it was drawn; when it was received in the lab; and what happened to it after that.

Sort out as best you can in this short time frame what went wrong. Report the facts to the nurse.

Case Study Answers

5. What should you do after that?

Analyze the event in detail with your staff. Determine the process steps that failed. Do not take staff to task for a failure to get the job done; most often this is a system and process problem, not a people problem. Record the results of this study for aggregated review at some later time. Begin the process of correcting identified problems.

Communicate with the surgeon that day. Try to engage in a realistic discussion of why expectations were not met. Reiterate your commitment to quality.

Case Study Answers

6. Should you include the event is quality discussions?

Absolutely. An important part of a quality plan is adverse event management. These need to be aggregated, quantitated and studied if you are to improve the quality of what you do. Also consider that, while TAT was the outcome measure in this case, it may not be the only one. To some extent, physician satisfaction can also be an outcome measure.