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Michael A Noble MD FRCPCChair – Clinical Microbiology Proficiency Testing
Chair – Program Office for Laboratory Quality Management
University of British Columbia
Counting the Costs of Poor Quality
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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
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Useful References for Cost and
Error
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Healthcare’s Biggest Challenges (Including medical laboratories)
The Quality – Error Dynamic
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Pressures Drive Error and Quality
Costs
Risk
Stress
Staffing
Culture
Urgency
Liability
Litigation
Regulation
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Quality–Error-Pressure
� Pressures drive up Error and drive down Quality.
� Error drives up Pressures and drive down Quality.
� Poor Quality drives up both Pressures and Error
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Quality-Error-Cost Dynamic
AND… Errors, Pressures and Poor Quality
ALL Drive up Costs
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To know and understand the dynamic of Quality and Costs, FIRST know and understand ERROR
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Eight things we know about Laboratory Error
1. Most errors are unrecognized or unreported
2. Systemic structures tend to stop most error from showing
3. Of the errors that are detected and studied, they are common and
frequent and occur during every phase of laboratory testing
4. Many personal errors have systemic causes.
5. Most errors have benign causes that are difficult to control
6. Many errors are seemingly benign with respect to Patient Care,
but are dire when viewed in the context of other stakeholders.
7. Even if an error appears benign, the outcome may be far reaching
or catastrophic.
8. Intact mitigation and continual improvement programs can
prevent dire consequences resulting from significant errors
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Analysis of laboratory patient safety event reporting in BC: Identifying opportunities to enhance data collection, support learning and promote quality improvement
Veronica Restelli; Michael Noble; Annemarie Taylor; D. Douglas Cochrane
In a population of approximately 4 million people with 105 medical laboratories
12,278 laboratory patient safety events reported75 laboratories - 18 months
On Average about 9 events were reported per month per laboratory
True number of occurring events is probably much higher40-100
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Why Most Errors are NOT
ReportedThe Wrong
Thing
Happens
There is
Inconvenience
or Harm
Someone is
Aware and Wants
to Report
A Reporting
Mechanism
Exists
The Reporting
Mechanism is
Available
The Reporting
Mechanism is
Easy to Use
No Negative
Reporting
Consequences
The Report
gets
Submitted
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Six Reasons Why Most Errors are NOT Reported
The Wrong
Thing
Happens
There is
Inconvenience
or Harm
Someone
Wants to
Report
A Reporting
Mechanism
Exists
The Reporting
Mechanism is
Available
The Reporting
Mechanism is
Easy to Use
No Negative
Reporting
Consequences
The Report
gets
Submitted
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Why most errors are not associated with observed inconvenience or harm
!James Reason1990
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The other reason that error goes undetected…
Downstreaming or
Butterfly effectsmall initial error leads to large unforeseen consequences over time
Occurrence
Effect
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Distribution of Reported
Patient Associated Medical Laboratory Error
80% 15%
5%
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Errors Impact More than Patient Care
Extended Definition for Critical ErrorAn error that results in inconvenience or harm involving
any or all:
PatientsFamily
Clinical care staffLaboratory staff
InstitutionCommunityEnvironment
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Medical Laboratory Error is the single greatest risk to:
� Patient Care� Work Flow
� Financial stability
� Worker satisfaction
� Credibility
� Investigation
� Litigation
� Regulation
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The Most Common Causes of Error are both benign and human
(probably also including medical laboratory error)
Slips: errant missteps or distractions
Mistakes: errant knowledge or errant judgements
Slips and Mistakes become addressable
when they occur over and over and over
James Reason
Sydney Decker
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The Most Common Factors that
Cause Slips and Mistakes
System FactorsPoor Work Distribution
Undue Time Constraints
Excessive Noise
Distractions
Confused instruction
Personal
FactorsRushing
Attitude
Stress
Injury
Health
Briggs Phillips
1986
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What we know about Error
� Common and Frequent
� Often missed or unreported
� Usually inadvertent and seemingly benign
� Can cause considerable wide spread harm and
inconvenience
� Drives down Quality
� Drives up Cost
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What we know about Cost
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Accounting Calculations for
Costs of Poor Quality
Prevention Costs� Standards� Equipment� Supplies� Training� Continuing Education� Implementing Quality
Management
Appraisal Costs• Quality Control
• PT/EQA
• Accreditation
• Competency Assessment
Failure Costs
Internal Failure
• Recognition• Repeat• Remediation
• IT• QC
• Correction• Prevention
ExternalFailure
• Contact• Recall• Remediation• Repeat• Correction• Prevention• Litigation
Joseph Juran
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Costs of Quality
0
5
10
15
20
25
30
35
40
45
50
PreventionAppraisal Internal External
S. Rodchua
ASQ, Quality Management
JourV16-1, 2009
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Costs of Quality:Quality Accounting Practices
0
5
10
15
20
25
30
35
40
45
50
PreventionAppraisal Internal External
Line Listed
Budget Adjusted
Directly Traceable
Not Line Listed
General ledger
Difficult to Trace
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Calculus of Costs of Quality
`
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Calculus of Costs of QualityRise in P/A costs can decrease both FC and TC
13
2
100%
Defective
Quality of Performance 100%
Good
…but overspending can make total costs rise
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Noble MA, K. Meghairbi. Proficiency Testing Can Improve
Medical Laboratory Clinical Testing Performance. Quality Management Conference for Medical Laboratories. Vancouver BC. October 2013
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When might a laboratory determine Poor Quality Costs
� As a regular or intermittent Quality Indicator for:�Common Error
�Patient recall
� As a special monitor indicator following Significant Error�Multiple analyzer errors
�Individual’s performance errors
�Laboratory safety failure
�Tracking failure costs sheds light.�Highlights costly errors�Assists learning from errors�Benefits continual improvement
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Some errors impact more than money
� Poor Quality is NOT just about money.
�Not all costs are financial.�Defining all costs as financial diminishes
impact.�Non financial costs also drive Error.
� Other Costs to consider�Time Costs
�Patient Costs
�Reputational Costs
�Staff Costs
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Laboratory Errors Costs Impact Patients� In Vancouver, how much does an out-patient recall
for repeat testing cost?
Out of PocketBus $ 5.00Drive/Parking $ 4.00 plus
Taxi $10.00Time
Home – to – Home: 60-120 minutes
Anxiety ???Management Delay (24 hours) ???
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Laboratory Errors Costs impact Staff and FamilyA laboratory proficiency testing program send simulated stool samples to 150 medical microbiology laboratories. The samples contained laboratorized strains of Shigellaflexneri.
7 laboratory technologists and 1 family member reported developing enteric symptoms. None were hospitalized but all required medical care and follow-up
Budget Impacts: Replacement costs
Total impact: Sick time, Healthcare costsCaregiver costs Family member lost work and income.
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Reputational Costs:far beyond the laboratory budget
� A Canadian laboratory started testing for hormone sensitivity tumor markers using an unvalidated assay.
� Many false positive and false negative test results
� 78 women died.
� Provincial enquiry (Cameron Commission)
� Millions of dollars spent
� People lost jobs
� People left jobs to work elsewhere.
� Unable to find people who would fill lost positions.
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Employee TEEM Costs
� TIME
� EFFORT
� ENERGY
� 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.
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Impacts of High Effort and Energy Costs
� Ergonomic Challenges
� Repetitive Stress Syndrome
� Repetitive accidents
� Safety complaints and citations
and
� Personal Stress and Infectious Stress
� Deteriorating Culture
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TEEM Compounding Impacts
SlipsDistraction
sErrors
Accidents
STRESSENERG
YANXIET
Y
STRAIN
EFF0RT
PAIN
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TEEM Warning Signs
Effort Energy� Dexterity discomfort
� Joint Aches and Pains
� Coughing and Breathing Problems
� Frequent Burns and Rashes
� Missing work
� Difficulty Sitting or Standing
� Dizziness or Falling
� Back Pain
� Inattention to Detail
� Distraction
� Rushing
� Headache
� Missing work
� Anxiety
� Anger
� Rage
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Failure Costs
ReputationCosts
CommunityEnvironment
Costs PatientFamilyCosts
EmployeeTEEMCosts
The New Dynamic
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In summary…
� Pressures, Quality, Costs, and Laboratory Error are intertwined and
feed on each other.
� Laboratory errors continue to be very common. Most are perceived
as causing no harm, but cause inconvenience.
� Small increases in performance and appraisal costs can result in
large decreases in Failure costs
� Laboratories can and should develop better ways to
track and control FAILURE COSTS
� TEEM Factors magnify the problems that
manifest cost and error and poor Quality
ERROR HAS MANY MANY COSTS
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Thank you…For more information on Quality and Cost and Error
� Making Medical Lab Quality Relevantwww.medicallaboratoryquality.com
� This Presentation is available at
www.POLQM.ca
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The New Dynamic Failure
CostsReputation
Costs
CommunityEnvironment
Costs PatientFamilyCosts
EmployeeTEEMCosts