4. An Unexpected Lesson In Quality February 6, 2014

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# 3.  Webinar #1.  The Journey is off to a bumpy start
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An Unexpected Lesson in Quality

Thursday January 30th saw the first webinar in the journey to Stats-Free Journey - sort of.The screen froze here

Part way through the presentation, the operator (that's me) made a technical error and the screen image froze.

The lesson:  Every quality failure you see:
  • Presents an Opportunity For Improvement.  (OFIs - look for them!)
  • Presents an Opportunity For Education (OFEs - take advantage of them!
  • has a corresponding failure of quality control. This applies to errors in lab results, to product recalls, to equipment failure, etc

The Quality Lesson
A webinar with no pictures fails quality standards. 50% of it was 'bad.' 
Would any lab consider method performance  acceptable if 50% of patient results were bad?  Some do!

•   Many labs do not set clinical quality standards
•   Most labs do not define when to stop
•   A lot of labs do not stop until 50% of results are bad
            20% said they stop when Sigma = zero.

            Watch video #4!   50% of results fail to meet TEa when Sigma = 0


Misunderstanding of statistics creates Q.C practices that are ineffective to prevent patients from lab errors.
 
Spread the Word!   This webinar and the unexpected lessons learned are posted on YouTube in 5-10 minute segments. 

AWEsome Videos on YouTube

Part 1.  
Introduction, Why Stats-Free; The Journey Ahead 
  
   Read More
These webinars are presented by Zoe Brooks and sponsored by AWEsome Numbers Inc. 
Zoe brings a unique perspective to medical laboratory quality control.
"The comments and thoughts in these webinars are my personal opinion.   They do not represent any company or organization.  SOMEBODY, PLEASE STAND UP AND PROVE ME WRONG!"  


Part 2.    The Q.C. Gap; The Quality Failure    Read More
The Q.C. Gap
The Dysfunctional Christmas Tree  (Lab Dis-organizational Chart)
Opinion Polls, and
An unplanned lesson in quality failure.


Part 3.  Q.C. Designed with the Front Line in Mind      Read More
Imagine a common language that relates quality to patient care -- for everyone who cares about lab quality.
Imagine a Q.C. process that means the needs of lab supervisors and managers
What do managers and techs want  in a QC system?

Now imagine what YOU can do to make this happen!


Part 4. Connecting Q.C. to Patients; A Quality Lesson      Read More 
Connect the dots from the effectiveness of quality control to patient care.
What are the driving and restraining forces for OptimiZed Q.C.
Bonus!  There was an unplanned lesson in what happens with ineffective Q.C. and uncertified staff. 
The video stopped part way through.  Would any lab consider method performance  acceptable if 50% of patient results were bad?  Some do!

 


 
Part 1.  Introduction, Why Stats-Free; The Journey Ahead 
These webinars are presented by Zoe Brooks and sponsored by AWEsome Numbers Inc.  Zoe Brooks brings a unique perspective to medical laboratory quality control. 
Zoe has:
  •  worried about Q.C. at the bench
  •  managed Q.C. in small & large labs
  •  published books & articles
  •  created and taught courses
  •  been international keynote speaker
  •  consulted on Q.C., and
  •  served on international committees.
Zoe's  passion for teaching has driven her to simplify expert quality control process so they can be understood and applied to guarantee clinically-acceptable patient results.

"After 40 years of practicing, teaching and studying lab quality control, I have concluded that the only way to improve quality control is to remove the confusion caused by statistics.
The comments and thoughts in these webinars are my personal opinion.   They do not represent any company or organization. PLEASE STAND UP AND PROVE ME WRONG!" 
Zoe Brooks,   February 4, 2014
 
This is an open dialogue.  Everyone who cares about quality is welcome.
Guest panelists, presenters, authors are welcome!
All presentations and discussions must relate Q.C. practice to patient care.
Submit Questions and Case Studies.   We'll use simulators to illustrate the cause and effect.
These sessions will not be free of commercial bias.  Commercial companies play the key role.  Everyone who cares about lab quality is welcome.

Return to list

Part 2.    The Q.C. Gap; The Quality Failure 
The Q.C. Gap;
The Dysfunctional Christmas Tree  (Lab Dis-organizational Chart)
Opinion Polls, and
An unplanned lesson in quality failure.
 
Poll Questions:
1. Where do you fit on the 'Dysfunctional Christmas Tree'?
2. How many hours a week do you spend on Quality Control of quantitative tests  - with numbers, charts & Q.C. rules.
3. When you first graduated, how many hours formal education did you have in the concepts and statistics of Q.C.?
4. How confident are you that your lab's QC protects patients from clinical error?

 
The Quality Failure:  An unplanned example of ineffective quality control and uncertified staff.  Could lab results ever be so bad?

Return to list


 Part 3.  Q.C. Designed with the Front Line in Mind
Imagine a common language that relates quality to patient care -- for everyone who cares about lab quality.
 
Imagine a Q.C. process that means the needs of lab supervisors and managers
• I want to have an alert sent to me daily about potential problems with a test based on continuous compiled data.
• I want everything connected to one central brain that can tell me and alert me to just about anything I want and don't want.
• I want immediate peer group data instead of having to submit and get it two weeks to a month later.
• Along with the control, a complete analysis of each test.
• Clear cut understanding to frontline staff of sequenced steps to take when QC issue
• Significant staff engagement about QC/ QA process and understanding to the direct link to patient outcomes.
• I need detail step by step.  
 

Now imagine what YOU can do to make this happen!

Return to list

 
Part 4. Connecting Q.C. to Patients; A Quality Lesson 
 
Connect the dots from the effectiveness of quality control to patient care.
What are the driving and restraining forces for OptimiZed Q.C.
 
Bonus!  There was an unplanned lesson in what happens with ineffective Q.C. and uncertified staff.  The video stopped part way through.
 
A webinar with no pictures fails quality standards. 50% of it was 'bad.'

Would any lab consider method performance  acceptable if 50% of patient results were bad?
Some do!
•   Many labs do not set clinical quality standards
•   Most labs do not define when to stop
•   A lot of labs do not stop until 50% of results are bad
            20% said they stop when Sigma = zero.
            Watch!  50% of results fail to meet TEa when Sigma = 0
•   Most labs that set standards do not stop unless more than 5% of results are bad

 
This fails the DIMS test! 
(It Does Not Make Sense!)  Mosby's Dictionary defines allowable error as the amount of error that can be tolerated without invalidating the medical usefulness of the analytical result.   Allowable error has a 95% limit of analytic error; only 1 sample in 20 can have an error greater than this limit.
Do you think it is OK for 1 result in 20 to be medically invalid?

Join the discussions!  Spread the word!  Link to discussions

Return to list
Date
Webinar Focus           Enroll in live webinars

30-Jan-2014

From Stats to Stats Free  25 Years in 25 Weeks

6-Feb-2014

 If we only knew then what we know now ... oh wait, we did!
"Clinical Standards of Quality Control"  1991

13-Feb-2014
Open Dialogue

20-Feb-2014

Using Total allowable Error to Qualify Reagents and Calibrators,  AACC Poster 1992

27-Feb-2014

 "Using Total Error to Monitor  Performance, Qualify  Reagents  and Calibrators, and Select QC Protocols - Real World  Examples";  AACC 1993

6-Mar-2014

The great bias study of 1994

13-Mar-2014

QC Statistics ... Confusion or Comprehension?
AACC Poster 1995

20-Mar-2014

Open Dialogue

27-Mar-2014

A total error graph of individual data points provides rapid, easy, practical assessment of laboratory performance”  IFCC Poster, England 1996

3-Apr-2014

AACC 1998 - Quality Control in Six Simple Steps 

A Different Perspective

Visit  AWEsome Numbers on Facebook!
Our goal -  clear communication between all the stakeholders in laboratory quality.
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Thanks for caring for quality!         
Please forward this to friends and colleagues.

Zoe Brooks     Feb 5, 2014
Please note.  I am not being critical of any individual person, institution or organization.  I want to express my most sincere respect, admiration and appreciation to  Dr. Westgard and so many others.  This process does not contradict  today's  published  recommended, principles and processes; it just implements them differently. 

Last modified: Wednesday, 19 February 2014, 3:47 PM