1  

TO RECEIVE CEU CREDIT…

To receive credits you must complete the following:

• View complete presentation

• Pass the Quiz with a 70% or higher score

• Fill out the Evaluation Form for the presentation

• Sign the hard copy roster provided by your laboratory manager

Visit www.auroradx.com/edutraining to access this presentation again, download a PDF of it, take your quiz and fill out your evaluation form as well as obtain instructions on how to report credits to NSH

Encourage your teammates to participate and become the top-notch facility in the Aurora Diagnostics family to show case the best well-trained laboratorians and recognized for excellence in performance.

2

QUALITY WITHIN THE LABORATORY

Sarah T. Bland Quality Management Coordinator Aurora Diagnostics GPA Laboratories

ABOUT ME

 Born and raise outside of Richmond, Virginia

 BS in Music (with the intention of being a Music Therapist)

 Started with Biopsy Diagnostics in 2010 as an Accessioner

 Transitioned to Aurora Diagnostics Georgia as the office administrator (2012-2013)

 Moved to GPA as the Quality Management Coordinator September, 2013

 In the process of completing a Masters of Business Administration and Masters of Public Health

INTRODUCTION

 Anyone who goes through an accreditation inspection knows that preparing for the inspection can be stressful.

 For CAP accredited labs, a defined Quality Management program is necessary.

INTRODUCTION GEN.13806 Documented QM Plan Phase II The laboratory has a documented quality management (QM) program.

NOTE: There must be a document that describes the overall QM program. The document need not be detailed, but should spell out the objectives and essential elements of the QM program. The QM plan may be based upon some reference resource such as CLSI HS01-A2, GP22-A2, or GP26-A3; the ISO 9000 series or ISO 15189; AABB's quality program; CAP's quality management publications; or it may be of the laboratory's own design. If the laboratory is part of a larger organization, the laboratory QM program is coordinated with the organization's QM plan.1

GEN.16902 QM Implementation Phase II For laboratories that have been CAP accredited for more than 12 months, the QM plan is

implemented as designed and is reviewed annually for effectiveness.

NOTE: Appraisal of program effectiveness may be evidenced by an annual written report, revisions to laboratory policies and procedures, or revisions to the QM plan, as appropriate.

Evidence of Compliance: ✓  Evidence that the plan has been implemented as designed requires all of the following: ●  quality measurements/assessments specified in the plan are being substantially carried

out; ●  there is evidence of active review of quality measurements; ●  if target performance levels are specified in the plan and the targets are not being met,

there is documented follow-up action; ●  any interventions/changes to operations that are specified in the plan have been carried

out as scheduled, or the reason for delay documented; AND ●  any communication of information that is required by the plan have taken place1

INTRODUCTION GEN.20208 QM Patient Care Services Phase II The QM system includes a program to identify and evaluate errors, incidents and other

problems that may interfere with patient care services.

NOTE: There must be an organized program for documentation of problems involving the laboratory that are identified internally, as well as those identified through outside sources such as complaints from patients, physicians or nurses. The program must be implemented in all sections of the laboratory, and on all shifts. Any problem that could potentially interfere with patient care or safety must be addressed. Clinical, rather than business/management issues, should be emphasized. The laboratory must document investigation and resolution of these problems. Laboratories must perform root cause analysis of any unexpected event involving death or serious physical or psychological injury, or risk thereof (including “near misses” and sentinel events). Laboratories must be able to demonstrate appropriate risk-reduction activities based on such root cause analyses. 1

GEN.20316 QM Indicators of Quality Phase II The QM program includes monitoring key indicators of quality in the pre-analytic, analytic,

and post-analytic phases.

NOTE: Key indicators should monitor activities critical to patient outcome and/or affect many patients. The laboratory must document evaluation of indicators by regularly comparing performance against available benchmarks. The number of monitored indicators should be consistent with the laboratory's scope of care. Special function laboratories may monitor fewer indicators; full-service laboratories should monitor multiple aspects of the testing process appropriate to their scopes of service.

While there is no requirement to monitor any specific laboratory monitor, the following key quality indicators listed below have been commonly used to measure laboratory performance in a consistent manner and are important to clinicians and patients as indices of care. 1

INTRODUCTION GEN.20325 Employee and Patient Quality Communication Phase II The laboratory has a procedure for employees and patients to communicate concerns

about quality and safety to management.

NOTE: The investigation and analysis of employee and patient complaints and suggestions, with corrective and/or preventive action as appropriate, should be a part of the laboratory quality management plan and specifically addressed in laboratory quality management records.

Evidence of Compliance: ✓  Records of employee and patient complaints (if any) with appropriate follow up1

WHAT IS QUALITY MANAGEMENT?  Quality Management is “an organization-wide approach to understanding precisely what customers need and consistently delivering accurate solutions within budget, on time, and with the minimum loss to society.” 2

 Quality is the degree to which healthcare services strive to provide accurate, desired outcomes for patients and are consistent with current professional knowledge.

WHAT IS QUALITY MANAGEMENT?  Pathology is a fundamental part of healthcare. Thus, deterioration in the quality of pathology services can compromise patient care and adverse health events. 3

WHAT IS QUALITY MANAGEMENT?

 Quality Control

 Quality Assurance

 Continuous Improvement

 Pre-analytical

 Analytical

 Post-analytical

 Safety

 Efficiency

 Effectiveness

 Value

 Service

 Accuracy

 Measurable

 Consistent

 Indispensable

WHAT QUALITY MANAGEMENT IS NOT:

 Indifferent

 Inefficient

 Sporadic

 Irregular

 Expendable

 Unnecessary

 Individual

WHAT QUALITY MANAGEMENT IS NOT:  Quality management is not just about errors, it is about doing what is right, period.

 Errors happen. To err is human, as they say. Quality Management is simply a feeble attempt to foster a culture of excellence.

LIFE WITHOUT QUALITY

 No expiration dates on milk (one of the most unpleasant surprises in life)

 Purchased strawberry yogurt, mislabeled and is beet yogurt (that’s a real thing, folks)

 Salmonella in peanut butter (the great Peter Pan debacle of 2007)

 Computer sold using bogus components (Dell, 2010)

 Brakes on a car sure are handy, hope they passed quality control… (Toyota, 2009 – 2011, 2014)

LIFE WITHOUT QUALITY

“Before talking about quality of life, physicians should call us by our names, instead of by the names of our diseases… To evaluate the quality of our life means knowing us, as people….Physicians often see us as boxes, with a disease inside. That's not what we are. We need time…The main result was to highlight the close relationship between quality of life and quality of care. Underlining the importance of a global approach to health, and the role of the physician as a leader in all aspects of care.” 4

WHAT IS QUALITY MANAGEMENT?  One last thing. Quality is intra-departmental. All departments are responsible for the quality of care.

 Quality does not discriminate and is an equal opportunity employer. It requires all employees to be involved. You do not have to be a leader to lead in quality.

A LITTLE HISTORY NEVER HURT ANYBODY.  “The year 1924—at the Hawthorne Plant of Western Electric Company in Cicero, Illinois—saw the start of two of the most important developments ever in managerial thinking. In May that year Walter Shewhart described the first control chart which launched statistical process control and quality improvement. In November of that year there began a series of research projects which came to be known as the Hawthorne studies. This body of work was central to the creation of the fields of the sociology, social psychology, and anthropology of the work place.” 4

A LITTLE HISTORY NEVER HURT ANYBODY.  “For over 50 years clinical laboratories have embraced Shewhart's ideas and incorporated statistical process control into standard operating procedures for clinical laboratory quality control and proficiency testing.” 4

 “While at Hawthorne, Shewhart met and influenced W. Edwards Deming who went on to champion Shewhart's methods.” 4

A LITTLE HISTORY NEVER HURT ANYBODY.  “The Shewhart cycle or Shewhart learning and improvement cycle combines management thinking with statistical analysis. The constant evaluation of management policy and procedures leads to continuous improvement. This cycle has also been called the Deming cycle, the Plan–Do–Check–Act (PDCA) cycle, or the Plan–Do–Study–Act (PDSA) cycle. While Deming marketed the cycle to the masses—a cycle which he called the Shewhart cycle—most people referred to it as the Deming cycle.

 The Shewhart cycle has the following four stages: ­  Plan: identify what can be improved and what change is needed ­  Do: implement the design change ­  Study: measure and analyze the process or outcome

­  Act: if the results are not as hoped for” 4

WHY DO ERRORS OCCUR?  Poor workflow control

 Inadequate attention to detail

 Poor quality control

 Non-validated or poorly validated tests

 Poor results verification

 Lack of consistency

 Poor workload management

 Time pressure and constraints

 Inadequate staffing

 Lack of team atmosphere

HOW SHOULD QUALITY MANAGEMENT BE USED? The following departments complete QM reports each month:

• 1st Pass Accessioning (QC10)

• Grossing (QC20/GR)

• 2nd Pass Accessioning (QC12)

• Embedding (QC20/EM)

• Microtomy

• IHC

• Special Stains

• Distribution

• Billing

• Client Services (SRD & Analytic) (SRD & QC50)

• Transcription

• Cytology (Analytic & Amends) (QC01)

• Clinical

• Phlebotomy

• Satellite locations

• Pathologist Assistants

• IT

HOW SHOULD QUALITY MANAGEMENT BE USED?  Quality Control:

 “Quality control is a system of routine technical activities, to measure and control the quality of the inventory as it is being developed. It provides routine and consistent checks to identify, address errors and omissions, ensures data integrity, correctness and completeness and also records all quality control activities.

 The quality control checks in a histopathology lab will include accurate patient identification, fixation, adequate processing, appropriate embedding techniques, microtomy, unacceptable artifacts and inspection of controls to determine correctness of special stains and immunohistochemical methods.

 It is the responsibility of the pathologist to perform the final quality control examination as they read the slide and determine whether the slide is adequate for the diagnostic interpretation.” 3

HOW SHOULD QUALITY MANAGEMENT BE USED?  Quality Assurance:

 “It includes a planned system of review procedures conducted by personnel not directly involved in the laboratory process.

 Statistical analysis of quality control provides the data for quality assurance activities where correlation of errors, complaints, failures or other unexpected results are evaluated against the laboratory expectations.

 There are two distinct systems that can be used to deliver quality assurance such as selective system where stained preparations from departmental archival records are used to assess the quality of staining or distributive system in which participating laboratories are asked to stain sections that have been submitted by the scheme organizer.” 3

WHAT ERRORS SHOULD BE MONITORED  At GPA, we monitor as much as possible. The next slides will show an example of our Specimen Requisition Deficiency Report.

 As previously stated, labs should be monitoring pre-analytic, analytic, and post-analytic activities.

January February March April May June July August September October November December AverageBAA 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%CAA 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%DAA 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%GP 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%JAA 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%NAA 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%SAA 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%TAA 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Total Errors 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Threshold 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0%

January February March April May June July August September October November December TotalSRD01/IP INTERNAL LAB PROCESS 0 0 0 0 0 0 0 0 0 0 0 0 0SRD02/LM LABEL MISMATCH 0 0 0 0 0 0 0 0 0 0 0 0 0SRD03/NC NO CLINICAL INFO 0 0 0 0 0 0 0 0 0 0 0 0 0SRD04/NO NO ORDER # 0 0 0 0 0 0 0 0 0 0 0 0 0SRD05/NB BIRTHDATE 0 0 0 0 0 0 0 0 0 0 0 0 0SRD06/NN PHYS-PRACTICE NAME 0 0 0 0 0 0 0 0 0 0 0 0 0SRD07/ND PROCEDURE DATE 0 0 0 0 0 0 0 0 0 0 0 0 0SRD08/NS NO SOURCE LISTED 0 0 0 0 0 0 0 0 0 0 0 0 0SRD09/OC OTHER (COMMENT) 0 0 0 0 0 0 0 0 0 0 0 0 0SRD10/QN QNS-CYTO 0 0 0 0 0 0 0 0 0 0 0 0 0SRD11/SL SPEC LEAKED 0 0 0 0 0 0 0 0 0 0 0 0 0SRD12/SN SSN 0 0 0 0 0 0 0 0 0 0 0 0 0SRD13/UC UNLABELED 0 0 0 0 0 0 0 0 0 0 0 0 0SRD14/MG GENDER 0 0 0 0 0 0 0 0 0 0 0 0 0SRD15/IF INCORRECT FACESHEET 0 0 0 0 0 0 0 0 0 0 0 0 0SRD16/PL PATIENT LINKING 0 0 0 0 0 0 0 0 0 0 0 0 0SRD17/CD CLINICAL HX/DIAG 0 0 0 0 0 0 0 0 0 0 0 0 0SRD18/NT NO SPEC/TISSUE IN VIAL 0 0 0 0 0 0 0 0 0 0 0 0 0SRD19/PN PATIENT NAME 0 0 0 0 0 0 0 0 0 0 0 0 0SRD20/ND SETUP NEW 0 0 0 0 0 0 0 0 0 0 0 0 0SRD21/IL ILLEGIBLE 0 0 0 0 0 0 0 0 0 0 0 0 0SRD22/MB MISSING BLOCK/SLIDE 0 0 0 0 0 0 0 0 0 0 0 0 0SRD23/MT MISSING VERIFY/TEST 0 0 0 0 0 0 0 0 0 0 0 0 0SRD24/NG NON GPA REQ 0 0 0 0 0 0 0 0 0 0 0 0 0SRD25/MO MARGIN ORIENTATION 0 0 0 0 0 0 0 0 0 0 0 0 0SRD26/MB MISSING BOTTLE 0 0 0 0 0 0 0 0 0 0 0 0 0SRD27/BS BROKEN SLIDES 0 0 0 0 0 0 0 0 0 0 0 0 0SRD28/SM SLIDES NOT MATCHING 0 0 0 0 0 0 0 0 0 0 0 0 0SRD29/MRN MRN ISSUE 0 0 0 0 0 0 0 0 0 0 0 0 0SRD30/RD RULE OUT DISCREPANCY 0 0 0 0 0 0 0 0 0 0 0 0 0SRD31/SD SPECIMEN DISCREPANCY 0 0 0 0 0 0 0 0 0 0 0 0 0QVF 0 0 0 0 0 0 0 0 0 0 0 0 0Total Error Volume 0 0 0 0 0 0 0 0 0 0 0 0 0Total Case Volume 0 0 0 0 0 0 0 0 0 0 0 0 1

January February March April May June July August September October November December AverageSRD01/IP INTERNAL LAB PROCESS #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD02/LM LABEL MISMATCH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD03/NC NO CLINICAL INFO #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD04/NO NO ORDER # #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD05/NB BIRTHDATE #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD06/NN PHYS-PRACTICE NAME #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD07/ND PROCEDURE DATE #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD08/NS NO SOURCE LISTED #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD09/OC OTHER (COMMENT) #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD10/QN QNS-CYTO #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD11/SL SPEC LEAKED #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD12/SN SSN #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD13/UC UNLABELED #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD14/MG GENDER #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD15/IF INCORRECT FACESHEET #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD16/PL PATIENT LINKING #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD17/CD CLINICAL HX/DIAG #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD18/NT NO SPEC/TISSUE IN VIAL #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD19/PN PATIENT NAME #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD20/ND SETUP NEW #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD21/IL ILLEGIBLE #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD22/MB MISSING BLOCK/SLIDE #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD23/MT MISSING VERIFY/TEST #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD24/NG NON GPA REQ #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD25/MO MARGIN ORIENTATION #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD26/MB MISSING BOTTLE #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD27/BS BROKEN SLIDES #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD28/SM SLIDES NOT MATCHING #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD29/MRN MRN ISSUE #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD30/RD RULE OUT DISCREPANCY #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD31/SD SPECIMEN DISCREPANCY #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!QVF #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

January

February

March

April

May

June

July

August

September

October

November

December

PROBLEM/CONSEQUENCE CORRECTIVE ACTION

SRD Rate By Case TypeThreshold 5.0%

Monthly Specimen Requisition Deficiency QA (Pre-Analytic)

SRD Rate By Type

SRD Count By Type

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

January February March April May June July August September October November December

I know you can’t read that. This is just to show you that on one of our 18 reports, we monitor a lot of errors. The following slides will break down each section.

January February March April May June July August September October November December AverageBAA 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%CAA 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%DAA 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%GP 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%JAA 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%NAA 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%SAA 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%TAA 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Total Errors 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Threshold 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0%

SRD Rate By Case TypeThreshold 5.0%

Monthly Specimen Requisition Deficiency QA (Pre-Analytic)

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

January February March April May June July August September October November December

The first section identifies the title, the period of analysis (pre-analytic) and the threshold (5%). Because the Specimen Requisition Deficiency (SRD) analyzes client errors that we have to catch, the threshold is much higher than most of our departmental thresholds. SRD Rate by Case Type breaks down the errors by, well, case type. This helps identify trends in specialties (derm, clinical, PC cases, etc.). Below the SRD Rate by Case Type is a graph to visualize the total errors to see monitor if we are above or below threshold.

January February March April May June July August September October November December TotalSRD01/IP INTERNAL LAB PROCESS 0 0 0 0 0 0 0 0 0 0 0 0 0SRD02/LM LABEL MISMATCH 0 0 0 0 0 0 0 0 0 0 0 0 0SRD03/NC NO CLINICAL INFO 0 0 0 0 0 0 0 0 0 0 0 0 0SRD04/NO NO ORDER # 0 0 0 0 0 0 0 0 0 0 0 0 0SRD05/NB BIRTHDATE 0 0 0 0 0 0 0 0 0 0 0 0 0SRD06/NN PHYS-PRACTICE NAME 0 0 0 0 0 0 0 0 0 0 0 0 0SRD07/ND PROCEDURE DATE 0 0 0 0 0 0 0 0 0 0 0 0 0SRD08/NS NO SOURCE LISTED 0 0 0 0 0 0 0 0 0 0 0 0 0SRD09/OC OTHER (COMMENT) 0 0 0 0 0 0 0 0 0 0 0 0 0SRD10/QN QNS-CYTO 0 0 0 0 0 0 0 0 0 0 0 0 0SRD11/SL SPEC LEAKED 0 0 0 0 0 0 0 0 0 0 0 0 0SRD12/SN SSN 0 0 0 0 0 0 0 0 0 0 0 0 0SRD13/UC UNLABELED 0 0 0 0 0 0 0 0 0 0 0 0 0SRD14/MG GENDER 0 0 0 0 0 0 0 0 0 0 0 0 0SRD15/IF INCORRECT FACESHEET 0 0 0 0 0 0 0 0 0 0 0 0 0SRD16/PL PATIENT LINKING 0 0 0 0 0 0 0 0 0 0 0 0 0SRD17/CD CLINICAL HX/DIAG 0 0 0 0 0 0 0 0 0 0 0 0 0SRD18/NT NO SPEC/TISSUE IN VIAL 0 0 0 0 0 0 0 0 0 0 0 0 0SRD19/PN PATIENT NAME 0 0 0 0 0 0 0 0 0 0 0 0 0SRD20/ND SETUP NEW 0 0 0 0 0 0 0 0 0 0 0 0 0SRD21/IL ILLEGIBLE 0 0 0 0 0 0 0 0 0 0 0 0 0SRD22/MB MISSING BLOCK/SLIDE 0 0 0 0 0 0 0 0 0 0 0 0 0SRD23/MT MISSING VERIFY/TEST 0 0 0 0 0 0 0 0 0 0 0 0 0SRD24/NG NON GPA REQ 0 0 0 0 0 0 0 0 0 0 0 0 0SRD25/MO MARGIN ORIENTATION 0 0 0 0 0 0 0 0 0 0 0 0 0SRD26/MB MISSING BOTTLE 0 0 0 0 0 0 0 0 0 0 0 0 0SRD27/BS BROKEN SLIDES 0 0 0 0 0 0 0 0 0 0 0 0 0SRD28/SM SLIDES NOT MATCHING 0 0 0 0 0 0 0 0 0 0 0 0 0SRD29/MRN MRN ISSUE 0 0 0 0 0 0 0 0 0 0 0 0 0SRD30/RD RULE OUT DISCREPANCY 0 0 0 0 0 0 0 0 0 0 0 0 0SRD31/SD SPECIMEN DISCREPANCY 0 0 0 0 0 0 0 0 0 0 0 0 0QVF 0 0 0 0 0 0 0 0 0 0 0 0 0Total Error Volume 0 0 0 0 0 0 0 0 0 0 0 0 0Total Case Volume 0 0 0 0 0 0 0 0 0 0 0 0 1

SRD Count By Type

The next section breaks down all the raw data by type. As you can see, we monitor almost every detail of specimen receiving. We also have QC codes for each error. These QC codes are put in by 1st Pass Accessioners in WindoPath in the case’s QC tab.

January February March April May June July August September October November December AverageSRD01/IP INTERNAL LAB PROCESS #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD02/LM LABEL MISMATCH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD03/NC NO CLINICAL INFO #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD04/NO NO ORDER # #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD05/NB BIRTHDATE #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD06/NN PHYS-PRACTICE NAME #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD07/ND PROCEDURE DATE #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD08/NS NO SOURCE LISTED #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD09/OC OTHER (COMMENT) #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD10/QN QNS-CYTO #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD11/SL SPEC LEAKED #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD12/SN SSN #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD13/UC UNLABELED #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD14/MG GENDER #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD15/IF INCORRECT FACESHEET #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD16/PL PATIENT LINKING #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD17/CD CLINICAL HX/DIAG #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD18/NT NO SPEC/TISSUE IN VIAL #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD19/PN PATIENT NAME #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD20/ND SETUP NEW #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD21/IL ILLEGIBLE #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD22/MB MISSING BLOCK/SLIDE #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD23/MT MISSING VERIFY/TEST #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD24/NG NON GPA REQ #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD25/MO MARGIN ORIENTATION #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD26/MB MISSING BOTTLE #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD27/BS BROKEN SLIDES #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD28/SM SLIDES NOT MATCHING #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD29/MRN MRN ISSUE #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD30/RD RULE OUT DISCREPANCY #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!SRD31/SD SPECIMEN DISCREPANCY #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!QVF #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

SRD Rate By Type

The next section takes those values and turns them into percentages based on the number of cases accessioned within the month. It’s very similar to SRD Count by Type, but it is another way to visualize a particular type of error, thus helping strategize how to reduce or eliminate the error.

January

February

March

April

May

June

July

August

September

October

November

December

PROBLEM/CONSEQUENCE CORRECTIVE ACTION

The last section of the report is open for any information that is pertinent for QM. Managers typically discuss outlier employees, causes for a high number of errors, or any events that are not worthy of a Root Cause Analysis, but should be noted. The most important part of this section is the corrective action. If you have taken the CAP Inspection Team Member training, this is discussed numerous times. In CAP inspections, CAP wants to see that corrective action is taking place, no “will continue to monitor” corrective action because really, that’s not corrective. In addition to putting the initial corrective action, follow-up corrective action 2-3 months after the issue is also helpful.

DIFFICULTIES IN MEASURING QUALITY • Data collection is not standardized

• Data are missing

• Variability in measurement

• Insufficient measurement tools

• Variation in reporting (not standardized lab-to-lab)

• Stigma of disclosing errors (protecting one’s department)

• Preceding errors can alter measurements throughout workflow

• Some metrics are not quantifiable

HOW CAN WE BE BETTER IN QUALITY?  This next section is dedicated to much more than quality. Quality Management is good, but it has its limitations. In our monthly QM meetings, the same mistakes are reported repeatedly. Why is this?

 This has led me to the conclusion that our laboratories will not improve quality until every employee feels empowered, responsible, and is focused on the path ahead.

HOW CAN WE BE BETTER IN QUALITY?  In my opinion, the best way to improve quality, best practices, etc., is to observe other companies’ practices to learn from each other.

• Observing other ADX labs • Observing other non-ADX labs • Observing other healthcare corporations • Observing businesses unrelated to pathology or healthcare

HOW CAN WE BE BETTER IN QUALITY? I am a business person, so a lot of this discussion will not only include healthcare terminology, but a lot of business terminology. I think it is necessary that each of us understand the industry that we are in, and not only the duties you perform on a daily basis.

Buckle up. We’re about to go on a little journey.

SUCCESSFUL COMPANIES…  What do successful companies have in common?

 Traditionally, it is assumed that the purpose of business is to make money, and the more money the better.

 It is not argued that more money means a business can grow, offer new services, hire more employees, etc. More money isn’t a bad thing.

 However, this narrow image, deeply embedded in American business, molds corporations and employees into focusing on maximizing short-term profits, not long-term strategies. 6

 Corporate strategies do not just involve maximizing profits. Corporate strategies, good or bad, shape the lives of employees, partners, and consumers they depend on. 6

SUCCESSFUL COMPANIES…  Great companies work to make money, and in their choices of how to do so, they think about building enduring institutions. They invest in the future while being aware of the need to build people and society. 5

 This is where institutional logic comes into play. Institutional logic is defined as, “The socially constructed, historical patterns of material practices, assumptions, values, beliefs, and rules by which individuals produce and reproduce their material  subsistence, organize time and space, and provide meaning to their social reality.” 7

 Thus, companies are not just for making money, they are conduits for accomplishing shared purpose, providing meaningful livelihoods for those who work in them. 6

WHY IS THIS IMPORTANT? WHAT DOES THIS HAVE TO DO WITH QUALITY?  Every day, regardless of your position within Aurora, your job will affect at least 50 lives, not including your coworkers’.

• Correctly (or incorrectly) entering in insurance information in data entry à a patient receives the correct (or incorrect) bill

• Embedding tissue à a patient is anxiously waiting on a diagnosis

• A patient waits for results to see if she will need a hysterectomy as a result of cervical cancer

• An elderly patient receives a bill for pathology, but does not understand what the bill means or when they had testing completed

Our decisions and values affect the quality of care we perform, regardless of the interaction we have with the patient.

WHY IS THIS IMPORTANT? WHAT DOES THIS HAVE TO DO WITH QUALITY?  In addition to patients, we affect the lives of our coworkers.

 “Rather than viewing organizational processes as ways of extracting more economic value, great companies create frameworks that use societal value and human values as decision-making criteria. They believe that corporates have a purpose and meeting stakeholders’ needs in many ways: by producing goods and services that improve the lives of users; by providing jobs and enhancing workers’ quality of life; by developing a strong network of suppliers and business partners; and by ensuring financial viability, which provides resources for improvements, innovations and returns to investors.” 6

WHY IS THIS IMPORTANT?  None of us are just someone who can get the work done. Each employee is a fundamental piece of the puzzle who can make Aurora Diagnostics a company that produces excellent pathology results, provides exceptional quality of life for employees, and ensures we are a leading company in pathology through innovation and expertise.

 Once each of us walks into the door of the laboratory, we are all responsible for doing our very best for ourselves, each other, and our patients.

INSTITUTIONAL LOGIC

 Rosabeth Moss Kanter is a professor of Business Administration at Harvard Business School. In her article “How great companies think differently” in the Harvard Business Review, Kanter provides six ways that companies can use institutional logic and how it can give them an advantage, and how the perspective can change leadership and behavior.

INSTITUTIONAL LOGIC

 A Common Purpose

 “Institutional grounding is an investment in activities and relationships that may not immediately create a direct road to business results, but that reflect the values the institution stands for and how it will endure.” 6

 Questions:

 What is Aurora’s common purpose?

 What are Aurora’s values?

INSTITUTIONAL LOGIC

 A Long-Term Focus

 “Thinking of the company as a social institution generates a long-term perspective that can justify any short-term financial sacrifices required to achieve the corporate purpose and to endure over time.” 6

 Short-term sacrifice is prudent risk management for long-term business.

 Question:

 Do you evaluate ways to improve how you perform your job?

INSTITUTIONAL LOGIC

 Emotional Engagement

 “The transmission of institutional values can evoke positive emotions, stimulate motivation, and propel self-regulation or peer regulation.” 6

 Questions:

 Do you feel that your service is at the center of a mission to better someone’s life?

 Are you able to feel proud of the work that you and your coworkers accomplish on a daily basis?

INSTITUTIONAL LOGIC

 Partnering with the Public

 “The need to cross borders and sectors to tap new business opportunities must be accompanied by concern for public issues beyond the boundaries of the firm, requiring the formation of public-private partnerships in which companies consider societal interests along with business interests.” 6

 We employ highly skilled personnel with a vast amount of knowledge. Speaking with staff always amazes me at how smart Aurora employees are.

 Question:

 Are you using your knowledge and experience outside of Aurora?

INSTITUTIONAL LOGIC  Innovation

 “Articulating a purpose broader than making money can guide strategies and actions, open new sources for innovation, and help people express corporate and personal values in their everyday work.” 6

 Two of the most detrimental mindsets I have seen in the workplace (and I’m guilty of them, too) is continuing work the same way because that’s the way we have always done it, or that’s how I was told to do it.

 If we continued with this thinking, a lot of strange medical procedures would still be happening. For example, lobotomies were still a “cure for depression” in the 1940s.

 Question:

 Can you identify practices in your daily work that could be enhanced through innovation?

 Are we finding new ways to improve patient care?

INSTITUTIONAL LOGIC

 Self-Organization

 “Great companies assume they can trust people and can rely on relationships, not just rules and structures. They are more likely to treat employees as self-determining professionals who coordinate and integrate activities by self-organizing and generating new ideas.” 6

 “Institutional logic holds that people are not paycheck-hungry shirkers who want to do the bare minimum, nor are they robots that can be ordered to produce high performance.” 6

 It is no doubt that in healthcare, high performance is a demand. However, our company has highly competent employees who go above and beyond to provide excellent patient care.

 Question:

 Are you willing to find ways to lead our company in the right direction?

INSTITUTIONAL LOGIC

 “Institutional logic assumes that people can be trusted to care about the state of the whole enterprise—not just about their own jobs or promotions—and to catalyze improvements and innovations without waiting for instructions or sticking to the letter of a job description.

 Job descriptions nowadays document only a part of what people do; performance reviews and salary bands capture only some of the activities though which people might add the most value for the company.” 6

SO, GOING BACK TO QUALITY…  Why does this all matter and what happened to the presentation on Quality Management?

 You, me, your lab, my lab, our company will never have a successful Quality Management program if we do not include ourselves as stakeholders in the success of our departments, our company, or in healthcare.

 In 2011, over 70% of the United States population (including healthcare workers) admit to not understanding healthcare. Thus, at least 70% of us go to a doctor, do not understand what the doctor says, what the tests are and what they mean, and what we are paying for.8

SO, GOING BACK TO QUALITY…  Imagine being a billing representative and having to explain to a patient what the CPT code 86317 (Immunoelectrophoresis assay) or 88311 (Tissue decalcification) means. If that patient is one of the 70%, it’s not going to be easy.

 It’s not up to just you or me to solve all the problems in healthcare or at our company, but it is up to each of us to do our part.

SO, GOING BACK TO QUALITY…  I would like to make a quick note. I might say “you” occasionally in this presentation, but I really mean “me” or “we.”

 This presentation is a gathering of my thoughts about how to be better at my own job. I’m nowhere near as good at my job as many of my coworkers are at theirs. The dedication from employees amazes me and throughout the conception of this presentation I have taken the time for personal assessment.

HOW TO FOSTER A CULTURE OF QUALITY  The direction of this is presentation is not to talk about Quality Management like it’s just another procedure manual.

 My hope is that we can all work together to foster a culture of quality within each Aurora lab and work together to make Aurora the best laboratory for pathology results.

 Ultimately, the point of Quality Management is to provide exceptional patient care.

CONCLUSION

 Thank you for participating in a Quality Management Coordinator’s ramblings.

 No one needs to lecture on how important each job is at Aurora, but taking the time to reflect on the importance is always beneficial.

 If this presentation leads anyone to have any ideas on how to improve Quality Management or anything related to improving Aurora, feel free to contact me.

 Always remember to eat your vegetables.

REFERENCES 1.  Laboratory General Checklist. (2013, July 29). College of American Pathologists.

2.  “What is quality?” (2014). In Chartered Quality Institute. Retrieved from http://www.thecqi.org/The-CQI/What-is-quality/

3.  Adyanthaya S, Jose M. Quality and safety aspects in histopathology laboratory. J Oral Maxillofac Pathol [serial online] 2013 [cited 2014 Jun 4];17:402-7. Retrieved from: http://www.jomfp.in/text.asp?2013/17/3/402/125207

4.  Bandiziol, P., Crosta, A., De Martino, F., Rizzo, G., Ventrella, M., Macaliuso, E., Goria, E., Milano, M., Sanfilippo, R., Mereu, C. & Piccoli, G.B. (2008, March – April). Life without quality. Reflections of a female focus group on life, health and kidney disease. J Nephrol, 23 Suppl 13:S124-8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18446745

5.  Best, M. & Neuhauser, D. (2006, April). Walter A Shewhart, 1924, and the Hawthorne factory. Qual Saf Health Care, 15(2): 142-143). doi: 10.1136/qshc.2006.018093

6.  Kanter, R.M. (2011, November). How great companies think differently. Harvard Business Review.

7.  Moscehera, L., Berni, A. & Cicellin, M. (2010). Institutional logics and the rise of a new organizational field. Retrieved from http://www.academia.edu/1463791/Institutional_Logics_and_the_Rise_of_a_New_Organisational_Field

8.  Collaboration Health Care, Inc. (2011, October). Health care’s institutional logic. Staying Informed, 4, (10). Retrieved from http://www.collaborationhealthcare.com/October2011CHCINewsletterTeachingHealthCare2.pdf