Monday, January 12, 2015

When the Public turns against Quality




I regularly refer to Quality Partners, as organizations committed to improving laboratory Quality.  At the same time, the single greatest impact on Quality comes from the public through its agents: the media, the regulators, and the legislators.  The following describes when the public conspires to kill Quality. 

For those outside Canada, Saskatchewan is a province just west of the true geographic centre of Canada.  It is a province big in size, small in population with a growing economy based largely on agriculture and resources.  It is currently run by a centre-right party (the Saskatchewan Party) with a substantial majority with a centre-left party in opposition (49 seats versus 9 seats).  Most would not be surprised knowing that the government is interested in being financially efficient through error and cost reduction. 

To do that it has turned to Quality and Lean, with particular attention on Healthcare (that is a good thing).  To accomplish this they decided to hire an American consultant group (not sure why; there are many Canadian organizations that could have done equally well) to investigate, advise, implement and train a team of Lean leaders throughout the province.  

One aspect of the implementation was right out of 5S (as in Sort - Straighten - Shine (clean) – Standardize – Sustain); they supplied templates and guides on how to Standardize procedures in Healthcare.  So that was what the team of Lean Leaders did.  They went through the healthcare system and wrote “SOPs” to standardize process.  To anyone reading this story on this site, that would all seem to make a lot of sense; Yes? (of course Yes!).

So now we enter into the politics.  The opposition party (remember their very weak position) decides to take a swipe at government because they say the contract with the American consultant was too rich.   Well, politicians are politicians and opposition parties are supposed to say bad things; so I can live with that.  Besides I’m still annoyed by a decision to go American, when there are lots of good Canadian organizations that can implement Lean programs.

But then things get stupid.  

First the opposition party report through the media that they found a standardized procedure for making coffee.  This, the media jump all over.  The coffee instruction became a major scandal.  The fact that it was not in a healthcare facility was irrelevant.  

Then they went on to complain that over the last few months the amount of savings due to Lean was paltry.  Then they complained that the problem with Lean is that uses too much jargon and is disliked by many front line health care workers [see: http://www.cbc.ca/news/canada/saskatchewan/sask-nurses-say-they-re-being-intimidated-over-lean-program-1.2610542 ].  This too becomes fodder for the cross-Canada media.  Then it is reported that the Lean program was implemented not only in acute care but also in nursing homes.  Shock upon shock.  

To be fair, there were some stupid things done, like deciding to import Japanese senseis to help in the Lean training [see: http://www.cbc.ca/news/canada/saskatchewan/wanted-japanese-translators-to-assist-lean-consultants-1.2816341 ], and an apparent decision to replace nursing home residents' facilities with space for health-care bureaucrats [see: http://www.leaderpost.com/news/Mandryk+Wall+must+avoid+another+lean+mess/10704492/story.html ], but by the end of all this, the opposition centre-Left and the hard left media (the Canadian Broadcasting Corporation – the CBC) have done the province of Saskatchewan and the Canadian news watching population a great disservice.

The outcome of all this is that with all the negative media attention, the government decides to back away from the Lean consultants and terminate the contract early.  No mention is made about if they plan to walk away from the Lean activities they have implemented.

Canadian healthcare is financially out of control and needs significant action, not only in Saskatchewan but all across the country.  One of the reasons that Canadian healthcare has so many problems is that it is controlled by healthcare unions that have no interest in addressing cost effectiveness, especially if it means reducing positions or union wages.  (Gee is it any wonder that these unions would resist and dislike a program like Lean.)   

Recently I wrote that Quality will inevitably fail when an organization has an endless supply of customers, with essentially no threat or consequence to counteract indifferent behavior [see: http://www.medicallaboratoryquality.com/2014/12/competition-and-quality-partner-dynamic.html ].  This is the very definition of Canadian healthcare system 

Going after a government plan to implement continuous improvement through a program like Lean, is easy, just blame it on a mean government being hard on those poor front line workers and point out some trivia like a scandalous instruction about coffee.  

But if this Quality initiative gets killed before it gets started, there will be blood on people hands, and everyone including the government, the opposition, the unions, and the media will all have to wear it.

At least that is my opinion.



Wednesday, December 17, 2014

The Quality Conversion and ZAMM




Bill, and Brooks Carder set out an interesting and challenging thesis that Qualitologists have gone through some form of epiphany and conversion that “we know in our hearts we can help make this world work better.”   As I read this I was intrigued, but with a nagging feeling that this was not the first time I had heard of Quality expressed in near-religious terms.

Back in the seventies, when I was barely out of medical school, and certainly not anywhere near the quality path, I read Robert Pirsig’s novel Zen and the Art of Motorcycle Maintenance  (affectionately referred to as ZAMM).  Pirsig was not so much a novelist; he was much more focused in Eastern philosophy with a passion for motorcycles to sooth a troubled spirit (a sort of Steve McQueen character).

ZAMM was not a light read, but was very much a book of the times.  Reading ZAMM was a way of signalling to yourself and others that you were “cool” and “in” and “hip”.  Talking about ZAMM was a great way to find women (or so we thought). 

The book tells the story of a father and son as they travel across America on a motorcycle, but is more about the human internal and external condition.  A key theme that ran through the book was his notion of Quality and its importance in all of life’s decisions.   

One gets the sense that many people of my generation who moved towards a career in Quality were influenced by Pirsig and ZAMM.  For example when Persig writes of Quality in it greater context it is always capitalized.  When discussed in a more prosaic smaller sense, it is in lower case.  I thought this was a style of my own invention.  Probably not.

Further in support, in the commentary of Brooks Calder that Bill includes in his entry, he says: “After all, … quality is responsible for many of the things that make life better.”  And his proposal for a new ASQ mission statement includes:  “To improve the function and value of goods and services worldwide, and to facilitate the development of new products and services that improve the quality of life.”
Parallel that with Pirsig who wrote:  “A person who connects with Quality … is filled with gumption, or enthusiasm, which literally means filled with God”.  A person filled with gumption doesn’t sit around and stewing about things.  He is at the front of the train of his own awareness and watching to see what is up the track” and further, and perhaps more importantly,  “when a person loses sight of Quality they lose enthusiasm for what they are doing”.   

Not to get too far down the road or too much off the deep end, Pirsig’s philosophical view of quality had a sense dualism: that it was perhaps, in part subjective, a part of the mind, and at the same time was in part, objective, a part of the material world.  Or it was neither and was a third entity and independent of both.

To Pirsig, Quality was more a sense of excellence and spirit.  It would be hard to fit into prosaic terms.  “Quality is another name for truth, but is something indefinable …“The moment you define it, the meaning of it changes.  But while definition remains aloof, it inexplicably makes things brilliant.   

In 1979 Philip Crosby (5 years after ZAMM) published his “4 Absolutes” of quality including  Quality is defined as conformance to requirements, not as 'goodness' or 'elegance  Certainly not as ethereal as Persig would have stated it, it is none-the-less  elegant in its own way.  I wonder if Crosby had been a ZAMM reader and if his definition of Quality was in some way a pragmatic response to a philosophical dilemma .

My point of writing about Pirsig and ZAMM is to indicate that the notion of a Quality conversion is not new.  Rather than being viewed as overly ambitious, I  see it as being the true core of what we are.  I encourage those of you of a more recent generation to pick up a copy of Zen and the Art of Motorcycle Maintenance and contemplate your greater self.

As a side note, Brooks uses the term “a bunch of nerd engineers” to describe the quality community.  Perhaps a bit too self-diminishing.  Pirsig saw Quality a little differently.  Said Pirsig’s in his immediate post-sixties era phraseology “When you subtract Quality, you get squareness.   Absence of Quality is the essence of squareness.  We are not the nerds, indeed we are the hip.

And as a final note, Robert Pirsig, is 84 years old.  He was interviewed by the BBC in 2012 (https://www.youtube.com/watch?v=m8zdT5jYlro) It is well worth watching.  Should  ASQ recognize him for his contributions to the study and recognition of Quality.

Monday, December 1, 2014

Competition and the Quality Partner dynamic



In 2011 I introduced into our Certificate Course the concept of medical laboratory Quality Partners to remind the participants that the laboratory is never alone when it comes to developing an shaping a quality managed laboratory.  [see http://www.medicallaboratoryquality.com/2011/06/more-musings-on-quality-partners.html ].  I created a definition for these Quality Partners as the network of organizations that develop and promote and provide services and assistance with the goal of supporting an effective laboratory foundation that is conducive of better patient safety and care.  The network includes Accreditation Bodies, Proficiency Testing Schemes, Education Providers, Professional Organizations, Materials Suppliers (including equipment and reagent bodies), and Standards Development Organizations.  These bodies surround the laboratory and provide documents and guidance and education, and assessment and support.  Taken as friends, these groups can help defray (mitigate) most of the risk of error that laboratorians bear when providing essential information that has direct impact on patient care and patient safety.  

But about a year or so later, I realized that I had left out an essential quality driver… the Public and its representatives including the media, the regulators, and the legislators.  As we have seen throughout many developed country, when the public experiences what it perceives as a loss of trust in the health system, change will inevitably result.  In the United States, that loss of trust resulted in CLIA.  In Canada it lead to a series of public enquiries including the Krever Commission and the Cameron Commission, both of which forced dramatic change.  We may not like the results of all the media attention and consequent change, but an angry public will always have its way.  


This lead to a revision of the Quality Partner graphic which indicates the light of public scrutiny exposing the potential warts and blemishes of laboratory error.
But recently I have realized that there is another driver that has great impact on Quality.  Competition.  I have written about this before.  Unfortunately we have lots of examples that indicate that when an organization has an endless supply of customers, with essentially no threat or consequence to counteract indifferent behavior, then performance may sink to the lowest level.  

I have mentioned before, the performance of some (but not all) public servants and other organizations.  When left to their own devices, it seems to become all to easy to stop meeting the Crosbyan and ISO definition of Quality. i.e. Meeting Requirements.  

Over the last while I have been on the road a lot, putting in a lot of air travel.  In the last few weeks I have spent well over 50 hours sitting in economy section seating, as airplanes have flown nearly 30,000 miles.

Now I understand that airlines are all now public corporations, with their primary responsibility being to generate profit and benefit to their shareholders.  And I also understand that running an airline is a risky and costly venture.  There is an old adage that says, the easiest way to become a millionaire is to start as a billionaire who runs an airline.  The reality is that while some airlines at the moment are experiencing a rise in stock value, this is not likely to be a permanent state of affairs.  Sooner or later, most airline companies will lose their value and their investors will lose their money.  

But as anyone who flies knows and understands, with the exception of the few business section travellers, customers are stuffed into seats too close together with little leg room.  Meals are either available only for purchase or if provided are of questionable quality and literally tossed.  There are insufficient toilets and insufficient cabin staff, insufficient luggage storage space and insufficient walking or exercise space.  

Don’t like it? Then you have two choices, either pony-up thousands of dollars or don’t travel.  Change to another airlines?  No difference.  They have you.  There is no tangible competition because they all work the very same way.  

But if you want to think of contrasting services in the travel industry, think about hotels and restaurants.  Those owners know and understand you can spend your travel dollars anywhere you want, and the place with the most comfortable bed or the best food wins, regardless of which price point you look at.  

So where there is competition the customer requirements are met, and where there is none, the customer has little choice but to tolerate the absence of meeting those needs or requirements.  

And so I have again revised the Quality Partner graphic.


And so here is my question to medical laboratory management.  We are a service industry, with by-and-large little competition.  We can, if we choose, ignore patients’ complaints and concerns with relative impunity.  

Which model do we want to follow, the airline or the restaurant/hotel? 
The choice is ours.

Monday, November 17, 2014

A look at ISO through the prisms of Risk and Uncertainty




I have had the opportunity to work with the International Organization for Standardization now for 20 years.  I have seen some very significant and positive contributions, and I have seen some contributions that have proved to be invisible.  And with regret I have seen some that would have been much better if they had been invisible or better yet, never created at all.  Like anything else, every individual ISO product has a certain level of hit-or-miss.  Each product carries its own level of risk (and beyond).

The positive about ISO, is the message that “all voices are equal” as the name ISO implies.  It means that folks from large countries and small countries, rich and poor can hammer out a set of principles to which everyone can concede, if not necessarily agree (consensus) which can be developed into a standard.   That being said, it should surprise no one that, with regret, that is more myth than reality.  I sometimes wonder if Orwell was thinking about ISO when he wrote “all animals are equal, but some animals are more equal than others”.

One of the extreme annoyances that used to bother me hugely was when one or more of the “more equal” countries would drive their influence and impact on document content, knowing full well that the resultant product would never see the light of day in their own country.   This seemed to me to be a certain power imbalance and injustice.  But I have since come to realize that in the international arena, countries get what they want and work for, and that imbalance and injustice are consequences that lesser countries can accept or tolerate, or not.  It is truly up to them.  There is a reality that if there is profit to be made by sitting at the table, and exerting influence, then one is foolish to ignore the opportunity.  

On a similar theme, there is an illusion that countries that provide documents to ISO as seeds for future standards gain in stature.   It is in fact false ego.  The reality is fraught more with risk than with benefit.   A group of local thinkers can collaborate and develop a guiding principle that will work very well in their own region or country.  They know their setting, they know local practices, and they can provide guidance that is (as they say) strongly fit for purpose.  

But when that document gets put in the hands of a broader community, it can get changed, not necessarily for the better. Indeed sometimes nonsense can get introduced.  And so when the final document is generated, the originators can find themselves with a dilemma; stick with what works, or adopt the broader document, even with the nonsense incorporated.   

So it has taken me 20 years to learn a lesson.  Some ISO documents are gold (ISO9001 comes to mind) while others may be of a lesser grade.  Adopting a document may be a giant step forward, or it may prove to be more illusion and politic.  It would be great if you could predict the outcome before you join the writing team.  

It is indeed all about Risk

About 10 years ago the phrase “unknown unknowns” became part of common parlance.  Decision making will always be impacted by the influence of factors that we didn’t know that we didn’t know.  That is not a new concept; it is simply a reiteration of Frank Knight’s near hundred year (1921) concept of uncertainty  which included two classes - one measureable uncertainty, which he called Risk, and the other which was the immeasurable.  Risk is the impact of measurable uncertainty on outcome or objectives.  If only that was sufficient.  The rest is more about rolling dice with an indeterminate and random number of sides where an outcome can be a mystery or surprise, either good or bad.   

You can deal with Risk with Knightian foresight, by considering the potential rate of occurrence or degree of severity of outcome.   Nassim Nicholas Taleb refers to  inherently unpredictable outcomes from unknown uncertainty as Black Swans.   In hindsight, some of them may have been predictable, and might have been avoidable (“black swan robust society”).

Two choices: live with “doodoo happens” or develop an active strategy of observation and preventive action s than may tease out a little more measurable Risk from the sea of uncertain uncertainty.