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Tuesday, April 12, 2011

One size does not fit all.

When I am doing project and lecture preparation, I tend to go back to basics; more times than not that means Deming and Crosby, two men with a common goal, but different approaches.  One place where they differ 180 degrees is in the area of error reduction and prevention.  Crosby promoted the principle that setting a goal of zero tolerance for error was the most effective way to prevent costs and consequence.  Do it RIGHT the first time (DIRFT).    Deming thought this was not only nonsense, but indeed dangerous and destructive nonsense, that would be used as a stick to punish and blame workers when things went wrong. 
 Forty years after the two were busy establishing the fundamentals of business Quality, the truth still lies somewhere in between.  

But as I was preparing for a presentation, I came across an now interesting 2007 article entitled ``Trying to Do It Right the First Time Isn't Always Best``.  Hooray for Google (see http://www.chacocanyon.com/pointlookout/070314.shtml) .  The author, a Quality consultant Rick Brenner, is rather dismissive of the concept of DIRFT (``These slogans might make some sense in the operational context, where tasks are very repeatable.``) , and then makes the points that an important aspect of project management and learning in general is to have the opportunity to do it wrong the first time and that risk taking is about giving permission to allow doing things wrong at first, if the consequence is that you might by accident or intent find a  better solution.

Well I can see where he is coming from.  In the research and development setting, we are looking for new insights, new knowledge, and novel approaches.  That is why we call it ``search and re-search``.  But as much as the medical laboratory is about new information, it is about correct information.  The right information from the right patient sent to the right clinician at the right time.  Everytime.  While  Brenner describes this as being merely operational, but it is pretty narrow-minded when describing this as repeatable as a simple repeatable task. 
 Clearly while being a consultant in one very narrow field, he has little interest or experience or expertise in the broader laboratory world.  
And can we agree that might not be the strategy of choice when building nuclear reactors!

From my perspective, in the medical laboratory, establishing DIRFT is not so much an imperative, but more a target and  attainable  goal, and the only way that we can move towards error reduction and reduced clinical consequence.

I recognize that in the busy laboratory there are many distractions that contribute to slips, but if information is delayed or faulty, the clinician and patient are not  interested in our problems.  They want what they want and they want it when they want it.   Period.

In 1986 Briggs Phillips published in an article entitled "Human Factors in Microbiological Laboratory Accidents" in Laboratory Safety: Practices and Principles.  Laboratory accidents, injuries and infections do not occur randomly;  most happen around a small group of people with repeat problems.  By case-control comparison to accident-free peers, accident involved people were less aware of work environment risks, Less aware of work behaviour risks, and were more prone to working quickly, especially before lunch and breaks and days end.  Accident involved people were more likely to take risks.

There is reason to suspect that similar issues are at play when it comes to Quality slips.  Most slips and errors occur in the laboratory in a similar fashion, a small group of workers represent the largest group of repeaters slippers.  I am not aware of any study that has looked at behaviors of this group, but it would not surprise me if we found a pattern similar to one described above.   Wouldn’t it be great if that type of information was available!

When we don’t don’t have an policy or a mechanism to deal with the repeaters, then we are only apt to find ourselves in the same place over and over again.  That doesn’t mean trashing the person.  Maybe  some investigation into causation and responses to distractions is in order, or some  re-training assistance may be  required.  

Regardless, at some point management needs to have a solution, and it seems to me that having accepted a DIRFT policy and principle to aim towareds is not a bad place to start.  

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