Saturday, January 18, 2014

The Error Cost Dynamic

The Error Cost Dynamic

We have started our new season for our UBC Certificate Course in Laboratory Quality Management and I have to say that this year is perhaps the most animated, most adventuresome group to date.  Day 3 and there is already a lot of mingling and interaction, which is incredibly special in an on-line virtual classroom course. It truly feels like if I should not be surprised if I were to have a tap on the door or a call on the phone.  This is a good thing.

One of the questions that has ready come up is on the impact of communication, or lack thereof, on laboratory error.  This is a very interesting topic  because communication is so multidimensional; there is communication in the form of person to person chitchat or communication in the form of information sharing or communication in the form of instruction - guidance - requirement.  Regardless of which form we are talking about communication can be either very positive or very not-positive depending on the clarity, understanding and intent.  Said in a way that is clear and precise in-laboratory communication is very helpful.  Said in a way that is muddled and ambiguous and a whole lot of bad consequences ensue.

That is a long way to get to the topic of error.  The point I am struggling to get to (talk about poor communication skills) is that in Quality, concepts that are expressed with clarity and brevity lead to new insights and new understanding.  Concepts presented as subtle nuanced and complicated are a struggle and are often dismissed. 
For me, I think I have developed a helpful way to express the dynamic impact of errors and causes of error on the costs of poor quality.

All organizations experience daily work pressures, many of which are addressable and potentially controllable: noise, crowdedness, clutter, work volume, time pressures, stress and anxiety, miscommunication, accidents and injury, and finances.  

As daily pressures rise, the risk of error rises in the same time or compounding at a faster rate.  

As the risk of error migrates to being the actually of error, the impact of error becomes an additional source of daily pressure, sometime impacting on finance, but more often on stress, anxiety, accident and injury, and time pressures. 
Increasing error is a leading indicator of deteriorating Quality, contributing to management dissatisfaction, customer dissatisfaction, staff dissatisfaction, more remediation and increased cost and usually reduced revenue streams, all of which are can be measured and compiled as the rising costs of poor quality. 
Recognizing this dynamic, leads to an important conclusion; addressing daily pressures before they lead to problems is the easiest way to prevent error and reduce poor quality costs.  

One can appreciate the dynamic graphically as a series of gears all moving in concert. 

It seems to me that thinking about quality from this dynamic there are some useful valuable insights and conclusions, the first of which is that the easiest way to reduce error and cost is to reduce pressures that lead to mistakes.  Many of them would be addressed through an active Lean campaign (think especially about Sorting, Streamlining, Shining, and Standardization) which would go a long way towards reducing noise, crowdedness, clutter, and time pressures. My guess is that the impact this would have on an organization’s work culture would be so powerful, that the drive to sustain the improvements would come from within rather than requiring management motivation.

My second conclusion is that trying to implement a new Quality system without first addressing these pressures would not solve the quality problems; indeed it would make them worse.

I wonder if that is why some many organizations that try to implement Quality systems through ISO9001, and probably 17025 and 15189 fail.  It’s not that these are bad systems, but if you don’t create the culture and  time-space in which the Quality system can grow, you can be surprised when it doesn’t.


  1. Hello Dr
    I completely agree with you in that eliminating pressure is a huge step in making the implantation of quality system works.
    Pressure does not only means heavy work load
    From my experience...If the worker is having a positive environment that helps and understands his needs...he can actually mange work load to more than could imagined.
    Eliminating pressure means many things
    *Understanding the need of the people that are actually doing the work..not what one read in a book..Reality sometimes different
    *Give the worker the chance to say what is wrong and how to improve it...usually they have wonderful ideas.
    *Guide not blame or punish
    *Specify how to deal with congested situations...Who can move to help...Who can’t leave his place...improving methods of analysis..Modifying the shifts or asking or more hands...Whatever works and needed.
    *workers are human...They need dignity and understanding and appreciation
    Ghada Gad

  2. Dr. Noble,
    I think you highlighted some very good points. To eliminate errors and sustain quality system, you need to get the real workforce to support and implement it. How communication is handled is a huge component of the work culture. It is important to be remind technical staff with no customer interface in their workflow of the impact of error and their role in the big picture. To be internally driven about quality, there has to be a sense of approaching quality issues as a team and this can be achieved through an open-continuous dialogue between management and the staff.


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