Friday, February 28, 2014


In a previous post ( I mentioned an observation reported in the Harvard Business Review about 47 percent of people regularly having a wandering mind.  The point was made that distraction is a very common cause of work related error. 
This raises in my mind a variety of interesting avenues, such as, if half of people working in your laboratory are intermittently or regularly distracted, how do we ever get anything done on time and right the first time.  Crosby’s DIRFT must be an impossible dream.  

Well in some respects I think there is some truth here, but we are protected from most disasters because of our own systemic ingenuity and maybe a lot of luck.  James Reason of “Error Fame” points to what some call the Swiss cheese barriers that block most bad events from manifesting.  

We pick up on clues that tell us that what is about to happen is nonsense or wrong.  The name or check mark is not present, the color or shape is wrong, the whistle is blowing.  Something alerts us that something needs fixing.  His point is that for most inadvertent errors to occur you have to experience the uncommon (not uncommon enough!) combination of bad timing, wrong circumstance, bad luck, and absolute obliviousness.  Most causes get stopped; very few work their way through to an outcome or effect.  

But I turned to a book by Edward Hallowell, who writes on attention deficit disorder to see if he had any suggestions that might help the 95 percent of us that do not have ADD, but nonetheless have episodes of distraction that could mess things us. 
So in the spirit of Culture of Quality improvement and Distraction Abatement and Error Avoidance in the medical laboratory and with thanks to Edward Hallowell and John Ratey, I offer the following:

  • ·       Both excess quiet and excess noise make a laboratory a not nice place to work.  Often you hear people say they don’t hear all those cabinet fans and motors anymore, but they are wrong.  They do hear them and they drive your staff crazy.  Background music can be a problem because of the wide variety of personal choice.  Some folks actually can work better with a personal headset and an iPod.  Don’t be afraid to give it a try.

  • ·       We are all visual beings.  Bright colour is a good thing.  There is no reason that all laboratories have to be monochromatic white or cream or grey.


  • ·       If your technologists need to regularly work through computer screens, get rid of those old green/white or black/white eye sore monitors and make sure the software screens have enough pizazz to capture your staff’s interest and attention.

  • ·       Provide for lunch and learn open-talk sessions on strategies that help reduce distraction and error.

  • ·       Encourage staff to take a regular break, even for a few moments when they have been sitting at their bench for more than 30 minutes.  They should stop doing what you are doing, stand-up, stretch and breathe.  Then start again. 

  • ·       To the extent possible, require people to take their mid-morning and mid-afternoon and lunch breaks and use it for want they were intended. In my son’s work-site people have access to ping pong, to exercise equipment, to music, or to just sitting or taking a walk.  I haven’t seen than in many laboratories (although lots of places have group exercise) but that would be wonderful.  Note to laboratory managers, spend a little money and make sure that your staff has some comfortable chairs and sofas in their break room. 

  • ·       Enough with those conference chairs!!

Sunday, February 16, 2014

What or Who is a Customer?

Recently I have been thinking about customers.  

A colleague of my recently said at a conference “You don’t need to take care of all your customers, just the ones that you want to keep”.  That is a truly great sentiment.  All too often folks in the public sector miss that concept.  If you doubt that, just go spend some time in your national Passport Office.  Even if the place in which you find yourself has a monopoly, these days even the civil service folks are very vulnerable to the well-placed complaint.  My point is they can run, but they cannot hide, at least not for very long. 

But the whole discussion started me thinking about who exactly is the customer.  Recently I have found this a harder question to answer.  I have found two definitions that take me in two very different directions.

When I go to the source (ISO 9000:2005 – Quality management systems – fundamentals and vocabulary) I get one definition which is a “customer” is a “person who receives a product” or but when I go further I get “a customer is an organization or person that buys goods or products or services or ideas from a seller, vendor, or supplier for a monetary or other valuable consideration”.  

There is a whole world of difference here.  In the ISO definition the word “receives” does not differentiate between a gift or a transaction.  When Oprah gives everyone in her audience (for which they received a free ticket and paid nothing) a free car, I don’t think that makes any of them customers.  When I walk down the street and give a homeless person a dollar or a free meal, I don’t think that makes that person my customer either.  And if I give someone a birthday  present, I don’t think that makes them my customer either.

But as soon as the exchange is transactional where I give them a product that they give me something of value, then a different relationship exists.  (For the moment let’s leave tips out of the discussion.)  I don’t want to say that the ISO definition is wrong, but I do think their definition is far too open and vague and unhelpful.

So where am I going here, and why does any of this matter?  Recently I got into a discussion about “internal customers” where they were defined as persons from within a company who receive products or services from their  own organization with the intended purpose of using them as inputs to their own work.  

Now I understand the notion of assembly work where a product goes from point to point until it reaches its finished state, but to refer to that next station in line as a “customer” is nonsense.  And if someone in my department comes to me and asks me to give them my presentation slides because they require them to give a lecture doesn’t mean I have to turn them over as a condition of customer satisfaction. 
If I on my own volition want to give someone a car, or a gift, or pass on my finished work to co-worker I may do this because I want to, or even have to, but neither of these defines the recipient as my customer.  And when I do these things, even if they make someone happy and even if they feel satisfied, neither my actions, nor their feelings have anything to do with “customer satisfaction”.

And when someone tells me that the relationship between management and staff is just a simple extension of the customer relationship, my head explodes.  

It is really easy to fall into a jargon trap where folks who buy my goods and services and folks who work with me and for me all get lumped into the category of “customer”  but none of this is helpful or contributory to understanding Quality or Management.  We have one set of responsibilities and authorities when it comes to our co-workers (staff), and we have another very different set when it comes to the folks that want what we have to sell (customers), and we have another very different set when it comes to recipients of gifts, and largesse and charity (?).  

I may want to keep them all happy and satisfied, but they are not all the same.

Monday, February 10, 2014

Validation Verification and Vindication

Validation Verification and Vindication

We live in an era that loves to believe in logic and discipline as the basis of progress.  In near every discipline the clarion call to quality is that decisions must be evidence-based.  Evidence-based medicine is touted as the foundation for all diagnosis, investigation and treatment, based on the assumption that the overwhelming mass of studies performed and published provides us with all the information that we need.  

But it is pretty clear that many (most ?) of those studies are too small, too uncontrolled, and too biased and essentially not reliable, but we can do our best by combining studies and through meta-analysis can make the proverbial silk purse.  Despite this we generate tons of confusing and contradictory guidance in most things that are important, such as nutrition, vitamin usage, cardiac risk and anti-lipid therapy, and exercise, and on and on.  

For an interesting read on this subject, today I found an editorial in the Saudi Gazette written by Gary Taubes of the New York Times in which he talks about the “field of sort-of-science” in which “hypothesis is treated as facts”.   

The problem is not that we suffer from insufficient data or insufficient tools; indeed we live in the era of Big Data Analysis where thousands of databases with billions (and trillions) of points are available for picking and mining.  No it is not a problem of insufficient data; rather it is a problem of dirty data, poorly defined, incomplete, improperly gathered, and all too often inappropriately or insufficiently analyzed. 
Ultimately the problem is that we are left with the same lingering question “Who do you trust?”

To get on top of the solution we think in terms of Verification (is the analyzer capable of providing a repeatedly reproducible result within a narrow range of allowable error?) or Validation (do test results provide a result that is consistent with the gold standard and can they distinguish groups of subjects who are consistently “positive” from those that are consistently “negative” as measured by other parameters?).
But in addition I argue that we even more heavily rely on Vindication, which in this context I use to mean, “My approach must be right because I came to the same conclusion as noted in this other study”.  It’s a pretty soft measure, and a throwback to “evidence by authority” which predominated in the Dark Ages.  But it does have its compelling aspects.
I will give you an example.  In the Winter 2013 edition of Harvard Business Review Edward Hallowell wrote an article about a study published by Gilbert and Killingsworth in Science (Nov 2010) about people’s ability to focus on what they are doing and their sense of happiness.  What the study pointed out was that based on a pool of 2200 adults and over 250,000 observations, about 46 percent of people will commonly have their minds wander, even if they are enjoying what they are doing.  Hallowell, a psychiatrist and prolific writer on the subject of distraction writes, “Not only does such a lack of focus lead to unhappiness, it results in errors, wasted time, miscommunication, and misunderstanding, diminished productivity, and who knows how much global loss of income…”   

Now I am not a psychiatrist  (although I did a huge wack of training in psychiatry in my younger years), but in that sentence Hallowell summarizes the singular challenge for medical laboratory, and indeed all, Quality.  Recognizing that distraction occurs regularly is totally consistent with James Reason’s views on human error (slips and mistakes) and is consistent with Decker’s views on response to error, and is consistent with non-linearity of cause and effect in Chaos theory.   Lots of people (maybe most? maybe all?) lose concentration during work, and when that happens the opportunities for error and confusion arise.   Telling people to try harder is not an answer.  Telling people to Do it Right the First Time, is not an answer either.

Putting in systems to prevent the consequences of inattention and distraction (think Lean Poka Yoke) and putting in systems that will pick up on errors as early as possible, and putting in systems to reduce the repeating of error have a far more reasonable likelihood of success. 

I understand that my buying-in to this hypothesis is exactly what Taubes (sort-of-science) was concerned about (hypothesis becoming fact).  He would say that the linkage between distraction and error remains unproven.  But I have to say, without apology, that it works for me and I believe it.


Sunday, February 2, 2014

Deming and the diversity of healthcare Quality

Deming and the diversity of healthcare Quality

I am going through a personal evolution in my Quality career.  It is starting to get very complicated.  

In many ways I am very typical of people of my age and era in that given the opportunity to get involved, my first instinct is always to say “Yes!  Part of this reflects my personal interest in the Quality process, part of it my ego that still leads me to believe that I can do everything and do it all very well.  And part of it is a protection strategy; given a choice between having to deal with a standard that someone else has written and having the opportunity to inject my own beliefs, I would rather fight the battle early rather than fight it late.  This strategy has stood me more in good stead than bad over the years, although it does take a certain toll on my time.

But as I get closer to thinking about going to the next phase, I do reflect on what I do and what it says about Quality.  The reality is that most of what I do is done on a volunteer or a small honorarium basis.  Most of it does not generate direct revenue.  Most of it exists because I have a position that provides me with an income base and a fair amount of flexible time.  It all keeps me very busy, but not of it is “busy work”.
As far as income generating activities, I have a faculty position at a university and as part of that position I operate a proficiency testing program that works across Canada and provides international training to personnel in developing countries so that they can learn how to develop similar PT programs in their own country.  I also teach an on-line course in medical laboratory Quality.  Both these activities   can take a lot of time.  I have learned that a program or a course that stands still and rests of success and laurels is a dead program or course, soon to become very obsolete and mowed over by competition.  Operating both of these activities has allowed me to develop and hone my innovation chops in order to stay one step ahead, or at least not two steps behind.   

But in order to support these two programs I have become directly involved with a variety of Quality Partner activities, primarily in the standards development and the educator/communicator arenas.  I sit on a variety of standards development technical committees on both the national and international level, in part developing documents which my programs are intimately involved with.  In my opinion I know of no better way of knowing exactly what and why a standard requires certain expectations than being involved in the writing.  

I also get a lot of opportunities to get involved in networking through education/communicator process.  Over the years we have trained and certified near 300 people as medical laboratory quality managers, many of whom have remained in contact, and some have remained close.  We regularly put on Quality oriented conferences which brings me together with the former group and creates connections with new and interesting speakers.  Of interest we are now in the planning phase for our next conference which will occur next year, and I have already got a collection of speakers who will be new and unique to our audience community.  

In addition I have just finished one book chapter and I have been asked to write a new book as part of a series focused on medical laboratory Quality and patient safety which will create potentially a broader audience for  the conference.   

And next week I get to travel internationally to a meeting on Excellence in Medical Laboratory Quality and give a presentation which likely will help foster both meeting attenders and course takers.   

My point is not to blow my own horn about how busy I am (well maybe a little bit), but rather to make a few points: 

  1. First and foremost the arena of medical laboratory Quality is very alive and very busy.  If you are bored with what you are doing, you aren’t trying.
  2. Second, if you want to have success in this arena you have to keep new and fresh and diversified but with clear links to your foundational base.   

And lest you miss the point, all of this is totally consistent with Deming and 5 of his 14 absolutes:

  • Create constancy of purpose for improving products and services.
  • Improve constantly and forever every process for planning, production and service.
  • Adopt and institute leadership.
  • Institute a vigorous program of education and self-improvement for everyone.
  • Put everybody in the company to work accomplishing the transformation.

I always have thought that if W.E.D. had taken the opportunity to adapt his list of absolutes he would have included “Plan for success by getting busy and staying busy”.