Monday, December 21, 2020

Organizational Quality and Competence (Part 1)


Organizational Quality and Competence (Part 1)

There is an international standard in my area of interest (Quality Assessment) that is undergoing its review and revision.  One “minor” revision proposed is the addition of the word “competence” into the title (requirements for the competence of proficiency testing providers).  This is NOT a minor revision. because it changes the use and intent of the standards document from defining what a provider is required to do as a provider, to providing a blueprint for the providers and the accreditation bodies on how the provider will demonstrate competence. 

Turns out, competent competency assessment standards are difficult to develop and use.  (More on this in Part 2)

There are many definitions that can define competence.   From its early roots, competence is linked to the notion of competition and sufficiency.  Common parlance would describes competence as the ability to do a task successfully and  efficiently.   The International Organization for Standardization goes further, defining competence as “ability to apply knowledge and skills to achieve intended results making the point there are some expected elements (knowledge and skills) that are relevant to do the job as intended, which fits with the Juran phraseology – “fit for purpose”. 

 Merriam-Webster goes further … having sufficient knowledge, judgement, skill, (or strength) for a particular duty.  By adding the element  “judgement” takes competence to yet another level.   Requiring judgement requires having sufficient grasp of the job expected, the person can consider situation and nuance and make decisions about when or how to perform the process or adjust as circumstances require. This is the true hallmark of modern thinking of competence. 

So how do people reach that level of ability? Hard to say, but not everyone in every organization reaches that point.  It comes in part from staff interest and understanding and part from management developing opportunities to delegate authorities for decision making.  This puts the onus on management to allow their staff to learn through continuing education and contributing to continual improvement. Developing staff competence means creating a work environment that supports learning and rewards success.

This definition puts a additional context on identify staff as competent.  Competent does is a derisive meaning adequate for the job.  Competence  goes beyond adequate.   It means that that management knows them to be knowledgeable, skilled, and understand their job well enough to show good judgement while making decisions and performing intended tasks in order to reach the expected results. 


So here is a question: If we have redefined competent to mean something like “the complete package”, how can we describe staff who are not there yet?

I found an interesting blog written by a Tom Graves, a self-described “Enterprise architect, business-anarchist, confusionist (?)” ( ).  He defines 3 competence categories, which can form sort of a framework.

Competence: is where someone knows what they’re doing, and does it.
[These are staff members we call valued and competent].

Non-competence: is where someone doesn’t know what they’re doing (completely), and will either not do it, or will do it, but only after clearly make the point that they not exactly skilled, but will go ahead if it is understood they are learning to improve. 
[ Non-competent may be an acceptable category but is too negatively charged  as a character description.  A more useful term might be a valued staff member well along the path to being fully aware and able].

Incompetence: is where someone doesn’t know what they’re doing but will do it anyways, concealing their gaps, perhaps to both the organization and themselves, creating the potential for all sorts of risks, damages and liabilities.   
[I think that incompetence is one correct word for these staff workers.  Perhaps another more transactional term might be “former staff workers”].

So in this definition of Quality and Competence, to get a position, you need to show you have the appropriate knowledge and skills to perform at a satisfactory, capable level.  But to hold and grow the position you need the impetus and initiative and encouragement to develop the judgement and nuance that distinguishes excellence.  You can call this competent or proficient or skilled.



PS1: There is another interesting synonym for competent, from the Latin (“proficere": to accomplish, make progress; have success) – proficiency.  A discussion for another time.

PS2: I have purposely left out describing an individual’s competence in terms of meeting a checklist of defined competencies.  There will be more on that topic in Part 2.





Wednesday, November 11, 2020

The Distributed Costs of Poor Laboratory Quality

 I have written about Costs of Poor Quality before (see: Tuesday, March 3, 2020CVP - The Coronavirus Vanity Project -or- Sunday, March 6, 2016 Another look at costing Quality-2016 -or- Saturday, June 7, 2014 Taking Charge - Taking Responsibility ) It is a favourite topic of mine.
While first introduced by Joseph Juran, it was best defined by Philip Crosby as the Measurement of Quality. “Take everything that would not have to be done if everything were done right the first time and count that as the price of non-conformance.” 

 Crosby made the point that all too often these non-conformance costs could add to more than 10 fold the costs of “doing it right the first time”. My guess is that he didn’t just pick that number 10-fold of the air; my guess it was probably based on a ton of calculation, which must have been a megaton of work considering the state of computers (by reference that was the year that I bought my first Commodore 64 with its amazing 64K of RAM).
Today we can take a better measure of the Costs of Quality and Costs of Poor Quality. My estimate is that today the Costs of Poor Quality can run up to 100-1000 times the cost of doing it right the first time round.

When thinking about Quality Costs any organization,  it becomes apparent that the Quality Costs are core or nuclear, but Poor Quality Costs are expansive, maybe explosive. Quality Costs can all be captured as a series of single line items in the laboratory’s budget. It is much harder to capture Poor Quality Costs because they not only affect the laboratory through extra reagent costs, extra staff work time, and repair and maintenance costs, but they also extent outside the laboratory hitting the budgets and pocketbooks of our customers. Think about these as the Distributed Costs of Poor Laboratory Quality

When a clinician is notified about an incorrect result, they will need to go into their files, find the patient, contact them and explain the problem and may have them go back to the laboratory for another test. They will need an additional note in the chart. That all takes time out of their day, maybe 20 minutes to an hour for each patient (more if contact requires a few phone calls) for which they probably cannot bill.
For the patient, their time and patience are consumed; they were notified and informed a test result may be in error causing stress and probably annoyance. They may need to have a retest; maybe they will need to get a sitter, or leave work early, or drive to the laboratory and park, all of which is money out of their pocket. Maybe they will lose work time and maybe lose income. Maybe they have already purchased medications based on the wrong information. Pretty sure the pharmacist is not going to take the pills back.
And what if the problem was a microbiological problem that got public health attention (an errant COVID-19 test, or stool pathogen test). The chase-down and corrections can consume many hours.
Worse, if the problem had some bad outcomes and lawyers got involved, there are going to be facility costs that could run into the thousands, if not millions of dollars.

And what if the error was not picked up right away and more than one patient was involved. Maybe it was 5, or maybe 10. I was involved in the investigation of one that involved over 100 patients.

So what starts as a simple “oops” can sometimes within the blink of an eye evolve into a very big deal. Capturing these distributed costs can be an important part of your awareness and corrective action process. Taking ownership may be a bitter pill to swallow, , but learning about these distributed costs has to be a part of the nonconformance / OFI investigation, which certainly is an accreditation requirement, and far more importantly and Quality requirement. 

If you want to visualize how much these distributed costs can climb, I have a tool that calculate the estimated costs and give you a graphic depiction in dollars and minutes. Let me know if you think it helpful.

Wednesday, September 30, 2020

Unintended Consequences


The other day I attended yet another Zoom meeting.  

In my province the Ministry of Health acknowledged from the beginning that there while there may be an outbreak of viral infection (COVID-19)  in the province and that the province believed that the province may be required to take some action, there was the probability that some "unintended consequences" may occur, and the province had an obligation to monitor  them and their potential impact.

One can take this at face value or consider it as some obscene rye joke.  To be fair and give credit where credit is due, I think you have to give them points for good intention and for having the foresight to acknowledge that there may be some negative (and maybe some positive) unanticipated outcomes when you decide to shut down a jurisdiction of some 5 million peoples. 

So we are now into the ninth month of this outbreak, and it has spawned what I think many would call the most egregious Satan’s baby of all times.  

Public Health folks and the Politicians and the media decided to focus on the weakest of all catchphrases of all times, clearly not understanding what any of it meant.  Flatten the Curve.  Surely someone understood that “Flattening the Curve” means “don’t let the caseload  peak, even if we have to extent the period of activity”. I know with absolute certainty that the docs understood this.   Probably so did some of the politicians.  But for politicians it is easier to sound wise that to actually be wise, and so off they ran with “Let’s Flatten the Curve… We’re all in this together” and not bother to know, explain or understand the downside risk of pushing too early.

So I argue the First Unintended Consequences of trying to Flatten the Curve, was the tragic shutting down the province, killing business and community spirit, all the while ensuring, indeed  guaranteeing that the outbreak would stay on and on. 

And what about Unintended Consequence number 2?  How about when you try to pretend that you can treat the whole province like a big hospital and use precautions (the other catchphrase that politicians love - PPE) that are intended for intensive care units.  By using them in all shops and in the streets of all the villages and cities, you end up finding that, just as they barely work  in the hospital, they don’t work at all in the street. 

What the public is apparently unaware is the tragic reality that every intensive care unit (ICU) in the world bounces from one outbreak to the next.  Despite all the gowns and gloves and masks and booties and caps, the secondary infections happen in ICUs all the time.  Infection spreads all the time.  They never stop.    C. difficile, MRSA, VRE, Klebsiella, Pseudomonas, pneumonia, diarrhea, …. over and over and over.  

So if all this protective gear barely works when used by knowledgeable, experienced healthcare professionals in confined specific spaces of single purpose, why would anybody think they would work just fine in the hands of uninformed amateurs?  

As for Unintended Consequence number 3, when you shut down businesses, and travel, and communities, and religious gatherings, people become isolated and scared, and angry and depressed.  Some people get into bad activities like drinking too much alcohol, taking too many drugs, watch too much television, get into fights, harm themselves, harm others, over-eat, don’t exercise, gain weight, don’t take care of their health.   And children (of ALL age groups)  stop learning. 

Did our leaders really think this through at all, or are all these just more unintended consequences?

So here is where we are now.  In this province of 5 million and 9 months in, we had about 8500 people who tested positive of which 880 ended up in hospital and 229 people died, most of who were elders living in nursing homes (another place where society has NEVER been able to contain outbreaks).   

Of the people who died the median age was 85(!) with a range of 44 to 104 years.  This is sad but the number is no greater than other years.  If they had not died from COVID-19, many would have died from strokes, or falls, or common colds, or influenza, or depression, or senescence because it was their time.   

To put the 229 number into context, over the same period we have had 1600 deaths by drug overdose, and 600 deaths by motor vehicle accidents.  And then there are some 23 deaths from avalanches and about the same for swimming pools deaths.  Maybe our leaders should require all people going into swimming pools wear goggles and water wings.  Probably as effective as wear an N95 mask.

So here is what we have learned. 

1.    People LOVE catchphrases, like superbug, flatten the curve, PPE and second wave and LOVE to scare themselves tragic.  Catchphrases allow people to sound so learned without actually having to know anything

2.    Leaders love to show how much they are in charge and how forcefully they can use their catchphrases, seemingly to no positive avail.

3.    People who are terrorized and traumatized by fear can be driven to show how compliant they can be,  but seemingly without much positive benefit.

4.    Pandemics can and do considerable harm to elderly vulnerable people, but no where in the scope of the damage that people  do to everything and everybody else with all their good intentions and forceful actions. 

5.    Hopefully we have learned that whatever we do the next time, let’s NOT do this again.

So I wonder if the first question is NOT what were the Unintended Consequences of our COVID actions, but rather, what were the INTENDED consequences and why did they fail so badly?