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.
