Attending Quality Conferences

Julia McIntosh of the American Society for Quality has created a really nice summary on why attending meetings promotes networking [see: http://asq.org/blog/2015/04/the-pros-and-cons-of-conferences/ ].  And many thanks for pointing to my blog on one of the challenges of meeting travel [see http://www.medicallaboratoryquality.com/2014/07/quality-standardization-and-mh17.html ]. 

To be clear, let me underscore that I absolutely agree with Julia.  First and foremost, I know there are some inherent risks, but on greater balance, attending meetings is  critically important to Quality and Communication.  As the old adage goes “the most important part of a meeting is that people meet”. 

When people get together, creative juices flow and innovation and collaboration and synergy opportunities abound.  It is tough (but certainly not impossible) to duplicate that over a telephone or by watching and participating through a computer or tablet screen.

But it is also fair to say that meetings can have costs which have to go into the planning mix.  Yes, even attending meetings is a Deming PDSA opportunity. 

You can’t be in two places at the same time, and sometimes urgent things can happen while you are way, and the longer the meeting, the greater the risk.  Also, it is pretty clear that the more flight legs it takes to get to a meeting, the higher the probability of a problem.  Lost luggage, missed connections, jet lag, and common colds, phlebitis, and more recently it seems, measles, can mess up your meeting.  And let’s not even talk about flying in or out of the North-east anytime between mid-December to early-March (?) with predictably unpredictable weather. 

And then there are the financials to take into consideration.  In my world, an average 3 day meeting can consume between 4 and 5 thousand dollars, for travel, hotel, registration and per diem costs.   

So I can agree that attending meetings is important, and you can optimise the up-side benefits and reduce the downside hazards, with the following:

1.    Ensure the meeting is worth the risk.  Are the people that you want to meet or listen to likely to be there?  In my world, ASQ meeting are right up at the top.

2.    And as an extension to the above, if you go to a meeting and talk only to your friends, or even worse, talk to nobody, that is opportunity lost.

3.    Look for meetings in the sweet spot, May-to-October, (maybe avoid August) to reduce risks of weather.

4.    Make it a meeting worth your while by balancing travel time against meeting time.  Do you really want to travel for hours-and-hours just to attend a one-dayer?  And on the other hand, do you really have the time to be away for 4-5 or 6 days?

5.    Look for meetings in locations that you can get to on one or two flights.  More than four flights is probably a guarantee for at least some lost luggage or a missed connection.

6.    And as another extension, look for meetings in places where you might like to visit. 

7.    Look to save some cash.  Book meetings at the Early-bird registration rate.   Usually the meeting hotel is going to give a good discount and sometimes, meals are included as part of the meeting. 

So ASQ World Conference on Quality and Improvement in Nashville, in a few weeks for most folks in North America would meet all those criteria. 

Where also would be an ideal meeting to consider, if you are in the medical laboratory/healthcare/safety business, is to think about visiting Vancouver BC and the UBC Program Office for Laboratory Quality Management Conference in October 28-30, 2015. 

Visit: http://polqm.ca/conference_2015/home.html

Doing it Right or Doing it Wrong?

Doing it Right

Recently I was reading the recent (August 2013) edition of ASQ’s Quality Progress and came across an opinion article by Bob Kennedy who jumped into the fray between W. Edwards Deming and Philip Crosby and said that in his opinion that Crosby’s first essential, Do it Right the First Time (DIRFT) was wrong on every level.  The foundation of his argument was that Deming proscribed against slogans and therefore Crosby and DIRFT was wrong.

 I have to say that Crosby was NOT wrong, and that DIRFT was NOT wrong.  I am not sure that Deming’s concerns about sloganism was meant to include concepts like DIRFT, but if they were, then in all due respect, in this circumstance, I would have to side with Crosby.  Even a pioneering genius like Deming could not always be correct all the time. 

When is comes to concepts like DIRFT, Crosby was spot on, and Deming should have acknowledged it.

First off, let me put some context around my opinion.  I understand Deming’s point of view.  There are some slogans that I think are unhelpful.  “There is no such thing as an Accident” .  “Accidents poison to our organization”.  “Time is money – time loss kills growth and progress”.  These are not slogans, they are less than idle threats that lead people to hide slips and simple mistakes.  There is little place for threats in the workplace.

But DIRFT is not a threat, and indeed makes sense.  Given the alternative I would hope that a neurosurgeon makes triplely sure he does it right the first time.  And by the same token, the same goes for the airplane pilot.  Even the woodworker says, “Measure twice and cut once”. 

DIRFT is in fact a reiteration of a concept that Deming was so proud to adopt, even if he did not state it, “PLAN DO CHECK ACT”.  (For the origins of PDCA see Deming did not create PDCA.  [ http://www.medicallaboratoryquality.com/2012/06/deming-did-not-create-pdca.html ] .

What DIRFT was intended to mean was before you do something, make sure that you have organized your thoughts before you put a plan into action.  It is the essential corollary to PDCA.  Think before you do. 

In the medical laboratory we have tons of examples where things don’t work that way.  Tests get implemented without proper validation.  Tests are done and reported before checking the Quality Control results.  Reports are sent to the wrong person before confirming who was truly was the intended receiver.  These happen all the time and in every instance they result in external failures with potential false reports, misleading information, loss of confidentiality and huge cost of poor quality.  And most of them were pointless and preventable. 

A few seconds or at most minutes of thought and planning could prevent most of these problems, and save the laboratory from embarrassment or potential liability, and save the patients from inconvenience or harm.

Perhaps in Deming’s time, folks were very aware and sensitive to threats in the form of slogans.  Labor protections, either under the umbrella union protection or workplace legislation either did not exist, or were in their infancy.

That is not the world in which we live today.  Today we live with 40 character headlines and 140 character tweets, and thirty second commercials.  We live in a slogan society, and we by-and-large put them into a more current context.  We may see slogans as jargon and trite or sophomoric, but we don’t see them as threats.

Personally I see DIRFT as rather aspirational.  I fatigue of avoidable errors, or repeated mistakes.  I embrace the notion that doing things RIGHT is better than doing things WRONG, and believe that many errors result from automaton-like behaviour.  I absolutely support “Plan before you do; Prevent the avoidable error”  and even more importantly, “Learn from mistakes; support continual improvement”.

So to Bob Kennedy I think with respect it is OK to relax on the absolute adherence to Deming’s word.  It is time to embrace context and circumstance, and to acknowledge that it is also possible to acknowledge that both Deming and Crosby were giant contributors to our current concepts of Quality. 

Drive-by Quality

Drive-by Quality

Paul B writes an interesting blog note about Quality solutions that you see in real life situations  [ see: http://asq.org/blog/2013/03/quality-solutions-in-unexpected-places/].   

In web-parlance we have a phrase that addresses unconscious or casually uninformed activities sometimes with unintended consequence.  You can call that drive-by Quality.   Sometimes drive-by activity is a negative, such as when you download some software that ends up causing grief.  In this situation, I consider drive-by Quality more as an unintended and unexpected but often very pleasant positive.  

I was working with a group of students who were given an assignment to do a presentation.  After being given their topic, the two students got together and scoped out their topic, and developed the list of items they wanted to talk about.  Then they assembled their presentation and did a practice run and found the places it didn’t flow properly and adjusted them.  Then when they were finished,  they invited me to hear the revised practice which went very well.  

“Have you ever heard of a guy named Deming or a process called PDSA before?” I queried, only to get a very blank look in response.  I pushed a little harder.  “What you just did is a really good example of what Quality folks call Planning – Doing- Studying - and Acting.  It’s kind of the cornerstone tool of Quality Management”.  Again I got the same “that’s interesting” response, but I knew that what they were really saying was “whatever!!”

Students tend to gather into two types; those that instinctively get the concept of PDSA and those that do not.  So much so, that in my mind I am tempted to think that it is an X-chromosome linked genetic trait.  Girls are more likely to organize their way through a problem, while guys are more likely to be of the “shoot from the hip” disposition.  I suspect it had something to do with survival of the fittest 50,000 years ago.

But there are clearly more environmental factors at play as well.  Think Nature-Nurture.   There are lots of guys who figure out that being burned from rapid-fire problem solving is not a good way to go forward in many (most?) modern life challenges.  Mature learners who start getting really busy in life and no longer have the time to recover from dumb and repeated mistakes figure out the P and S are real time savers.  

I know from my own personal experience that if I was borne with the PDSA gene, it was very very recessive.  It took me a long time to realize that making the same mistake over and over and over was not a good strategy.  But even I was able to figure it out and start some Quality learning.  Fortunately both of my sons inherited a more potent version of the gene from their mother who clearly has a double dose carrying PDSA on both her X chromosomes.  

Bottom line, the concept of quality may be inherent in some people and you will see “PDSAers” all over the place.  That is a good thing.

PS:    To be clear, there are lots of girls in this world who appear to be PDSA gene deficient.  Some of them go on and learn the concept later in life, but many don’t.  Just like guys.

PPS:  To be equally clear, I don’t know if PDSA is a genetic trait of not.  This falls into the category of evidence and proof known as speculative conjecture or a “hunch”.

Planning for Planning.

It has become an absolute truth that if a person, organization, business or government starts a new initiative without spending some effective planning time, based largely on measureable evidence, the initiative will likely fail.  The more time that is put into developing the plan, the greater the likelihood of success.  “Shooting from the hip” is rarely (if ever) a good idea.

The concept has its origins in the 20^th century literature tied to the thinking and writings of Walter Shewhart, either in the original (1939) form of Specification – Production – Inspection or the ultimate adapted form by Deming:  Plan – Do – Study – Act.  Reality is that the concept has its true origins much earlier, perhaps to the early introductions of scientific method, but for purposes of modern systems, if you haven’t learn from the lessons of the past 70 years, then adding more historical perspective will contribute nothing.    

The larger question is not so much whether planning is a good idea, but rather are there tools that can help the Quality Team and the organization get to the point of a cohesive designed plan.    And the answer is yes.  Depending on the size of the task, the tools will vary, although the principles remain the same.

For simple measures like planning for an internal audit the process can be pretty straight forward. What is our goal, what instruments do we need to develop.  Who will be involved, who needs to be notified, and can we set a timeline to complete the task; an all internal operation.  

If the goal is to create a new product or service then having discussions with the “customer” is a good place to start.  You likely will want to include the design people to make sure that the organization has the structured and skilled where-with-all to achieve what needs to be achieve.  If the project is about introducing innovation, then sort out that it is an innovation that forks are interested  in having.  

If everyone is clear on what exactly the end-point is supposed to look like, then the process to be travelled has a chance of being accomplished on-time and on-design.

With organizational renewal or restructure, the introspective approach of a SWOT analysis can be helpful.  By collectively putting a critical and objective eye to an organization’s Strengths and Weaknesses, and Opportunities and Threats, an approach to maximize the positives and minimize the negatives can be organized, prioritized, constructed and put into operation.  The process may or may not involve the thoughts, opinions and inputs from folks from outside the operation, but does need a cold look at objective evidence and the ability to acknowledge weakness.  Looking inward will reduce the risk of starting along a path that does not take appropriate advantage of what exists or stumbles over what is missing.

Recently I was introduced to a new planning-for-a-plan tool called a Policy Lens.  While new to me, there is a considerable literature on the concept going back over 40 years.  It may well be the instrument of choice for policy advocates by which I mean folks and organizations that live for the opportunity to establish policy in large structures such as government, international mega-corporations, academia, and industry sectors.  If you do an internet scan on “policy lens” or “conceptual scan” you will understand where this tool gets its most common usage, especially over the last 5 years.

The term “lens” is and example of organizational jargon, and is probably better replaced by terms such as point-of-view or perspective or vision. 

For establishing as trivial example policy to address the creating of a webjournal (blog) on laboratory quality management one could look at the topic from the perspective of (a) writers (b) blog-space providers (c) quality teams, (d) academics, and (e ) laboratorians.  Each group could be asked to consider impacts on (1) TEEM units (2) credibility (3) risks and liabilities and (4) quality improvement, plus issues of (i) continual professional development, and regional autonomy and (ii) international applicability or (iii) short-term or (iv) long-term application.  To the extent possible, options should be supported by objective measure and consensus.  Each step would needs tools such as questionnaire designs to be developed.  And all this would need to go through the steps of priority and consensus.

This is obviously not a short term exercise and one would be strongly cautioned against developing a “lens” infrastructure for a trivial topic such as blog writing.  But it would certainly be a useful approach for establishing health policy or delivery systems.   Done properly with appropriate validations and confirmations and broad based objective recordable and measurable inputs, thia is a major exercise. 

Can you go through this whole exercise and still end up with flawed policy?  Of course you can.  That is why Planning leads to Doing and then Studying and then Acting. 

But if the policy is big enough or important enough, the risks associated with under-Planning or non-Planning are guaranteed to be profound.   

The problem with Management (1)

I got a great gift the other day, a new book (published 2010) entitled Management Mythbuster by David A. J. Axson (John Wiley ans sons publisher).  It is a great read.   Axson is a banker, finance management, consultant, author of considerable experience who went through the financial meltdown that started in 2008.  I don't know what he was like before, but at the time of his writing he had a pretty cynical edge to this book.  From what I know and understand, that cynicism is well deserved.  

The last several years have not been particularly kind to traditional management.  At the time of the writing of “Mythbuster” the media had already said an awful lot about the problems that management had caused in the financial world.  And the world has continued along that line.  What with the ongoing pressures on sovereign debts of Greece and revelations of pretty gross banker salaries and benefits, and  the whole Occupy Wall Street movement  focus on CEOs and really obscene payments for failure, a lot of the business-as-usual of management has come under considerable scrutiny.  I suspect that that trend is likely to continue for some time yet.  (Noble’s law: Nothing moves Quality more effectively than an angry public.)

What AXSON writes about is not a defence of management practices, but rather he takes a pretty harsh look at really shoddy performance at missions and visions and envisioning and projections and use of consultants.  Quality and Risk and Budget management are not spared. 

First of all let me say that the big part of my own belief system is pretty much in full support.  When I see what has been wrought in Canadian Healthcare with excessive payouts to a slew of pretty unimpressive consultants, and the massive expansion of management positions with little to show on the improvement side, I have to say I was pretty “right-on” with Axson.  But before we all the way to bring in the marauding hoards to storm the hospital executive suites, I think that it is more important to step back and take another look. 

Before we trash all these tools, I think we need to acknowledge that while there are lots of examples of excess, let’s not through the baby out with the bathwater. 

Take Six Sigma for example.  There are many examples of laboratories that have bought into six sigma in a very big way.  I know one laboratory network that has taken on a six sigma staff of more than 10 folks.  All sorts of projects being done, some simultaneously, some back to back, some leading to implementation plans, but most not.  Problem is that all that activity costs a fortune, with salaries and benefits alone, well in excess of million dollars a year.  Throw in meetings, and travel, and implementation trials and that value doubles or trebles.  With all due respect, the chances that any of this will even come close to breaking even is near zero.  That sort of use of Quality tools has more in touch with faddism and cult belief and the use of “OPM” (aka “other people’s money”).    Axson says in essence that this is a tragic waste.

I would not go that far. 

I think the folks at Motorola were on to a good thing.  Six Sigma was a simple extension of ISO9000 which in turn was a basic codification of the knowledge and experience gathered first and foremost by W. Edwards Deming and Walter Shewhart.  Define Measure Analyze Improve and Control the future (aka DMAIC) is just another more complex way of saying Plan Do Study Act.  That’s a good thing.  The problem with Six Sigma as it is practiced in the places that I have seen is that it is always project oriented with little continuity.  That is a bad thing.

If AXSON presents an overall philosophy it is to keep things simple and flexible and rational.  And that is a concept with which I am complete on-board. 

If we start of a point of error awareness and the need to remediate and correct, and we focus on continuous improvement, our focus is more refined, and our opportunities for success are enhanced.  Simple is better.

If you have the time, you will find Management Mythbuster on both Amazon and Indigo on-line.

Cycle Gipe

WARNING:  THIS ENTRY IS A LITTLE LONG.

I used to worry about creating neologisms (new words) because in psychiatry it is said to be a symptom of psychotic behaviour.  But I decided what-the-heck.  English has always been a language in transition.  Besides this is not so much a new word as maybe a new acronym, and we know that English is inundated with new acronyms every hour.  So with that let me introduce my new phrase: cycle gipe.

Walter Shewhart got it right in 1920 when he created the notion of a series of events that follow a regular pattern.  First you Plan, then you Do, then the Check the Results and then do fix through Acting and then you do it again and again.  W. Edwards Deming understood it and modified it slightly; but the concept remained the same.  We can call these good examples of a continuum of activity, but since the point was made that the process should be one of continual repetition, these are good examples of what we can appropriately call cycles. 

But sometimes things don’t work out just that way.  Not only does the process sometimes not go through the repetition process (hence not a cycle) all too often they barely make it through the first stage of continuum.  So do we have a word for that?

Well we do.  Impolitely one might think about another acronym (fubar) but wanting to be a little more positive, I thought about NCC for non-continued continuum.  But I decide to be even more positive with "cycle gipe" (a cycle with Good Intention but Poor Execution). 

I will use it in a sentence.  Our laboratory’s continual improvement program was cycle giped when we stopped doing our internal audits.    

Here are a few additional examples of cycle gipes.

The intra-laboratory continuum failure

A laboratory needs to create and provide and update job descriptions because the job description tells workers what you want them to do and describes their reporting process.  This document can become the employee’s training manifest and their training compliance record, and then form the basis for their competency assessment manifest.    Rather than being a one-size fits all document, it is a record personalized for each employee.  Rather than being written as a one-time document, it is a living document that undergoes continual revision and is repeats through a cycle process. 

I know it sounds like a lot of work, but compare to all the time lost with work confusion, it actually should save time.  And rather than having one part in HR and another with the supervisor, and another in the quality records file, It becomes the one fit-for-purpose document which again saves time and confusion.

So why does this fall into cycle gipe?  I suspect the main reasons are tradition and distraction.  Historically job-descriptions have always resided in the Human Resources Department, and training records live somewhere else.  And even if we do update one part, we usually don’t get around to updating the others.   Or worse one person updates one part, and someone else updates another.  So even if we start off with a unified document, given a few months all the parts get changed.  A good example of “Good Idea but Poor Execution”.

The answer here is simple.   The document is created in one place and is maintained centrally.  All the departments have access to it, but only one person controls it.  It becomes a single document under document control. 

The control is greater, the utilization is uniform and the outcome is better, but the net work involved is less. 

The Cross-System Continuum Failure.

This is a more insidious failure but with much broader implications, and is much harder to control because the responsibility for monitoring success or failure does not lie in the hands of people with the responsibility for creating the process in the first place. 

For the best of intention, a standards development organization (SDO) creates a document that describes from first principles a policy statement.  Let us take for sake of argument and example, a policy about patient identification.  The policy makes sense and takes into consideration certain basic principles.  If undertaken as written and intended, it should prevent or reduce many laboratory errors.  This would be a good thing.  An accreditation body reads the policy statement and it sounds good, and adopts this as a requirement in their accreditation standard. 

So it comes down to the laboratory with an expectation that certain activities will occur.  The laboratory reads the requirement and implements it as policy and instructs that it should be put into action.  So far all is good and the continuum has worked as intended. 

The problem occurs at the next level when put in the hands of the front-line worker the good idea doesn’t work as intended.  Maybe it is a language issue or a cultural issue or a work pattern issue.  Whatever the reason, the process is not implemented.   That should be picked up as a non-conformity through internal audits or competency assessment , but that only works if there is an audit process in place.  And all too often there is not.  So there is no record that implementation has not succeeded.  But that should be OK because the accreditation team should pick up the absence of a record, but that doesn’t happen either.  And monitoring live activity is not something that is done effectively during accreditation assessments.   So the SDO never finds out that the policy is not working, and so with each new version of their document it keeps on getting repeated. 

Ergo, we have another good idea and good intention but poor execution. 

So how often does that happen?   Must be pretty rare, right? 

Wrong. 

So here is the message.  Over and over we see that Shewhart and Deming were right.  Continuums and cycles work when we go through a step-by-step process.  But they all have opportunity to fail when we forget or neglect to go through all the steps.   

Plan - Do - Study - Act.