The dark side of customer satisfaction

Four stories:  

• On a recent television show in Canada on customer service, the most common complaint was that all too frequently Canadians could not find customer service staff, and when they did, all too often the staff were ill informed.  The comment was made that many large companies find that hiring and training customer service staff did not result in increased sales.  In a related story, retail outlets are losing business to on-line services.
  
• I did an inspection for a laboratory recently where I was given the names of two clients that account for a huge amount of the work done by the laboratory.  One gave an OK review of the laboratory and the other trashed them.  When I asked if the complaints had gone to the laboratory the response was something to the effect of they know how I feel.
  
• I booked a large chain hotel in the United States a little over 2 month ago for a meeting next week.  I thought everything was in place, but I was wrong.  I went to the ‘net and checked out reviews on travelocity, tripadvisor, and hotels.com and found that others had had similar dissatisfaction.  I decided to cut my losses and cancelled my reservation and stay elsewhere.
  
• In an informal survey of 20 accredited medical laboratories around the world, I identified only 5 that maintained a formal log of received/resolved complaints, and all the logs that did exist, were incomplete (they only recorded complaints submitted in writing).  Only one laboratory maintained and monitored received/resolved complaints as a regular metric.

A few questions came to mind.  Why do some very large retailers and apparently some laboratories and profession groups see so little return on investing in customer service?  I can understand part of it. 

In the public sector laboratory and indeed throughout all the civil service the work process is near always the same; work comes in and work goes out.  Workflow in most laboratories is not obviously associated with complaints.  Institutional budgets are set based on factors all independent of satisfaction.   As budgets become constrained, it is easier to focus on the issues that sit front of mind, which continues to mean stamping out fires and trying to keep up with technological and human resources change.

Even if laboratory management want to reward good service, it is very difficult, indeed often impossible.  While there is much discussion around reward programs such as pay-for-performance, most programs have either been blocked or have failed because they are seen as too subjective, or too easily manipulated.  Pay-for-performance in the teaching profession is viewed as striking right to the heart of unionism and the concepts of collective bargaining.

The observation that some (many?) medical laboratories do not maintain an active and complete complaints received/resolution log is troublesome especially since addressing complaints is identified as an accreditation issue in the United States (College of American Pathologists) and by ISO15189:2007.  An argument might be made that just because there is not a metric that monitors complaints doesn’t mean that complaints aren’t taken seriously.  But how would anyone, including an accreditation assessor know?

The unfortunate reality is that with larger institutions and organizations the only driver that pushes for more attention to customer satisfaction is certification and in some laboratories, accreditation.  And that is too bad.  The reality is that is unhappy customers have all sorts of ways of sharing their experiences these days that didn’t exist before.  Until about 10 years ago, complain options were fairly limited.  One could write a letter or make a phone call, but short of making a formal complaint to formal state or college authorities, or spending money on civil suit action, that was about all that could be done.  Both of these are processes that most of folks find either unduly bureaucratic and time consuming or expensive. 

Today people can complain far more broadly with less problems.  There is email, and Twitter, and Facebook, and blogs and public review sites.  In healthcare you can register both positives and negatives about pathologists and clinics and laboratories in a variety of sites (www.ratemds.com, www.ratemymd.ca, www.healthcarereviews.com).  Word can spread in a very public way in a heartbeat. 

By the way, as mentioned before, the increasingly present option that patients have for direct-to-patient reporting will inevitably mean more unhappy people, more complaints and more public awareness. The general public I suspect will be less tolerant of wrong identifications, late reports, misleading results, false positives, and false negatives.  Poor customer service is no longer remains a private issue.  It can become very public and very ugly.

Welcome to the dark side of unhappy folks with access to social media.

Modern Metric Morass.

First off, I personally am looking forward to a happy, healthy and successful 2012, and I wish the same to the readers of this blog.

To continue on, I have mentioned on a number of occasions David Axson’s  book The Management Mythbuster.  Today I will make my last commentary on this book.  First off, I want to say that this book is a valuable read for anyone interested in Quality, not because it is brilliant and agrees with everything that I believe, but rather because it is brilliant and puts forward some very compelling discussion points on organizational management.   That being said it is an opinion book. 

If there is one area where Axson falls down it is in his 10^th chapter, Lies, Damn Lies and Performance Metrics.   It is not really his fault, we all are pretty schizoid when it comes to statistic and measurement.  On the one side we all recognize that if we don’t study (as in PDSA) then we can’t meaningfully Act. 

The problem is at the other end.  First there is a notion that if one metric is good then 10 is better and a thousand has to be even better (Axson’s first sentence is “we are drowning in metrics”).  Second we gather metrics based more on what seems to be popular (what we hear about or read about) rather than based on a strategic process.  (Axson calls them the Metric of the Month).  And third, even though many (most) of us are pretty statistics illiterate, we gather all sorts of analyses because we can.  The reality is that statistics software doesn’t require much statistics knowledge; all you do is fill in the fields and hit “return”. The computer doesn’t care if the result is meaningful or nonsense; it just spits out a number.

The result is that all too frequently we spend too much time measuring and not a lot of time testing the relevance and utility of the information.  Excessive metrics gathering is a classic form of TEEM (Time Effort Energy and Money) wasting.

Axson provides a pearl when he offers that the way out of the metrics morass is to focus first on what is really important (core) to the organization.  In business it is about profit and loss and in baseball is it about wins and losses.  I suggest that for the medical laboratory is about getting the right result to the right set of eyes at the right time.   

So if a good approach is to focus metrics on what matters, let me offer the following:

• Right result:   Measure of pre-and analytic error reported in errors per million tests.
• Right eyes:     Measure of misdirected reports reported in errors per million tests.
• Right time:     Measure of late reports again reported in errors per million tests.

Actually that is a pretty good place to start.   All three should be straight-forward to capture and measure.  Since all calculations are calculated to a common base value, significant improvements or deterioration can be monitored.   If we have problems here we are not doing what we are supposed to be doing.

One can argue about whether one would need to bench mark results to industry standards, but the reality is that there are no or few benchmarks for medical laboratory quality other than the expectation for ZERO defects.   We will talk about the definition of what constitutes a late report another time. 

Now I would like it to be that simple; but I also recognize that I know that laboratory life tends to get more complicated.   There are other important issues like safety and competency and quality control performance that laboratories also need to monitor.  There will always be new issues that arise and require monitoring.  And there will always pressures to measure more.  That being said let me offer the following:

1. Indicators implemented to follow up on a single point-in-time problem rarely need to be followed for any more than 4-6 months; at the very most a year.  
2. If you have not used the information garnered by a metric for 2 years, then decide if the measurement is worth the time and effort it takes to generate.
3. If you cannot explain in specific terms what a metric provides, then don’t measure it. 
4. If there is no organizational memory about why you are measuring something, then it probably makes a lot of sense to stop immediately.
5. If a metric does not fluctuate, either because it is always provides positive information or always provides negative information regardless of the amount of focused action, there is something wrong somewhere.  

POLQM Course 2012

Our course begins on January 11^th and we have closed admissions.  This is going to be a great year.  We have had a 20 percent increase in participant intake and our geographical spread involves North America, Central America, the Middle East and Asia.  It is truly an around-the-world experience.

I get a number of messages from this.  First, that the interest in Quality in the medical laboratory continues to grow and second this growth is not limited to one country or one region.   I could say that experience says that this growth and interest is tied to the use of ISO15189:2007 (Medical laboratories – particular requirements for quality and competence) as an international foundation for Quality in the medical laboratory, but my argument would probably be biased.  ISO 15189 was first published in 2003, the year before our course began, so it would be more fair to say that the two have grown up together. The reality is that the course offers a broader view of Quality than just international standards.

Growing up or maturing is a good way to think about our course.  Over the years it has continued to evolve.  When we started it was mostly about international standards.  Over time we built in discussions about the Quality tool box (including Lean and Six Sigma) and Quality Partners and Costs of Poor Quality.  This year the addition has to do with Quality and sustainability and a bit on the US system known as Clinical Laboratory Improvement Amendments (CLIA)  In many ways the course today is very different from what we offered back in the beginning. 

On a technical side we have gone through 3 versions of course software, each with its own improvements.  And this year we are adding in private viewing course video clips via YouTube to help the course continue along a progress line. 

So to be fair, and albeit a little biased,  both technically and content wise the course is not only different, it is better.

To that point over the last few years we have offered a variety of renewal options for folks that took the course in the early years and who continue to be engaged in Quality management.  To date there have been no takers.  I could interpret this as a negative, but in the absence of information I prefer to interpret this more positively.  Because our course is less about a specific how-too and more about reading and thinking and engaging in conversation we strive to create a community of folks who do progressive learning.  By remaining in contact with the folks from their group (I know that happens) the group continues to teach itself.  Thus the reason that they do not feel the need to come back to us for a refresher is because they are doing that on their own. 

I understand that point of view.  While our course is not unfairly priced, it is not free, and for many getting access to education support is harder than it should be.  If money is going to be spent to upgrade knowledge, there should be an upgrade in qualification.  So with that in mind, we are making a lot of progress towards the University of British Columbia Masters in Laboratory Quality Management (MLQM).  I see this as an option to others Masters programs that the university offers including a Masters in Business Administration, a Masters in Health Administration, and a Masters in Public Health and a Masters in Management in Operational Research.  Some might see these as competitive but I see them as complementary, each with a different focus but all bringing a new dimension to Health environment. 

The UBC MLQM will be a two-year program of education, experience and research.  It will be available both as a primarily on-line and a primarily on-site experience suitable for people with backgrounds in Quality, administration, technology and medicine.  The Masters qualification will have the ability to lead to a PhD.

If we stay on track we will start to intake participants either in the fall of 2012 or the spring of 2013. 

Bottom line:  For those interested in learning more about Quality with a medical laboratory focus, there are now options which over the short term will grow.  The notion of learning on ones own or on the job or off the side of the desk is pretty much unnecessary, and might I add, not optimal.  We can do it better.

PS:    Registration for the 2012 UBC Certificate Course is now closed.

Quality Teaching Aids

As much as we know that folks interested in laboratory quality are mostly adults with a focus on learning, we are also aware that adult learners just, just like kids, get bored easily, and bored folks stop learning.  Educators need to have a well stocked tool box filled with all sorts of education assists.

Word Searches work at almost every level as one way to introduce vocabulary.  Crossword Puzzles work to reinforce vocabulary.  Word Quizzes are another variation.

Attached, for your entertainment is Medical Laboratory Quality Word Search.     Print it out and enjoy.  It may take a little while to complete.  One way to prevent against boredom sneaking in is to set a time limit  (10 minutes) and see how many words can be found.  
This was created using a free-on-line teacher resource at http://tools.atozteacherstuff.com/word-search-maker

PS: I can't find DEMING.  If you find it, let me know where it is.

A different view of RISK

Previously I mentioned Management Mythbuster by David Axson as a great read.  I still support that.  But it is important to say that David Axson is not a laboratorian and he did not write the book as a guide to medical laboratory quality.  So that creates a challenge; how to find useful information that has applicability across the broad spectrum.


Take the topic of risk. 
Medical laboratories carry all sorts of risk.  Although Axson does not classify risks in this way, I can, by extension from the chapter, put together the following:

• Patient risk: for example when a test is easy to perform and is repeatable (verifiable) but the test results have no discrimination value to document or diagnose pathology or wellness (not validated). This would also apply to the opposite (validated but unverifiable, or insensitive or non-specific).
• Innovation risk: if a new piece of equipment obtained to perform the test proves to be unstable or unreliable or inefficient.  (Another version of innovation risk is when you sink a lot of money into a piece of equipment or assay only to find that the next new-and-improved version comes out two years later)
• Organizational risk:  when inappropriate policies get introduced, or the very opposite.
• Community risk: where a procedure or a reagent or equipment can constitute a safety risk to staff or the public. 
• Reputational risk:  Even in the public sector a black eye is a still a black eye.  Think about those jurisdictions that have been tainted by tumor marker or HIV and Hepatitis B or infection control scandals.  All too often the reputation damage goes on for years making it tough to get but public confidence or to recruit the staff that you want.  And the staff whose names get tied to a mess can pretty much shrink their expectations for an upward career.
• Financial risk: associated with investing in equipment to perform a specific test only to find out that either the test has no interest for users, or there is lots of interest but the insurance bodies decide that the test will not be reimbursed. 
• Fiduciary risk: when things go sufficiently wrong to the point where all sorts of bad legal things happen. 
• And risk from the unknowns:  (Think Donald Rumsfelt – there are the known risks, there are the risks you know but don’t have information, and then there are the unknown unknowns where you don’t know what you don’t know).

Taken as a whole you could argue that taking on new tests and new equipment and new personnel can generate enormous risk, but in my experience many laboratories create all sorts of problems for themselves by being attracted to new tests or procedures based more on the number of bells and whistles than on risk assessment.  Business cases rarely take into consideration any acknowledgement or awareness of potential downside risk.


With respect to the unknown and unplanned, Axson writes that bad things happen all the time and “success …is more about how [organizations] deal with the unplanned adverse events than how you execute when everything is going smoothly”. 


Axson makes a number of points that I think not only apply to the business world, they apply to medical laboratories as well. 

1. If you are taking on a new project, try to plan not only for traditional risk, but think also about non traditional considerations as well (reputation, environmental impact).
   
2. Risk management is more about preparation than it is about reaction.  If you aren't looking for bad outcomes, then you probably won’t find them until it is way too late.  You may not know why problems are developing but if you know the problems are occurring (and increasing?) you can jump into action.
   
3. When bad things happen, success can be much about quickly identifying and correcting bad decisions. Have some sort of contingency plan structure available.  Have the courage to admit mistakes and quickly take corrective action.

All in all a fresh new look and an old problem.

Originally written December 26, 2011.  Updated July 10, 2012

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.

TDG - a call to action

Sometimes they just get it wrong.

I have been reflecting on a truth that I have held about laboratory Quality (and Quality in general) that the greatest mover of quality is an angry public and the actions of the public action arm (the media, legislators and the litigators). We have good examples of this.  The Clinical Laboratory Improvement Act and Amendments would never have occurred if the public had not been outraged by poor PAP test readings.  The Cameron Commission would not have demanded Newfoundland laboratories start along a quality improvement path if the public had not been aghast at the incompetence of laboratory diagnosis.  There are all sorts of examples that make the point.

But recently I have been aggravated by the other side of public engagement in laboratory decision making when it drives excessive utilization and huge TEEM* expenditures with absolutely no tangible benefit.     

Transportation concerns.  For programs like proficiency testing programs, or clinical laboratories sending samples to reference laboratories, or research sending samples, in particular microbial samples, a major concern is the cost and procedures required to ship a sample container.  This is one of the best examples of governmental excess response to public unknowledged anxiety.  (Unknowledged anxiety is the easy but inappropriate over-response of the public or its representatives to perceptions of risk or danger predicated solely on myth or misunderstanding.    

Any laboratory that is involved in long distance transport of samples by road, rail, ship or air learns about “Transport of Dangerous Goods” regulations, affectionately known as TDG.  In order to send a simple sample one needs to have specially trained and certified personnel, access to special packaging materials, special labels, special way-bills and then pay really outrageous transport surcharges on top of already expensive regular shipping fees.  It is the perfect example of lost time, effort, energy and money. 

I would like to be able to say that all this TEEM is well spent, but the reality is that it is not.  It is near impossible to find even a single accident that all this regulation has prevented. 

I have been railing against the TDG impediment for a long time.  I have been involved in transport issues since the late 1970’s and have been engaged in trying to modify regulations since the mid 1990’s.  In Canada, I have had some successes, but we still are plagued by huge costs and lost time.

Over the years in my program we have shipped approximately 40,000 boxes containing proficiency testing materials without a single reported leak, damage, or exposure event reported.  For programs like UK NEQAS or CAP the numbers would likely be 100 times that much but again one can’t find any examples of published exposure events.  But in the meantime this is costing our laboratories collectively millions of lost dollars.  Even if we push the cost on to the receiving laboratory it is still lost dollars. 

We have performed and reported upon and published transport studies looking at the risks associated with leaks and damage.  We have studied other contributions to the literature.  And we have come to the clear conclusion that the levels of risk are completely theoretical. 

I calculated the risk of an exposure being about 1:250 billion over a 10 year time with adding in estimated under-reporting raising the risk to 1:2.5 billion.  These are both below the level for calculating a risk sigma value.  In addition, for transport that may cross an international border it can cause delays of near a week, which can cause all sorts of sample damage. 

You might argue that what we are doing protects us from illicit exposure to dangerous pathogens, but of course that would be wrong as well because the true illicit plan would be to purposefully NOT add the markings.   Truth be told it would be impossible to know how many samples are transported without any markings.

A few years ago I had a discussion with a senior person in transport administration when the comment was made that if one of my packages containing live organisms was to fall out of the sky from a damaged airplane, then I could be held responsible for an outbreak.  When I commented that the jettisoned jet fuel or lost metal parts from said damaged plane would be a much bigger concern, there was not even a crack of a smile.  And my comments about the risks associated with falling body parts only made things worse. 

So what does all this have to do with Quality?  Well clearly the first job of the Quality Manager is to take their lumps and make sure that TDG training and certification is up to date.  Make sure that the packaging is correct as well as the labelling and resultant paper work.  While you probably would get away without it, the TEEM costs of getting cost would be infinitely worse.

But knowing that TDG is driven by myth and misunderstanding creates an obligation and knowing that the incumbent costs in time and money and potential damage to samples is a call to Quality arms.  Engage your colleagues and start a letter campaign or better yet, a telephone campaign.   Apply pressure, respectfully but directly and with reasonable force.  Seek the exemptions possible as described within the regulation.

Giants of Innovation

I have been ruminating upon this for several weeks, and so I apologize for being late out of the gate. 

By now everyone is aware that Steve Jobs passed away on October 5, 2011 as did October 11, six days later.  I have, like most, known of both men for years, but never had the opportunity to meet either.  I am saddened by the loss of what these two giants represent, the faces of American innovation.

Robert Galvin was the President and CEO of Motorola, the company that created “wireless world” first with the walkie talkie* and then the cellular phone, and then the cellular phone network.  Steve Jobs had the vision to see the power of these incredible tools and developed his communication powerhouse accordingly.  Jobs’ early computer, the Apple II, was built around the Motorola 6502 microprocessor, and the MacIntosh was built around the Motorola 6800.  Had Motorola not created the foundations, there would be no iPhone, or iPad, or iPod. 

I imagine that these two men knew each other, probably very well.  This adds a certain poignancy to the two deaths.  Indeed one can forgive me for “seeing” their companion deaths as being somewhat akin to the death pairs of close life partners.  That being said, I suspect that it would not have been a particularly “happy union”; the two particularly did not care much for each others company.  They were apparently very different people with Galvin being a warm family man with many hobbies.  Two day the two companies spend a lot of time in the law courts around the world.

So why am I writing about this?  First off, the obvious; Robert Galvin and his link to Quality through Motorola’s development of Six Sigma.  Galvin did not invent Six Sigma, it was the creation of Bill Smith and Mikel Harry, a modern inspiration derived from Shewhart and Demining and Ohno.  But Galvin saw the power of the new language and measure tool based on defects per million.  Galvin had the vision to promote this revitalization of the quality movement.  The characterization of a sigma metric of 5.5 versus 4.1 has provided quality oriented minds a whole new appreciation of the power of simple expression of complex values.

But equally important is the lesson the innovation has many approaches and many faces, and all of them move us forward.  One does not have to invent a new industry, one only needs to see it and improve upon it.  And even if you see the iPhone as perfection, I think what is more important is how it has inspired the next wave of even greater perfections. 

I suspect that neither Galvin nor Jobs thought much about the medical laboratory (well probably Jobs did), but these two innovators are directly responsible for most of our evolution over the last 35 years.  (I set up my first crude laboratory information system on the Apple II).   Near every aspect of what we do, in near every laboratory in the world, benefits from these giants of innovation.   All I can say is “thank you”.

*      A sort of personal interest note: Robert Galvin hired Daniel Noble as the engineer to develop the walkie talkie.  I am unaware of any connections between my family and his.

Policy and the Law - word games?

The word policy is one that requires definition.  According to ISO9000:2005 (fundamentals and vocabulary) the term policy means an “overall intentions and direction of an organization as formally expressed by top management”.  Well if that's how it appears in ISO9000, that must be right. 

But I must admit that I take the definition a bit little further.  I think of policy as a statement of principle established by top management that serves as a foundation for action (processes and procedures)  implemented for meeting the requirements.  Policy exists to answer the question “why do we do that?” 

An example would to address the question “why do we do proficiency testing?” with the statement “because we have a policy that says that we monitor our performance in a variety of ways including PT to ensure that we are meeting Quality expectations” rather than “because we do” or “because I told you so”. 

(I once asked someone in my training days why we always treated all children in a specific way and receiving the answer “we do it that way because that is the way we do it”.)

As opposed to the traditional view of policy, as the apex of a triangle above process and procedure, I tend to think in reverse with policy being the roots that provide nurture and foundation throughout the Quality Tree.

Policy is a form of a top management  instruction or guidance or rule.  Taken one step further policy is a form of  law. 

I mention that because recently I have been reading an English translation of an old book by Frédéric Bastiat entitled “The Law” (Ludwig von Mises Institute, Auborn Alabama).  

Bastiat was an early French economist writing around the time of part of the French Revolution in1848.  (note: many are aware of the first French Revolution of 1789-1799, but know less about the revolutions in 1830 and  1848!)  In many respects the conditions in France of 1830 and 1848 had a lot of similarity to recent events that have led to the “Arab Spring” and the “Occupy Movement”, so reading Bastiat today is not solely of arcane interest.  Lessons may still apply.

In any event, I did a little experiment. 
I took an available electronic copy of an English translation of  “The Law” (The Foundation for Economic  Education, Inc. Irvington-on-Hudson, New York)  and did a global search and replace changing the word “law” to “policies”.  I then scanned the product and adjusted for grammar.

The results by and large were what you might expect when you start to fiddle with words; a lot of nonsense sentences.  For example:

·        policy is the organization of the natural right of lawful defense (?)

But there were a number that had a certain resonance and relevance.  These include:

Policies cannot operate without the sanction and support of a dominating force, this force must be entrusted to those who make the policies.  (meaning policies are useful if they are understood to be by the authority of top management).

·        It ought to be stated that the purpose of policies to prevent injustice from reigning.  (meaning the reasons that we write policies is to ensure consistency and prevent certain unfairnesses.)

·        Policy is the common force organized to act as an obstacle of injustice. In short, policy is justice. (see above).

·        In this matter of education, policy has only two alternatives: It can permit this transaction of teaching-and-learning to operate freely and without the use of force, or it can force human wills in this matter… (meaning we should use policy as an educational approach for training ).

Additionally there was one that I found particularly interesting:

 “Policies … have acted in direct opposition to its own purpose”. 
It is not uncommon for folks to have a bad event, maybe a problem with a customer complaint or a lost sample.  In the process of remediating the problem and then starting a corrective action, there is a moment where someone decides that the laboratory needs a new policy like “samples collected on the week-end shall only be collected by an on-call technologist”.  That solved the problem until folks everywhere started seeing an easy way to have samples collected at the laboratories on-call expense.  All of a sudden the policy has created a whole new problem which would have been averted if someone had taken a moment before announcing a new policy. 

All this being said, I acknowledge that this is a bit of a “geek game” playing with words and creating new interpretations.  Not everything is a pearl.  But taken in the spirit by which it was intended, there are some grains of useable message in the exercise.

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.