Challenge the Intuitively Obvious

The Challenger     (Image credit https://blog.historicenvironment.scot)

We all know Murphy's Law that states that if something can go wrong it will.
After that law became famous, a number of clever people added to "Murphy's Laws" and I've even seen books about Murphy's Laws. It is very true that "You always find something in the last place you look."  One that I read that has relevance to this blog post is, "In any accounting problem, the source of the error is the figure that is obviously correct."

Without being aware of it, our lives can be driven along a path where most of the decisions we make and the actions we take follow the line of least resistance. This line is usually bolstered by assumptions that we make, and the greatest assumptions are the ones that appear to us as obvious and self-evident, without any need for reasoning or logic. In other words, the "intuitively obvious".

The intuitively obvious pops up in different areas of our lives without us even noticing: parenting practices, voting choices, business strategy - to name a few.

Parenting

I know someone who grew up in a place and time where it was normal and expected for parents to discipline their children with corporal punishment, whether the bare hand, a belt or rod or paddle. Their religious upbringing reinforced this with the proverb, "Spare the rod and spoil the child." It was held intuitively obvious that if children are not physically punished when they do wrong, their character and behaviour development will suffer. It was not really until psychology studies were clearly demonstrating a link between aggression in children and aggressive parenting styles, and between later life behavioral problems and childhood physical discipline, that societies slowly started to question and reject what had been intuitively obvious for generations of parents and disciplinarians.

Elections

One of the problems about the intuitively obvious is that it is usually driven by our feelings. We stick with whatever we feel comfortable about and avoid what makes us feel uncomfortable or anxious. For many people this manifests when it is time to vote in an election. A large number of people vote for the same political party all their lives. They started voting that way because that was how their family voted and voting that way became part of their self-image. If you question them, very often you find that they actually know very little about the various party platforms. More often there is merely an enduring belief about one or two particular areas of policy. You hear statements like, "Those guys can't be trusted with the economy," or "Our party policy is based on a good moral compass." If you ask for evidence, whether on the left or right side of the political aisle, it is usually in short supply and you might even get a belligerent, adversarial reply.

Business and Professional

One of the differences between some smaller businesses and most larger business organisations is in the area of business and strategic planning. It does not have to be that way and a number of smaller organisations do engage in periodic strategic planning. Those that do not are at the greatest risk of following along the path of the intuitively obvious. This might work well for a while for any given small business, but the guarantees are no better than for relying on the intuitively obvious for our parenting style or our political decisions. In fact, the prospects are probably worse because, being a small business, you do not have the protection of the herd.

But even many large businesses fall into the trap of the intuitively obvious by presuming you can increase urgently needed profits merely by cutting immediate costs, usually by laying off staff. That is a short term trap. Why? Because it is not sustainable over the long term. You cannot sustain sales and revenue without maintaining quality of products and services. And you cannot maintain a consistent standard of quality without retaining a sufficient number of the right people for the job. W Edwards Deming used to say, "If you want to increase profits then improve quality of products and services."

Perhaps it is time to identify, challenge and probe the 'intuitively obvious' in your own personal and professional life?

Long-Term Care Homes Were Short-Staffed Before Coronavirus

There is so much more to improving quality than increasing inspections - and inspections need to focus on what really matters: management responsibility. In the Sixties, Seventies and Eighties of the last century W. Edwards Deming was teaching auto manufacturers that you cannot inspect in quality, it has to be built in. Catching defects at inspection is too late. The Japanese listened and their auto industry overtook the American industry in quality, sales and profits - in that order. Quality drove sales which in turn drove profits.

Nathan Denette/Canadian Press

Conducting Internal Audits for ISO 9001:2015

I recently received an email from a newly trained lead auditor asking for advice on conducting an internal audit. He was totally focused on a massive and detailed checklist for identifying gaps with ISO 9001:2015. When one receives ISO 9001:2015 lead auditor training, they generally teach you how to do Third Party audits - and little else. Therefore, it is a common but understandable mistake for newly trained lead auditors to conduct internal audits as if they were conducting a certification or surveillance audit by a 3rd party auditor. I know, because I did it myself for a while. So, here is a handful of important considerations to make your first internal audit less daunting. Or, if you have been treating your internal audits as mini certification audits then there is something here for you too.

The Quality Management System (QMS)

If your organization is, indeed, ISO 9001 certified, then an accredited auditor has certified that your QMS is ISO 9001:2015 conformant. You do NOT have to do that all over again. What you have to do now is verify - from evidence - that the people in your organization are executing on the procedures and processes that are laid out in your Quality Management System (QMS). It should go without saying that you need to be familiar with your organization's QMS, and the roles and responsibilities defined in its processes.

Internal Audit Process

First off, your QMS should have procedures and processes covering internal audits. You need to conduct your internal audits in conformity with that. If those procedures/processes are deficient then you should write up an appropriate finding. The audit process as laid out in your QMS should include something about having a schedule of internal audits. A good practice is to have an internal audit every quarter of the year where each audit covers at least a quarter or more of the QMS. Your internal audit should follow a plan that you, the lead auditor have drawn up based on  the scheduled content of internal audits. This plan is reviewed and approved by top management in the organization before the opening meeting of your internal audit.

Corrective Action (CA)

An important item to be audited in each audit is to follow up on corrective actions for nonconformities (NCs) found in the previous audit. Your QMS should have one or more processes defined for the handling of corrective actions. Is your organization following that process? NCs from previous audits, especially 3rd Party audits, are the most important corrective actions to follow up on, but a sample of other NCs should be reviewed as well, especially those originating from customer complaints.

Sampling

You cannot audit every single operational thing that an organization does. Have a system of sampling. This could be random sampling where, for example, you throw dice for your starting point and then take every Nth instance to ensure a certain percentage coverage; or risk based, where you focus on items that are safety related or that suggest financial risk if not performed satisfactorily. For random sampling I like to use Random.Org. (https://www.random.org/)

Nonconformities

When you think you have found a nonconformity (NC), be very clear in your own mind what the requirement is in terms of your QMS process. If the QMS states: "Document the customer's training needs in such-and-such a file in the customer's folder" - and this is simply being held in someone's emails instead, then write up your finding clearly showing where the requirement can be found in the QMS - chapter and verse. Somebody following in your footsteps should be able to locate the same evidence that you used and reproduce your findings and, from the evidence, come to the same conclusion as you did. As far as possible, without being argumentative, the manager or lead responsible for the process should be in agreement that the requirement has not been met.

Transparency

Remember, an important rule of auditing is that an auditor may not audit their own work. If you are the Sales Manager in the organization, or in charge of Quality Control, then you may not audit those departments if you have performed or signed off on any of the work that is being audited. This means that you will need to train one or more other people in your organization to be part of an audit team which you would lead. They do not need to have Third Party Lead Auditor training; they do need to have some introductory training in the requirements of the ISO 9001 standard and familiarity with the QMS. To preserve their freedom to audit without fear of repercussion, they should not be in your reporting structure. Even if you are well respected, there should be no perception of a conflict of interest. When you move on, your replacement in the organization may not be such a nice person as you. In the meantime, while you are the only auditor, you can begin auditing other parts of the organization. For all the same reasons, it is not a good idea for you to interview personnel who report directly to you.

The Audit Report

Look for the positive - where people are doing a good job, and where the QMS is working well for the organization. Make sure that this comes out in the beginning of your audit report. Very importantly, remember that we AUDIT THE SYSTEM, NOT THE PEOPLE. If there is an NC it is because the system has allowed it to happen. Ensure that people associated with an NC are given an opportunity to explain why it might not be an NC, or that they agree that it is, indeed, a nonconformity. They will, in all likelihood, be involved in the corrective action and so the organization needs them to be on board during root cause analysis.


Have you watched my video, A Common Mistake in ISO training?
Nothing else that I can tell you is more important that what I say there!

"EVERY SYSTEM IS PERFECTLY DESIGNED TO GET THE RESULTS IT GETS"

- W. Edwards Deming quoting Arthur Jones.

Does ISO 13485 imply that a medical device is proven effective?

I received the following question from someone who viewed my video What is ISO 13485 for medical devices?

If a product has ISO 13485 certification, it means the product is of high quality, trustworthy, and reliable enough to be used as a medical device in any hospital / medical setting - correct?

Does it also imply that its performance or effectiveness is proven too?


Here is my reply...

Remember, it is the organisation, not the product, that is certified. Once the organisation is certified, all product should be manufactured following due process according to the quality management system as laid out in the Quality Manual.

For me, if a medical device manufacturer does not have ISO 13485 certification then they do not warrant a second look. ISO 13485 should be the first requirement for supplier qualification, but certainly NOT the only requirement.

Having ISO 13485 merely gets a manufacturer to first base. It is not a home run. The customer needs to do due diligence to ensure the medical device truly meets all requirements that are critical to quality for their use including, if appropriate, satisfactorily passing a supplier (2nd party) audit.

6-Sigma DMAIC - What Happens Before Define?

A prerequisite of any successful 6-Sigma DMAIC project is that the project be aligned with the strategic vision, goals and objectives of the organization.

What comes before the 'Define' phase is the selection of the most appropriate project to take the organization along that road.

Project proposals will define the problems at a high level: why is this a problem?



If your organization does not have explicitly formulated goals and objectives aligned with a strategic vision, then you do not have the maturity to run a 6-Sigma project.

The WRONG Reason to Get ISO 9001:2015 Certification

Yes - This is the wrong reason because if this is what is driving your organisation to seek ISO 9001 certification you are in for a rough ride. This is one of the reasons why ISO gets a bad rap from companies: both management and staff.

How to Reduce Costs

In the words of the master, W. E. Deming:

Image credit: www.azquotes.com

You cannot decrease costs by focusing on the costs: decreased costs are a by-product of quality and productivity. "Improve constantly and forever the system of production and service, to improve quality and productivity, and thus constantly decrease costs." - W. E. Deming

DO NOT BLAME THIS ON HUMAN ERROR !!!

"We're working proactively to address this as quickly as possible." 

Canadian navy ship spills 30,000 litres of fuel in Strait of Georgia

No, Sir. You cannot address an event proactively after it has happened. That is working REactively and is technically called a CORRECTION.

You can, and should, work proactively to prevent that exact same event recurring on that or any other vessel of the Canadian Navy. Technically, this is known as CORRECTIVE ACTION. If you decide that it was human error (as opposed to sabotage or bloody-mindedness which is deliberate,) then you have to ask, "What was missing in our procedures that allowed this human error to occur?" ...and then change the operational procedures accordingly. That would be the corrective action.

The fault is not with the seaman who screwed up, but with naval command who let that screw-up happen.

If this has never happened in a foreign navy but they, hearing about the Canadian debacle review their operational procedures and make changes to prevent such a thing happening in their navy, that is working proactively and is technically known as PREVENTIVE ACTION.

PLEASE DO NOT BLAME THIS ON HUMAN ERROR !!!

Photo: cbc.ca

Have you "made it to the top"?

The following is a post in LinkedIn by Ahmed Hafez, Business Development Manager for Interface HCP, reproduced here with permission of the author.

I called a candidate about a new opportunity.  It was a promotion from his current role, and he had the right skills and qualifications.

"Sorry but I'm not interested," he politely said.

I pressed him on it until he said something that really confused me.  He told me that he "already made it to the top".

I was familiar with his current company and looked at his CV again.

He wasn't anywhere near the top.  He would have needed binoculars to see the top.  He wasn't even a manager yet.

He explained to me that "making it to the top" for him meant he loved the exact work he did each day, he loved his company, he was treated fairly and with respect, he made enough money to be comfortable, he had excellent benefits, he had flexibility, and most importantly to him, he's never missed a single football game, school play, parent-teacher conference, anniversary, birthday, or any family event.

He knew what taking the next step in his career meant.  More time, travel, and sacrifice.  "Not worth it," he said.

Your definition of "making it to the top" doesn't have to be society's or anyone else's definition.  You Do You.

From the post in LinkdIn by Ahmed Hafez, reproduced here with permission.

Is saying, "as a goodwill gesture…" really an apology?

By now the whole world knows about Doctor David Dao who needed hospital treatment after being dragged off a United Airlines flight.


And many of us, meanwhile, will have heard that United Airlines again allowed too many passengers to board a plane, this time on a flight from Houston to Boston, resulting in a mother having to hold her 27 month old son on her lap in violation of FAA safety guidelines. The mother did not protest too strongly because she "did not want anyone to get hurt," the experience of Dr. Dao still fresh in her memory. (You can read about that here.)

This is the statement from United Airlines on this most recent event as reported by ABC News:

https://hub.united.com/sp/purposes/

"On a recent flight from Houston to Boston, we inaccurately scanned the boarding pass of Ms. Yamauchi's son," the statement read. "As a result, her son's seat appeared to be not checked in, and we released his seat to another customer, and Ms. Yamauchi held her son for the flight."
It continued, "We deeply apologize to Ms. Yamauchi and her son for this experience. We are refunding their tickets and providing compensation as a goodwill gesture. We are also working with our employees to prevent this from happening again."

From my experience in quality management, albeit in healthcare and design, development and production, allow me three general observations with lessons beyond the airline industry.

1. "… working with our employees to prevent this from happening again."

Put very simply, United Airlines top management have just thrown their employees under the bus but, not to worry, management will work with their employees to fix the problem. Read: we will give the employees concerned a dressing down and explain to them how they screwed up - in words they can really understand!

One of my quality heroes is Dr. W. Edwards Deming who was passionate about not “blaming” workers for poor quality when so much of the problem was because "the system" allowed it to happen. It is top management who are responsible for the system. Maybe one or more workers did screw up, but the fact remains that the system allowed too many passengers to board the plane, and this mere weeks after their experience with Dr. Dao. "Working with their employees" might help somewhat, but it is even less of a guarantee once there is employee turnover and a new crop of employees takes over. The problem is in the system more than with the employees. That is a management responsibility.

https://hub.united.com/sp/purposes/

2. Violation of FAA safety guidelines

Hello?  Is anybody listening? Does anybody care? A cabin crew member of my acquaintance decades ago told me that the most important responsibility of cabin crew is the safety of passengers. Has that changed? The element of safety is completely lacking in the reported statement by United Airlines. The fact that no serious injury occurred is no excuse for placing the child at risk - something that the system did not prevent from happening.

3. "… providing compensation as a goodwill gesture."

Let's not play with words. Compensation is something that is due, either for work performed or as a recompense for loss, injury, or suffering. It is an insult to say you are paying compensation "as a goodwill gesture." It is also an implicit denial of responsibility for the loss, injury or suffering for which compensation is being paid. The depth of the apology ("We deeply apologize…") is revealed as actually being very shallow indeed.

The four words, "as a goodwill gesture," are also a huge PR gaffe. I have no reason to suspect that top management at United Airlines really have the importance of their customers as people at heart, that customer satisfaction has any value beyond dollars and cents. In fact, I doubt that they would even understand the intent of this paragraph.


In my opinion, if United Airlines really wants to improve as a company, their top management needs to have an attitude transplant to understand what it means to be responsible for the system and the inter-related processes required to ensure the quality service it is supposed to produce.

Internal Audit Question: What about out-of-scope NC's?

So your company is certified to ISO 9001:2015 and you are the lead auditor on a team of two for an internal audit. The scope for this audit is Planning (Clause 6), for which you are interviewing, and Operation (Clause 8), for which the other auditor is interviewing. On reviewing the records for Design and development inputs (8.3.3) the other auditor finds that the latest specifications have not been reviewed and approved as is required in the Product Design SOP and writes up the following:

Requirement	7.5.2(a) When creating and updating documented information, the organization shall ensure appropriate review and approval for suitability and adequacy.
Finding	Nonconformity
Evidence	Interviewed Engineer Abel Baker. Sampled design specs for Project "Daisy Chain". The following design records have not been reviewed and approved: DES-677, DES-678, DES-679.

The Engineering Manager cries foul, that the finding is out of scope.
What do you do?

This case is easy because the requirement for review and approval is stated in the company's own requirements for its quality management system: the Product Design SOP.

Internal audits are mandated by clause 9.2 of the ISO 9001:2015 Standard which states in 9.2.1:
The organization shall conduct internal audits at planned intervals to provide information on whether the quality management system:
a) conforms to:
1) the organization’s own requirements for its quality management system;
2) the requirements of this International Standard;
b) is effectively implemented and maintained.

The Engineering Manager was half right. The N/C as stated was, indeed, out of scope. Nevertheless, it was an N/C, but against the organization’s own requirements for its quality management system. The wrong requirement was stated by the internal auditor.

Third Party (CB) auditors have to audit to the Standard - whichever standard they are certifying to. But it is a mistake to think that internal auditors have to audit in the same way as third party auditors and always quote a requirement from the ISO Standard. The Standard merely states WHAT is required. It is the Quality Management System (QMS) in the form of a Quality Manual (QM), Standard Operating Procedures (SOP's) and Work Instructions (WI's) that describe HOW the requirements of the Standard will be implemented in the form of integrated processes.

On certification the CB auditor has already declared that the QMS effectively implements the Standard. Really, employees of the company, including internal auditors, should only have to worry about the processes documented in the QMS.

Simplify Clarify Control

The banner maxim for my company, tcmc Quality Management Services, is Simplify Clarify Control. This is not just meant to look good as a catchy slogan: it is what I really try to help my clients achieve and the way I operate and do what I do.

Simplify

You simplify by having a standard process for each of the value-adding steps of your core operations, ensuring that these integrate into one system that provides defined products and services.If you can identify busy work that does not add value for your customers, try to eliminate it or minimize the impact on your organization's resources.
As importantly, simplify the work environment and resources by applying 5S:
Sort: sort everything into one of Retain, Return, Rid
Straighten:  a place for everything and everything is in its place.
Scrub: clean everything regularly.
Systematize: have maintenance schedules and systems to keep it this way.
Standardize: create a culture with new habits for keeping things simple.

Clarify

You clarify by ensuring that every value-adding process has assigned roles and responsibilities and that everyone in the organization clearly understands and takes pride in their own roles and responsibilities: who their customers are, who their suppliers are, why they do what they do and why that is important.
Customers and suppliers are not just external to the organization; in fact, for most employees, their customers and suppliers are within the organization itself: who is the first recipient of my work output? That is my customer. Who gives me raw material/components to assemble - whatever I have to add value to by transforming into something for my customer? That is my supplier. How do I get along with my own customers and suppliers? Is there good rapport and mutual respect?

Control

Senior management controls by measuring and monitoring the performance of key, value-adding operational processes, setting SMART objectives that align with the strategic direction of the organization and its stated policies and mission.
SMART objectives are: Specific, Measurable, Attainable, Relevant and Time-bound.

Reap the reward - Quality

If you do the above for your organization - simplify, clarify and control - you should find greater predictability and quality in your products and services, less waste, improved morale and, most importantly, happier customers.

Regulatory Compliance is Not an Alternative to a Culture of Caring

This article appeared in today's Toronto Star:

Watchdog raises alarm over restraints used on children in care.

The article is on  a new report by Ontario’s Advocate for Children and Youth into the province’s (troubled) system of residential care with the subline: Confused, incomplete reporting of serious incidents makes it hard to know if guidelines on restraints followed, children’s advocate says.

Many people, both inside and outside regulated care organizations such as those for foster and group homes for youth, for people with mental health challenges and for seniors, confuse regulatory compliance with quality care. There is an assumption by outsiders, including governments, that enforcing regulations with inspections and a big stick will achieve the standard of care needed for vulnerable populations. Such people, and many inside these organizations - management and staff - who should know better, insufficiently grasp the important role of organizational culture for achieving a quality standard of care. Many managers and staff don't know or have forgotten why they're there and so, not being mindful of why they should do what they have to do, they take short cuts for convenience, defeating the purpose of the regulation or quality standard.

On top of it all, they are under-staffed and misunderstood which exacerbates everything.

Yes, we absolutely need adequate inspections for regulatory compliance, and getting further certification and accreditation to standards can also help, but we also need senior organizational leaders with vision who understand what Peter Drucker meant with his now famous quote, "Culture eats strategy for breakfast." If changing the culture is not part of the strategy, the strategy is doomed.

Why do I do what I do?

People ask me, what do you do?

When I wake up in the morning, what I want to do is make the world a better place. Most of us, if not all of us, walk around with problems, some personal, but also many business or professional. What fires me up professionally is to help leaders in small and medium size organizations approach their problems as challenges, as fish to be caught, and then help those organizations fashion fishing rods or fish nets for themselves to catch these fish and turn them into opportunities; opportunities to make their organization, including their staff, more successful in achieving their vision and objectives, more successful in meeting and exceeding customer and client expectations and, as a consequence, more profitable.

How do I do this?

Credit: advisera.com

I am a big believer in process; namely, a consistent way of taking things as input, and turning them into some valued output, whether as a product or service. When you break it down, any enterprise uses a system of processes to do what it has to do - whether those processes are formal and written, or informal and intuitive. I have yet to find a production or service problem that cannot be tied back to a process. What I do is help organizations improve their system of processes to be more effective and efficient, and to eliminate or mitigate problems, especially problems that lead to client or customer complaints.

Beyond the short term, the cost of improving process effectiveness is a lot less than the cost of perpetuating a process that keeps spawning problems. It's a bit like the leaky tap or faucet: at some point the cost of water wastage exceeds the cost of repair and, at that point, the total cost is the cost of repair plus the cost of all the water that had been wasted in the meantime.


So that's what I do, and why I do it. If you would like to see whether and how your processes can be more effective and less wasteful, please talk to me. Let's continue the conversation and make the world a little bit better, together.
Leave a comment below or CONTACT ME.

Implementing ISO 9001:2015 – The Process Approach

Paul Simpson

In his excellent post, Implementing ISO 9001:2015 – The Process Approach, blogger Paul Simpson focuses on the ‘deep dive’ required to really understand our processes in order to capture them accurately.

"We’ve probably all seen the extremes – on the one hand perhaps a wall full of mind sapping detail, on the other a series of banal boxes neither helping staff and leaders.  So this quote, ‘Everything should be made simple as possible, but no simpler‘ attributed to Albert Einstein, is a useful stimulus in thinking about making process analysis useful, and to help ISO 9001:2015 registration.

"The point of analysing our processes is to ensure we understand how each process works and what we need to do as individuals, leaders and organisations to ensure the process operates efficiently and delivers effectively."

"We have to break each process down into as few simple steps as possible based on our experience of how they work in real life. And we must ensure that we understand their relationships and contribution to the other processes in the overall system in generating outputs for the customer."

Read the full post here: Implementing ISO 9001:2015 – The Process Approach

ISO 9001:2015 - What are the BIG CHANGES?

What are the big changes in ISO 9001 2015? Don't get trapped in the weeds as you transition from ISO 9001:2008 to ISO 9001:2015.

The "Gemba Walk" Pope surprises an Italian family with a Christmastime call

According to an article in the LA Times, when Pope Francis was still an archbishop in Argentina some years ago the archdiocese had a limo that that he could have driven around in. Parishioners of Our Lady of Caacupe tell how, instead of taking the limo to get to the church, he would take the bus and then walk half a mile to the church operating out of a converted warehouse. People knew him and would walk with him. "Once I met him at the bus stop and offered to carry his briefcase the rest of the way, but he wouldn't hear of it," said Monica Morales, a church volunteer and mother of six.

Fast forward to December, 2015. The Pope, who sometimes eats in the staff canteen and who already has a reputation for occasionally picking up the phone and calling ordinary people, repeats the surprise, calling a family whose little boy had written him out of concern for his ailing aunt. He is reported to have had a 15 minute chat with the boy's mother, putting her at ease and enquiring about the family.

The Pope has probably never heard of 'gemba' or 'genchi genbutsu', but he sure knows how to practice it. Cynics might argue that this is just a PR stunt. I cannot prove that it is not. However, in none of these events has the publicity come from the papal marketing department; it is the people that he touched who went public, directly or indirectly. Vatican comment has always been very muted about these incidents. In my opinion the Pope sees this as a two-way street the value of which he learnt long ago in the barrios of Argentina. Sure, he is being a pastor and setting example, and so on. But he is also observing, engaging and learning. He learnt to deal compassionately with pastoral and moral problems not so much out of text books but by being close to the people who were suffering. He encountered the problems by engaging with the people who have the problems, listening to them, learning from them, empathizing with them.

Without going to gemba a manager is operating in an ivory tower. Who would have thought that the Pope has something to teach managers and CEO's?  Genchi Genbutsu. "Go, Look, See". Then you will discover opportunities for kaizen improvements.

(With material from Religion News Service and Los Angeles Times.)

A Crisis of Junk Science

When the noble science of Science degenerates into junk science the ripples of scepticism resulting from feelings of betrayal and anger have the potential to become a tsunami.

"In the U.S., the Federal Bureau of Investigation admitted last April that hair identification testimony from its forensic scientists was flawed in 95 per cent of the 268 cases before 2000 it has reviewed so far. In 32 of those cases, the defendant was sentenced to death."

The above is from an op-ed by criminal defence lawyer, Daniel Brown, in today's Toronto Star.

Before Canadians feel too smug here's another snippet:

"Bad science is an alarming thread that runs through almost two dozen Canadian wrongful murder convictions exposed in recent years by the Association in Defence of the Wrongly Convicted (AIDWYC). The roll call of errors in these cases includes clothing fibres mistakenly believed to match one another; experts who incorrectly concluded that dog bites on a dead child were knife wounds inflicted by her mother; inept autopsies that misinterpreted the cause of death; biology samples contaminated by a government lab technician; and hair samples that anchored a murder conviction, yet later turned out to be worthless."

The only consolation for Canadians is that Canada does not have a death penalty. Innocent people have not been killed; they have simply languished in jail while their children were removed and placed in group homes, foster care or adoption.

In his piece, Brown observes,

"Wealthy defendants are able to afford top lawyers and expert witnesses, but indigent accused or those from marginalized communities frequently bear the brunt of bad science evidence. They cannot match cases assembled by well-funded police and prosecutors, sometimes pleading guilty to obtain a reduced sentence in the face of superficially overwhelming evidence."

The Alchemist by Pieter Bruegel

Brown makes some conclusions that I think are predictable and precisely to my first point about scepticism:

At precisely the time we ought to be exercising heightened skepticism, a mistaken belief is developing that wrongful convictions are a thing of the past.

And again…

Judges must be better trained to weed out junk science and unwarranted opinions offered by experts. And they must warn juries about the perils of placing too much reliance on science or picking sides in a battle of experts.

This reminds me of manufacturers relying on inspectors to 'inspect in' quality. As W. Edwards Deming pointed out decades ago, that is far too late in the production cycle and way too susceptible to error. Would we fly to our vacation spots knowing the plane we are on did not have adequate requirements and design review, risk and failure modes analysis, verification and validation prior to 'inspection'? Heck, let alone fly, we don't even allow cars on the road that have not been built according to this process, and yet we trust that our 'scientists' all use correct scientific methods and design of experiment even though they often do not bother with peer review. Hello?


Read the entire op-ed here: Junk science is undermining our justice system

Photo credit: http://www.wikiart.org/en/pieter-bruegel-the-elder/the-alchemist

A Look Back at the Early Days of Lean

Dr. W. Edwards Deming

This fascinating article, A Look Back at the Early Days of Lean  by John Dyer was published by Industry Week back in September. John is one of those people who was lucky enough to have done a (now famous) 4-day seminar with Dr. W. Edwards Deming.

The article contains seven of John's favourite quotes by Dr. Deming and a link to a very informative podcast that he did with Mark Graban.

Here are 3 of his Deming quotes that I particularly like.

“No knowledge without theory. Schools teach information, not knowledge. Information is not knowledge. People go to Japan (to copy what they are doing there) and don’t learn anything because they don’t understand the theories. I hope they enjoyed the ride!”

“We must focus on win-win. Would you want to be married to a loser? Would you want to be in business with a loser… work with a supplier that is a loser or employees that are losers? We must work as a system, Union and Management. Everybody wins.”

“What state of a company is in the best position to improve quality? A healthy company is in an excellent position to improve and has the greatest obligation to improve. A company on the rocks can only think of survival.”

Lean 101 - A 5-Part Introduction to Lean - from pretty high up

If you know nothing, or just a very little, about Lean, here is a five part, easy-to-follow video series that will introduce you to all the major concepts and elements. The whole series takes just under 50 minutes to watch.

The first video on the history of lean is optional. stands alone and can be watched any time. I do recommend watching the others in sequence as they build on each other.

The full series consists of:
Brief History of Lean
What is Lean?
What is Waste?
What is Heijunka and Value Stream Mapping?
What is Kaizen?