As it turns out, the reality-based, science-friendly communities and information sources many of us depend on also largely failed. We had time to prepare for this pandemic at the state, local, and household level, even if the government was terribly lagging, but we squandered it because of widespread asystemic thinking: the inability to think about complex systems and their dynamics. We faltered because of our failure to consider risk in its full context, especially when dealing with coupled risk—when multiple things can go wrong together. We were hampered by our inability to think about second- and third-order effects and by our susceptibility to scientism—the false comfort of assuming that numbers and percentages give us a solid empirical basis. We failed to understand that complex systems defy simplistic reductionism.
On point analysis. Hits many of the themes of this blog, including system thinking, complexity and risk and makes some excellent points that all of us in quality should be thinking deeply upon.
COVID-19 is not a black swan. Pandemics like this have been well predicted. This event is a different set of failures, that on a hopefully smaller scale most of us are unfortunately familiar with in our organizations.
I certainly didn’t break out of the mainstream narrative. I traveled in February, went to a conference and then held a small event on the 29th.
The article stresses the importance of considering the trade-offs between resilience, efficiency, and redundancy within the system, and how the second- and third-order impacts can reverberate. It’s well worth reading for the analysis of the growth of COVID-19, and more importantly our reaction to it, from a systems perspective.
We write and use procedures to help the user complete the task successfully and avoid undesired outcomes. Well-written procedures are an integral part of any organization for operation, managing risks, and continuous improvement. Effective procedures are important for the transfer of knowledge from the engineers/architects of the system to the users of the system.
Good procedures, and we are not talking format so this can be paper documents to a mixed reality guide, provide these four categories of information:
Goal: The goal presented to the user as a state to be realized. This can be an end state or an intermediate state of the overall system.
Prerequisites: The condition for moving toward the desired state or goal. These are the conditions that must be satisfied so that the user can achieve the goal.
Actions and reactions: These states are reached through actions of the user and the reactions of the system. They may have milestones or sub-goals. It involves the description of (a series of) action steps.
Unwanted: These are the states to be avoided (e.g., errors, malfunctions, injuries). It provides guidelines on what to avoid for successful and safe execution of procedure and may include warning, caution, or instruction for solving a potential problem.
Procedures have a lifecycle through which they are developed, administered, used, reviewed, and updated. In the post “Document Management” I discussed the document management lifecycle.
In want to focus specifically on procedures by covering five distinct phases: procedure plan, design and development, procedure authorization, procedure administration, procedure implementation and use, and procedure review and maintenance.
Identifying whether a procedure is necessary; collecting required information; producing instructions and information on the work, regulatory compliance, process and personnel safety; a walkthrough to ensure quality and potential compliance of the procedure
“New SOP is needed” Drafting
Procedure review; publishing the final document; revision control; the approval process.
Managing procedure repository, control, and deployment; identifying administers how, when, and to whom procedures are to be delivered.
Procedure Implementation and Use
Procedure is used in operations
Procedure review and maintenance
Periodic review of documents, as well as updates from the CAPA and Change Management processes
Procedure Professionals Association (PPA), 2016. Procedure Process Description. (PPA AP-907-001)
Van der Meij, H., Gellevij, M., 2004. The four components of a procedure. IEEE Trans. Prof. Commun. 47 (1), 5–14
Risk Management often devolves into a check-the-box, non-valued activity in an organization. While many organizations ensure they have the right processes in place, they still end up not protecting themselves against risk effectively. A lot of our organizations struggle to understand risk and apply this mindset in productive ways.
As quality professionals we should be applying the same improvement tools to our risk management processes as we do anything else.
To improve a process, we first need to understand the value from the process. Risk management is the identification, evaluation, and prioritization of risks (defined in ISO 31000 as the effect of uncertainty on objectives) followed by coordinated and economical application of resources to minimize, monitor, and control the probability or impact of unfortunate events or to maximize the realization of opportunities.
The risk evaluation is the step where the knowledge base is evaluated, and a summary judgment is reached on the risks and uncertainties involved in the case under investigation. This evaluation must take the values of the decision-makers into account and a careful understanding has to be had on just what the practical burden of proof is in the particular decision.
Does Risk Management then create value for those perceived by the stakeholders? Can we apply a value stream approach and look to reduce wastes? Some common ones include:
Waste in Risk Management
“The things that hurts you is never in a risk matrix” “You have to deliver a risk matrix, but how you got there doesn’t matter”
Missing stakeholder viewpoints, poor Risk Management process, lack of considering multiple sources of uncertainty, poor input data, lack of sharing information
“if it is just a checklist sitting somewhere, then people don’t use it, and it becomes a wasted effort”
Missing standardization, serial processing and creation of similar documents, reports are not used after creation
“we’re uncertain what are the effect of the risk as this early stage, I think it would make more sense to do after”
Documented risk lay around unutilized during a project, change or operations
Unnecessary movement of people
“It can be time consuming walking around to get information about risk”
Lack of documentation, risks only retrievable by going around asking employees
“Time spend in risk identification is always little in the beginning of a project because everybody wants to start and then do the first part as quickly as possible.”
The documents were supposed to be updated and re-evaluated, but was not, thus becoming partially obsolete over time
Common wastes in Risk Management
Once we understand waste in risk management we can identify when it happens and engage in improvement activities. We should do this based on the principles of decision quality and very aware of the role uncertainty applies.
Anjum, Rani Lill, and Elena Rocca. “From Ideal to Real Risk: Philosophy of Causation Meets Risk Analysis.” Risk Analysis, vol. 39, no. 3, 19 Sept. 2018, pp. 729–740, 10.1111/risa.13187.
Hansson, Sven Ove, and Terje Aven. “Is Risk Analysis Scientific?” Risk Analysis, vol. 34, no. 7, 11 June 2014, pp. 1173–1183, 10.1111/risa.12230
Walker, Warren E., et al. “Deep Uncertainty.” Encyclopedia of Operations Research and Management Science, 2013, pp. 395–402, 10.1007/978-1-4419-1153-7_1140
Willumsen, Pelle, et al. “Value Creation through Project Risk Management.” International Journal of Project Management, Feb. 2019, 10.1016/j.ijproman.2019.01.007
Talk about strategy, risk management or change and it is inevitable that the acronym VUCA — short for volatility, uncertainty, complexity, and ambiguity—will come up. VUCA is basically a catchall for “Hey, it’s crazy out there!” And like many catch-all’s it is misleading, VUCA conflates four distinct types of challenges that demand four distinct types of responses. VUCA can quickly become a crutch, a way to throw off the hard work of strategy and planning—after all, you can’t prepare for a VUCA world, right?
The mistake folks often make here is treating these four traits as a single idea, which leads to poorer decision making.
VUCA really isn’t a tool. It’s a checklist of four things that hopefully your system is paying attention to. All four represent distinct elements that make our environment and organization harder to grasp and control.
One of the dangers in any organization is that the hard-won know-how of our experts remains locked in their brains and is not shared. To beat this tendency, knowledge management should be a continuous activity in any quality system. So why not start by documenting your own knowledge as an expert?
Answer these Questions
Things to clarify
What reference materials do you use?
How do you track technical trends?
Should a knowledge recipient own any of these reference materials? What are the best websites? Are there particular journals that you fi nd useful? What about associations?
What kinds of problems do people come to you to solve?
What are the biggest risks in the project, process, or system you manage?
Can you describe a problem brought to you recently? What technical mistakes is a novice likely to make in that project or process?
Whom do you ask about technology trends and innovation?
Whom do you contact for information about government regulations?
What is this go-to person’s complete contact information? What medium does he or she prefer (email versus telephone)? What is his or her background? How do you know this person?
Who are the major stakeholders in the project, process, or system you manage?
What are the biggest mistakes newcomers make in trying to get projects going here?
What are the positions of the major stakeholders? Where are there competing priorities? Can you give me an example of a newcomer mistake and suggest how to avoid such mistakes?
Regarding team leadership, what criteria do you use to select team members?
How do you ensure the team is connected to the overall business strategy?
On a general level, how do you motivate people who report to you?
Why do you use these particular criteria? Have you ever chosen unwisely? What communication strategies are most effective? Can you give an example of what has really helped?
Once you’ve documented this knowledge, identify who else needs to know it, and then ensure the knowledge is transferred.