A 2025 Retrospective for Investigations of a Dog

If the history of pharmaceutical quality management were written as a geological timeline, 2025 would hopefully mark the end of the Holocene of Compliance—a long, stable epoch where “following the procedure” was sufficient to ensure survival—and the beginning of the Anthropocene of Complexity.

For decades, our industry has operated under a tacit social contract. We agreed to pretend that “compliance” was synonymous with “quality.” We agreed to pretend that a validated method would work forever because we proved it worked once in a controlled protocol three years ago. We agreed to pretend that “zero deviations” meant “perfect performance,” rather than “blind surveillance.” We agreed to pretend that if we wrote enough documents, reality would conform to them.

If I had my wish 2025 would be the year that contract finally dissolved.

Throughout the year—across dozens of posts, technical analyses, and industry critiques on this blog—I have tried to dismantle the comfortable illusions of “Compliance Theater” and show how this theater collides violently with the unforgiving reality of complex systems.

The connecting thread running through every one of these developments is the concept I have returned to obsessively this year: Falsifiable Quality.

This Year in Review is not merely a summary of blog posts. It is an attempt to synthesize the fragmented lessons of 2025 into a coherent argument. The argument is this: A quality system that cannot be proven wrong is a quality system that cannot be trusted.

If our systems—our validation protocols, our risk assessments, our environmental monitoring programs—are designed only to confirm what we hope is true (the “Happy Path”), they are not quality systems at all. They are comfort blankets. And 2025 was the year we finally started pulling the blanket off.

The Philosophy of Doubt

(Reflecting on: The Effectiveness Paradox, Sidney Dekker, and Gerd Gigerenzer)

Before we dissect the technical failures of 2025, let me first establish the philosophical framework that defined this year’s analysis.

In August, I published The Effectiveness Paradox: Why ‘Nothing Bad Happened’ Doesn’t Prove Your Quality System Works.” It became one of the most discussed posts of the year because it attacked the most sacred metric in our industry: the trend line that stays flat.

We are conditioned to view stability as success. If Environmental Monitoring (EM) data shows zero excursions for six months, we throw a pizza party. If a method validation passes all acceptance criteria on the first try, we commend the development team. If a year goes by with no Critical deviations, we pay out bonuses.

But through the lens of Falsifiable Quality—a concept heavily influenced by the philosophy of Karl Popper, the challenging insights of Deming, and the safety science of Sidney Dekker, whom we discussed in November—these “successes” look suspiciously like failures of inquiry.

The Problem with Unfalsifiable Systems

Karl Popper famously argued that a scientific theory is only valid if it makes predictions that can be tested and proven false. “All swans are white” is a scientific statement because finding one black swan falsifies it. “God is love” is not, because no empirical observation can disprove it.

In 2025, I argued that most Pharmaceutical Quality Systems (PQS) are designed to be unfalsifiable.

  • The Unfalsifiable Alert Limit: We set alert limits based on historical averages + 3 standard deviations. This ensures that we only react to statistical outliers, effectively blinding us to gradual drift or systemic degradation that remains “within the noise.”
  • The Unfalsifiable Robustness Study: We design validation protocols that test parameters we already know are safe (e.g., pH +/- 0.1), avoiding the “cliff edges” where the method actually fails. We prove the method works where it works, rather than finding where it breaks.
  • The Unfalsifiable Risk Assessment: We write FMEAs where the conclusion (“The risk is acceptable”) is decided in advance, and the RPN scores are reverse-engineered to justify it.

This is “Safety Theater,” a term Dekker uses to describe the rituals organizations perform to look safe rather than be safe.

Safety-I vs. Safety-II

In November’s post Sidney Dekker: The Safety Scientist Who Influences How I Think About Quality, I explored Dekker’s distinction between Safety-I (minimizing things that go wrong) and Safety-II (understanding how things usually go right).

Traditional Quality Assurance is obsessed with Safety-I. We count deviations. We count OOS results. We count complaints. When those counts are low, we assume the system is healthy.
But as the LeMaitre Vascular warning letter showed us this year (discussed in Part III), a system can have “zero deviations” simply because it has stopped looking for them. LeMaitre had excellent water data—because they were cleaning the valves before they sampled them. They were measuring their ritual, not their water.

Falsifiable Quality is the bridge to Safety-II. It demands that we treat every batch record not as a compliance artifact, but as a hypothesis test.

  • Hypothesis: “The contamination control strategy is effective.”
  • Test: Aggressive monitoring in worst-case locations, not just the “representative” center of the room.
  • Result: If we find nothing, the hypothesis survives another day. If we find something, we have successfully falsified the hypothesis—which is a good thing because it reveals reality.

The shift from “fearing the deviation” to “seeking the falsification” is a cultural pivot point of 2025.

The Epistemological Crisis in the Lab (Method Validation)

(Reflecting on: USP <1225>, Method Qualification vs. Validation, and Lifecycle Management)

Nowhere was the battle for Falsifiable Quality fought more fiercely in 2025 than in the analytical laboratory.

The proposed revision to USP <1225> Validation of Compendial Procedures (published in Pharmacopeial Forum 51(6)) arrived late in the year, but it serves as the perfect capstone to the arguments I’ve been making since January.

For forty years, analytical validation has been the ultimate exercise in “Validation as an Event.” You develop a method. You write a protocol. You execute the protocol over three days with your best analyst and fresh reagents. You print the report. You bind it. You never look at it again.

This model is unfalsifiable. It assumes that because the method worked in the “Work-as-Imagined” conditions of the validation study, it will work in the “Work-as-Done” reality of routine QC for the next decade.

The Reportable Result: Validating Decisions, Not Signals

The revised USP <1225>—aligned with ICH Q14(Analytical Procedure Development) and USP <1220> (The Lifecycle Approach)—destroys this assumption. It introduces concepts that force falsifiability into the lab.

The most critical of these is the Reportable Result.

Historically, we validated “the instrument” or “the measurement.” We proved that the HPLC could inject the same sample ten times with < 1.0% RSD.

But the Reportable Result is the final value used for decision-making—the value that appears on the Certificate of Analysis. It is the product of a complex chain: Sampling -> Transport -> Storage -> Preparation -> Dilution -> Injection -> Integration -> Calculation -> Averaging.

Validating the injection precision (the end of the chain) tells us nothing about the sampling variability (the beginning of the chain).

By shifting focus to the Reportable Result, USP <1225> forces us to ask: “Does this method generate decisions we can trust?”

The Replication Strategy: Validating “Work-as-Done”

The new guidance insists that validation must mimic the replication strategy of routine testing.
If your SOP says “We report the average of 3 independent preparations,” then your validation must evaluate the precision and accuracy of that average, not of the individual preparations.

This seems subtle, but it is revolutionary. It prevents the common trick of “averaging away” variability during validation to pass the criteria, only to face OOS results in routine production because the routine procedure doesn’t use the same averaging scheme.

It forces the validation study to mirror the messy reality of the “Work-as-Done,” making the validation data a falsifiable predictor of routine performance, rather than a theoretical maximum capability.

Method Qualification vs. Validation: The June Distinction

I wrote Method Qualification and Validation,” clarifying a distinction that often confuses the industry.

  • Qualification is the “discovery phase” where we explore the method’s limits. It is inherently falsifiable—we want to find where the method breaks.
  • Validation has traditionally been the “confirmation phase” where we prove it works.

The danger, as I noted in that post, is when we skip the falsifiable Qualification step and go straight to Validation. We write the protocol based on hope, not data.

USP <1225> essentially argues that Validation must retain the falsifiable spirit of Qualification. It is not a coronation; it is a stress test.

The Death of “Method Transfer” as We Know It

In a Falsifiable Quality system, a method is never “done.” The Analytical Target Profile (ATP)—a concept from ICH Q14 that permeates the new thinking—is a standing hypothesis: “This method measures Potency within +/- 2%.”

Every time we run a system suitability check, every time we run a control standard, we are testing that hypothesis.

If the method starts drifting—even if it still passes broad system suitability limits—a falsifiable system flags the drift. An unfalsifiable system waits for the OOS.

The draft revision of USP <1225> is a call to arms. It asks us to stop treating validation as a “ticket to ride”—a one-time toll we pay to enter GMP compliance—and start treating it as a “ticket to doubt.” Validation gives us permission to use the method, but only as long as the data continues to support the hypothesis of fitness.

The Reality Check (The “Unholy Trinity” of Warning Letters)

Philosophy and guidelines are fine, but in 2025, reality kicked in the door. The regulatory year was defined by three critical warning letters—SanofiLeMaitre, and Rechon—that collectively dismantled the industry’s illusions of control.

It began, as these things often do, with a ghost from the past.

Sanofi Framingham: The Pendulum Swings Back

(Reflecting on: Failure to Investigate Critical Deviations and The Sanofi Warning Letter)

The year opened with a shock. On January 15, 2025, the FDA issued a warning letter to Sanofi’s Framingham facility—the sister site to the legacy Genzyme Allston landing, whose consent decree defined an entire generation of biotech compliance and of my career.

In my January analysis (Failure to Investigate Critical Deviations: A Cautionary Tale), I noted that the FDA’s primary citation was a failure to “thoroughly investigate any unexplained discrepancy.”

This is the cardinal sin of Falsifiable Quality.

An “unexplained discrepancy” is a signal from reality. It is the system telling you, “Your hypothesis about this process is wrong.”

  • The Falsifiable Response: You dive into the discrepancy. You assume your control strategy missed something. You use Causal Reasoning (the topic of my May post) to find the mechanism of failure.
  • The Sanofi Response: As the warning letter detailed, they frequently attributed failures to “isolated incidents” or superficial causes without genuine evidence.

This is the “Refusal to Falsify.” By failing to investigate thoroughly, the firm protects the comfortable status quo. They choose to believe the “Happy Path” (the process is robust) over the evidence (the discrepancy).

The Pendulum of Compliance

In my companion post (Sanofi Warning Letter”), I discussed the “pendulum of compliance.” The Framingham site was supposed to be the fortress of quality, built on the lessons of the Genzyme crisis.

The failure at Sanofi wasn’t a lack of SOPs; it was a lack of curiosity.

The investigators likely had checklists, templates, and timelines (Compliance Theater), but they lacked the mandate—or perhaps the Expertise —to actually solve the problem.

This set the thematic stage for the rest of 2025. Sanofi showed us that “closing the deviation” is not the same as fixing the problem. This insight led directly into my August argument in The Effectiveness Paradox: You can close 100% of your deviations on time and still have a manufacturing process that is spinning out of control.

If Sanofi was the failure of investigation (looking back), Rechon and LeMaitre were failures of surveillance (looking forward). Together, they form a complete picture of why unfalsifiable systems fail.

Reflecting on: Rechon Life Science and LeMaitre Vascular

Philosophy and guidelines are fine, but in September, reality kicked in the door.

Two warning letters in 2025—Rechon Life Science (September) and LeMaitre Vascular (August)—provided brutal case studies in what happens when “representative sampling” is treated as a buzzword rather than a statistical requirement.

Rechon Life Science: The Map vs. The Territory

The Rechon Life Science warning letter was a significant regulatory signal of 2025 regarding sterile manufacturing. It wasn’t just a list of observations; it was an indictment of unfalsifiable Contamination Control Strategies (CCS).

We spent 2023 and 2024 writing massive CCS documents to satisfy Annex 1. Hundreds of pages detailing airflows, gowning procedures, and material flows. We felt good about them. We felt “compliant.”

Then the FDA walked into Rechon and essentially asked: “If your CCS is so good, why does your smoke study show turbulence over the open vials?”

The warning letter highlighted a disconnect I’ve called “The Map vs. The Territory.”

  • The Map: The CCS document says the airflow is unidirectional and protects the product.
  • The Territory: The smoke study video shows air eddying backward from the operator to the sterile core.

In an unfalsifiable system, we ignore the smoke study (or film it from a flattering angle) because it contradicts the CCS. We prioritize the documentation (the claim) over the observation (the evidence).

In a falsifiable system, the smoke study is the test. If the smoke shows turbulence, the CCS is falsified. We don’t defend the CCS; we rewrite it. We redesign the line.

The FDA’s critique of Rechon’s “dynamic airflow visualization” was devastating because it showed that Rechon was using the smoke study as a marketing video, not a diagnostic tool. They filmed “representative” operations that were carefully choreographed to look clean, rather than the messy reality of interventions.

LeMaitre Vascular: The Sin of “Aspirational Data”

If Rechon was about air, LeMaitre Vascular (analyzed in my August post When Water Systems Fail) was about water. And it contained an even more egregious sin against falsifiability.

The FDA observed that LeMaitre’s water sampling procedures required cleaning and purging the sample valves before taking the sample.

Let’s pause and consider the epistemology of this.

  • The Goal: To measure the quality of the water used in manufacturing.
  • The Reality: Manufacturing operators do not purge and sanitize the valve for 10 minutes before filling the tank. They open the valve and use the water.
  • The Sample: By sanitizing the valve before sampling, LeMaitre was measuring the quality of the sampling process, not the quality of the water system.

I call this “Aspirational Data.” It is data that reflects the system as we wish it existed, not as it actually exists. It is the ultimate unfalsifiable metric. You can never find biofilm in a valve if you scrub the valve with alcohol before you open it.

The FDA’s warning letter was clear: “Sampling… must include any pathway that the water travels to reach the process.”

LeMaitre also performed an unauthorized “Sterilant Switcheroo,” changing their sanitization agent without change control or biocompatibility assessment. This is the hallmark of an unfalsifiable culture: making changes based on convenience, assuming they are safe, and never designing the study to check if that assumption is wrong.

The “Representative” Trap

Both warning letters pivot on the misuse of the word “representative.”

Firms love to claim their EM sampling locations are “representative.” But representative of what? Usually, they are representative of the average condition of the room—the clean, empty spaces where nothing happens.

But contamination is not an “average” event. It is a specific, localized failure. A falsifiable EM program places probes in the “worst-case” locations—near the door, near the operator’s hands, near the crimping station. It tries to find contamination. It tries to falsify the claim that the zone is sterile, asceptic or bioburden reducing.

When Rechon and LeMaitre failed to justify their sampling locations, they were guilty of designing an unfalsifiable experiment. They placed the “microscope” where they knew they wouldn’t find germs.

2025 taught us that regulators are no longer impressed by the thickness of the CCS binder. They are looking for the logic of control. They are testing your hypothesis. And if you haven’t tested it yourself, you will fail.

The Investigation as Evidence

(Reflecting on: The Golden Start to a Deviation InvestigationCausal ReasoningTake-the-Best Heuristics, and The Catalent Case)

If Rechon, LeMaitre, and Sanofi teach us anything, it is that the quality system’s ability to discover failure is more important than its ability to prevent failure.

A perfect manufacturing process that no one is looking at is indistinguishable from a collapsing process disguised by poor surveillance. But a mediocre process that is rigorously investigated, understood, and continuously improved is a path toward genuine control.

The investigation itself—how we respond to a deviation, how we reason about causation, how we design corrective actions—is where falsifiable quality either succeeds or fails.

The Golden Day: When Theory Meets Work-as-Done

In April, I published “The Golden Start to a Deviation Investigation,” which made a deceptively simple argument: The first 24 hours after a deviation is discovered are where your quality system either commits to discovering truth or retreats into theater.

This argument sits at the heart of falsifiable quality.

When a deviation occurs, you have a narrow window—what I call the “Golden Day”—where evidence is fresh, memories are intact, and the actual conditions that produced the failure still exist. If you waste this window with vague problem statements and abstract discussions, you permanently lose the ability to test causal hypotheses later.

The post outlined a structured protocol:

First, crystallize the problem. Not “potency was low”—but “Lot X234, potency measured at 87% on January 15th at 14:32, three hours after completion of blending in Vessel C-2.” Precision matters because only specific, bounded statements can be falsified. A vague problem statement can always be “explained away.”

Second, go to the Gemba. This is the antidote to “work-as-imagined” investigation. The SOP says the temperature controller should maintain 37°C +/- 2°C. But the Gemba walk reveals that the probe is positioned six inches from the heating element, the data logger is in a recessed pocket where humidity accumulates, and the operator checks it every four hours despite a requirement to check hourly. These are the facts that predict whether the deviation will recur.

Third, interview with cognitive discipline. Most investigations fail not because investigators lack information, but because they extract information poorly. Cognitive interviewing—developed by the FBI and the National Transportation Safety Board—uses mental reinstatement, multiple perspectives, and sequential reordering to access accurate recall rather than confabulated narrative. The investigator asks the operator to walk through the event in different orders, from different viewpoints, each time triggering different memory pathways. This is not “soft” technique; it is a mechanism for generating falsifiable evidence.

The Golden Day post makes it clear: You do not investigate deviations to document compliance. You investigate deviations to gather evidence about whether your understanding of the process is correct.

Causal Reasoning: Moving Beyond “What Was Missing”

Most investigation tools fail not because they are flawed, but because they are applied with the wrong mindset. In my May post “Causal Reasoning: A Transformative Approach to Root Cause Analysis,” I argued that pharmaceutical investigations are often trapped in “negative reasoning.”

Negative reasoning asks: “What barrier was missing? What should have been done but wasn’t?” This mindset leads to unfalsifiable conclusions like “Procedure not followed” or “Training was inadequate.” These are dead ends because they describe the absence of an ideal, not the presence of a cause.

Causal reasoning flips the script. It asks: “What was present in the system that made the observed outcome inevitable?”

Instead of settling for “human error,” causal reasoning demands we ask: What environmental cues made the action sensible to the operator at that moment? Were the instructions ambiguous? Did competing priorities make compliance impossible? Was the process design fragile?

This shift transforms the investigation from a compliance exercise into a scientific inquiry.

Consider the LeMaitre example:

  • Negative Reasoning: “Why didn’t they sample the true condition?” Answer: “Because they didn’t follow the intent of the sampling plan.”
  • Causal Reasoning: “What made the pre-cleaning practice sensible to them?” Answer: “They believed it ensured sample validity by removing valve residue.”

By understanding the why, we identify a knowledge gap that can be tested and corrected, rather than a negligence gap that can only be punished.

In September, “Take-the-Best Heuristic for Causal Investigation” provided a practical framework for this. Instead of listing every conceivable cause—a process that often leads to paralysis—the “Take-the-Best” heuristic directs investigators to focus on the most information-rich discriminators. These are the factors that, if different, would have prevented the deviation. This approach focuses resources where they matter most, turning the investigation into a targeted search for truth.

CAPA: Predictions, Not Promises

The Sanofi warning letter—analyzed in January—showed the destination of unfalsifiable investigation: CAPAs that exist mainly as paperwork.

Sanofi had investigation reports. They had “corrective actions.” But the FDA noted that deviations recurred in similar patterns, suggesting that the investigation had identified symptoms, not mechanisms, and that the “corrective” action had not actually addressed causation.

This is the sin of treating CAPA as a promise rather than a hypothesis.

A falsifiable CAPA is structured as an explicit prediction“If we implement X change, then Y undesirable outcome will not recur under conditions Z.”

This can be tested. If it fails the test, the CAPA itself becomes evidence—not of failure, but of incomplete causal understanding. Which is valuable.

In the Rechon analysis, this showed up concretely: The FDA’s real criticism was not just that contamination was found; it was that Rechon’s Contamination Control Strategy had no mechanism to falsify itself. If the CCS said “unidirectional airflow protects the product,” and smoke studies showed bidirectional eddies, the CCS had been falsified. But Rechon treated the falsification as an anomaly to be explained away, rather than evidence that the CCS hypothesis was wrong.

A falsifiable organization would say: “Our CCS predicted that Grade A in an isolator with this airflow pattern would remain sterile. The smoke study proves that prediction wrong. Therefore, the CCS is false. We redesign.”

Instead, they filmed from a different angle and said the aerodynamics were “acceptable.”

Knowledge Integration: When Deviations Become the Curriculum

The final piece of falsifiable investigation is what I call “knowledge integration.” A single deviation is a data point. But across the organization, deviations should form a curriculum about how systems actually fail.

Sanofi’s failure was not that they investigated each deviation badly (though they did). It was that they investigated them in isolation. Each deviation closed on its own. Each CAPA addressed its own batch. There was no organizational learning—no mechanism for a pattern of similar deviations to trigger a hypothesis that the control strategy itself was fundamentally flawed.

This is where the Catalent case study, analyzed in September’s “When 483s Reveal Zemblanity,” becomes instructive. Zemblanity is the opposite of serendipity: the seemingly random recurrence of the same failure through different paths. Catalent’s 483 observations were not isolated mistakes; they formed a pattern that revealed a systemic assumption (about equipment capability, about environmental control, about material consistency) that was false across multiple products and locations.

A falsifiable quality system catches zemblanity early by:

  1. Treating each deviation as a test of organizational hypotheses, not as an isolated incident.
  2. Trending deviation patterns to detect when the same causal mechanism is producing failures across different products, equipment, or operators.
  3. Revising control strategies when patterns falsify the original assumptions, rather than tightening parameters at the margins.

The Digital Hallucination (CSA, AI, and the Expertise Crisis)

(Reflecting on: CSA: The Emperor’s New Clothes, Annex 11, and The Expertise Crisis)

While we battled microbes in the cleanroom, a different battle was raging in the server room. 2025 was the year the industry tried to “modernize” validation through Computer Software Assurance (CSA) and AI, and in many ways, it was the year we tried to automate our way out of thinking.

CSA: The Emperor’s New Validation Clothes

In September, I published Computer System Assurance: The Emperor’s New Validation Clothes,” a critique of the the contortions being made around the FDA’s guidance. The narrative sold by consultants for years was that traditional Computer System Validation (CSV) was “broken”—too much documentation, too much testing—and that CSA was a revolutionary new paradigm of “critical thinking.”

My analysis showed that this narrative is historically illiterate.

The principles of CSA—risk-based testing, leveraging vendor audits, focusing on intended use—are not new. They are the core principles of GAMP5 and have been applied for decades now.

The industry didn’t need a new guidance to tell us to use critical thinking; we had simply chosen not to use the critical thinking tools we already had. We had chosen to apply “one-size-fits-all” templates because they were safe (unfalsifiable).

The CSA guidance is effectively the FDA saying: “Please read the GAMP5 guide you claimed to be following for the last 15 years.”

The danger of the “CSA Revolution” narrative is that it encourages a swing to the opposite extreme: “Unscripted Testing” that becomes “No Testing.”

In a falsifiable system, “unscripted testing” is highly rigorous—it is an expert trying to break the software (“Ad Hoc testing”). But in an unfalsifiable system, “unscripted testing” becomes “I clicked around for 10 minutes and it looked fine.”

The Expertise Crisis: AI and the Death of the Apprentice

This leads directly to the Expertise Crisis. In September, I wrote The Expertise Crisis: Why AI’s War on Entry-Level Jobs Threatens Quality’s Future.” This was perhaps the most personal topic I covered this year, because it touches on the very survival of our profession.

We are rushing to integrate Artificial Intelligence (AI) into quality systems. We have AI writing deviations, AI drafting SOPs, AI summarizing regulatory changes. The efficiency gains are undeniable. But the cost is hidden, and it is epistemological.

Falsifiability requires expertise.
To falsify a claim—to look at a draft investigation report and say, “No, that conclusion doesn’t follow from the data”—you need deep, intuitive knowledge of the process. You need to know what a “normal” pH curve looks like so you can spot the “abnormal” one that the AI smoothed over.

Where does that intuition come from? It comes from the “grunt work.” It comes from years of reviewing batch records, years of interviewing operators, years of struggling to write a root cause analysis statement.

The Expertise Crisis is this: If we give all the entry-level work to AI, where will the next generation of Quality Leaders come from?

  • The Junior Associate doesn’t review the raw data; the AI summarizes it.
  • The Junior Associate doesn’t write the deviation; the AI generates the text.
  • Therefore, the Junior Associate never builds the mental models necessary to critique the AI.

The Loop of Unfalsifiable Hallucination

We are creating a closed loop of unfalsifiability.

  1. The AI generates a plausible-sounding investigation report.
  2. The human reviewer (who has been “de-skilled” by years of AI reliance) lacks the deep expertise to spot the subtle logical flaw or the missing data point.
  3. The report is approved.
  4. The “hallucination” becomes the official record.

In a falsifiable quality system, the human must remain the adversary of the algorithm. The human’s job is to try to break the AI’s logic, to check the citations, to verify the raw data.
But in 2025, we saw the beginnings of a “Compliance Autopilot”—a desire to let the machine handle the “boring stuff.”

My warning in September remains urgent: Efficiency without expertise is just accelerated incompetence. If we lose the ability to falsify our own tools, we are no longer quality professionals; we are just passengers in a car driven by a statistical model that doesn’t know what “truth” is.

My post “The Missing Middle in GMP Decision Making: How Annex 22 Redefines Human-Machine Collaboration in Pharmaceutical Quality Assurance” goes a lot deeper here.

Annex 11 and Data Governance

In August, I analyzed the draft Annex 11 (Computerised Systems) in the post Data Governance Systems: A Fundamental Shift.”

The Europeans are ahead of the FDA here. While the FDA talks about “Assurance” (testing less), the EU is talking about “Governance” (controlling more). The new Annex 11 makes it clear: You cannot validate a system if you do not control the data lifecycle. Validation is not a test script; it is a state of control.

This aligns perfectly with USP <1225> and <1220>. Whether it’s a chromatograph or an ERP system, the requirement is the same: Prove that the data is trustworthy, not just that the software is installed.

The Process as a Hypothesis (CPV & Cleaning)

(Reflecting on: Continuous Process Verification and Hypothesis Formation)

The final frontier of validation we explored in 2025 was the manufacturing process itself.

CPV: Continuous Falsification

In March, I published Continuous Process Verification (CPV) Methodology and Tool Selection.”
CPV is the ultimate expression of Falsifiable Quality in manufacturing.

  • Traditional Validation (3 Batches): “We made 3 good batches, therefore the process is perfect forever.” (Unfalsifiable extrapolation).
  • CPV: “We made 3 good batches, so we have a license to manufacture, but we will statistically monitor every subsequent batch to detect drift.” (Continuous hypothesis testing).

The challenge with CPV, as discussed in the post, is that it requires statistical literacy. You cannot implement CPV if your quality unit doesn’t understand the difference between Cpk and Ppk, or between control limits and specification limits.

This circles back to the Expertise Crisis. We are implementing complex statistical tools (CPV software) at the exact moment we are de-skilling the workforce. We risk creating a “CPV Dashboard” that turns red, but no one knows why or what to do about it.

Cleaning Validation: The Science of Residue

In August, I tried to apply falsifiability to one of the most stubborn areas of dogma: Cleaning Validation.

In Building Decision-Making with Structured Hypothesis Formation, I argued that cleaning validation should not be about “proving it’s clean.” It should be about “understanding why it gets dirty.”

  • Traditional Approach: Swab 10 spots. If they pass, we are good.
  • Hypothesis Approach: “We hypothesize that the gasket on the bottom valve is the hardest to clean. We predict that if we reduce rinse time by 1 minute, that gasket will fail.”

By testing the boundaries—by trying to make the cleaning fail—we understand the Design Space of the cleaning process.

We discussed the “Visual Inspection” paradox in cleaning: If you can see the residue, it failed. But if you can’t see it, does it pass?

Only if you have scientifically determined the Visible Residue Limit (VRL). Using “visually clean” without a validated VRL is—you guessed it—unfalsifiable.

To: Jeremiah Genest
From: Perplexity Research
Subject: Draft Content – Single-Use Systems & E&L Section

Here is a section on Single-Use Systems (SUS) and Extractables & Leachables (E&L).

I have positioned this piece to bridge the gap between “Part III: The Reality Check” (Contamination/Water) and “Part V: The Process as a Hypothesis” (Cleaning Validation).

The argument here is that by switching from Stainless Steel to Single-Use, we traded a visible risk (cleaning residue) for an invisible one (chemical migration), and that our current approach to E&L is often just “Paper Safety”—relying on vendor data that doesn’t reflect the “Work-as-Done” reality of our specific process conditions.

The Plastic Paradox (Single-Use Systems and the E&L Mirage)

If the Rechon and LeMaitre warning letters were about the failure to control biological contaminants we can find, the industry’s struggle with Single-Use Systems (SUS) in 2025 was about the chemical contaminants we choose not to find.

We have spent the last decade aggressively swapping stainless steel for plastic. The value proposition was irresistible: Eliminate cleaning validation, eliminate cross-contamination, increase flexibility. We traded the “devil we know” (cleaning residue) for the “devil we don’t” (Extractables and Leachables).

But in 2025, with the enforcement reality of USP <665> (Plastic Components and Systems) settling in, we had to confront the uncomfortable truth: Most E&L risk assessments are unfalsifiable.

The Vendor Data Trap

The standard industry approach to E&L is the ultimate form of “Compliance Theater.”

  1. We buy a single-use bag.
  2. We request the vendor’s regulatory support package (the “Map”).
  3. We see that the vendor extracted the film with aggressive solvents (ethanol, hexane) for 7 days.
  4. We conclude: “Our process uses water for 24 hours; therefore, we are safe.”

This logic is epistemologically bankrupt. It assumes that the Vendor’s Model (aggressive solvents/short time) maps perfectly to the User’s Reality (complex buffers/long duration/specific surfactants).

It ignores the fact that plastics are dynamic systems. Polymers age. Gamma irradiation initiates free radical cascades that evolve over months. A bag manufactured in January might have a different leachable profile than a bag manufactured in June, especially if the resin supplier made a “minor” change that didn’t trigger a notification.

By relying solely on the vendor’s static validation package, we are choosing not to falsify our safety hypothesis. We are effectively saying, “If the vendor says it’s clean, we will not look for dirt.”

USP <665>: A Baseline, Not a Ceiling

The full adoption of USP <665> was supposed to bring standardization. And it has—it provides a standard set of extraction conditions. But standards can become ceilings.

In 2025, I observed a troubling trend of “Compliance by Citation.” Firms are citing USP <665> compliance as proof of absence of risk, stopping the inquiry there.

A Falsifiable E&L Strategy goes further. It asks:

  • “What if the vendor data is irrelevant to my specific surfactant?”
  • “What if the gamma irradiation dose varied?”
  • “What if the interaction between the tubing and the connector creates a new species?”

The Invisible Process Aid

We must stop viewing Single-Use Systems as inert piping. They are active process components. They are chemically reactive vessels that participate in our reaction kinetics.

When we treat them as inert, we are engaging in the same “Aspirational Thinking” that LeMaitre used on their water valves. We are modeling the system we want (pure, inert plastic), not the system we have (a complex soup of antioxidants, slip agents, and degradants).

The lesson of 2025 is that Material Qualification cannot be a paper exercise. If you haven’t done targeted simulation studies that mimic your actual “Work-as-Done” conditions, you haven’t validated the system. You’ve just filed the receipt.

The Mandate for 2026

As we look toward 2026, the path is clear. We cannot go back to the comfortable fiction of the pre-2025 era.

The regulatory environment (Annex 1, ICH Q14, USP <1225>, Annex 11) is explicitly demanding evidence of control, not just evidence of compliance. The technological environment (AI) is demanding that we sharpen our human expertise to avoid becoming obsolete. The physical environment (contamination, supply chain complexity) is demanding systems that are robust, not just rigid.

The mandate for the coming year is to build Falsifiable Quality Systems.

What does that look like practically?

  1. In the Lab: Implement USP <1225> logic now. Don’t wait for the official date. Validate your reportable results. Add “challenge tests” to your routine monitoring.
  2. In the Plant: Redesign your Environmental Monitoring to hunt for contamination, not to avoid it. If you have a “perfect” record in a Grade C area, move the plates until you find the dirt.
  3. In the Office: Treat every investigation as a chance to falsify the control strategy. If a deviation occurs that the control strategy said was impossible, update the control strategy.
  4. In the Culture: Reward the messenger. The person who finds the crack in the system is not a troublemaker; they are the most valuable asset you have. They just falsified a false sense of security.
  5. In Design: Embrace the Elegant Quality System (discussed in May). Complexity is the enemy of falsifiability. Complex systems hide failures; simple, elegant systems reveal them.

2025 was the year we stopped pretending. 2026 must be the year we start building. We must build systems that are honest enough to fail, so that we can build processes that are robust enough to endure.

Thank you for reading, challenging, and thinking with me this year. The investigation continues.

The Deep Ownership Paradox: Why It Takes Years to Master What You Think You Already Know

When I encounter professionals who believe they can master a process in six months, I think of something the great systems thinker W. Edwards Deming once observed: “It is not necessary to change. Survival is not mandatory.” The professionals who survive—and more importantly, who drive genuine improvement—understand something that transcends the checkbox mentality: true ownership takes time, patience, and what some might call “stick-to-itness.”

The uncomfortable truth is that most of us confuse familiarity with mastery. We mistake the ability to execute procedures with the deep understanding required to improve them. This confusion has created a generation of professionals who move from role to role, collecting titles and experiences but never developing the profound process knowledge that enables breakthrough improvement. This is equally true on the consultant side.

The cost of this superficial approach extends far beyond individual career trajectories. When organizations lack deep process owners—people who have lived with systems long enough to understand their subtle rhythms and hidden failure modes—they create what I call “quality theater”: elaborate compliance structures that satisfy auditors but fail to serve patients, customers, or the fundamental purpose of pharmaceutical manufacturing.

The Science of Deep Ownership

Recent research in organizational psychology reveals the profound difference between surface-level knowledge and genuine psychological ownership. When employees develop true psychological ownership of their processes, something remarkable happens: they begin to exhibit behaviors that extend far beyond their job descriptions. They proactively identify risks, champion improvements, and develop the kind of intimate process knowledge that enables predictive rather than reactive management.

But here’s what the research also shows: this psychological ownership doesn’t emerge overnight. Studies examining the relationship between tenure and performance consistently demonstrate nonlinear effects. The correlation between tenure and performance actually decreases exponentially over time—but this isn’t because long-tenured employees become less effective. Instead, it reflects the reality that deep expertise follows a complex curve where initial competence gives way to periods of plateau, followed by breakthrough understanding that emerges only after years of sustained engagement.

Consider the findings from meta-analyses of over 3,600 employees across various industries. The relationship between organizational commitment and job performance shows a very strong nonlinear moderating effect based on tenure. The implications are profound: the value of process ownership isn’t linear, and the greatest insights often emerge after years of what might appear to be steady-state performance.

This aligns with what quality professionals intuitively know but rarely discuss: the most devastating process failures often emerge from interactions and edge cases that only become visible after sustained observation. The process owner who has lived through multiple product campaigns, seasonal variations, and equipment lifecycle transitions develops pattern recognition that cannot be captured in procedures or training materials.

The 10,000 Hour Reality in Quality Systems

Malcolm Gladwell’s popularization of the 10,000-hour rule has been both blessing and curse for understanding expertise development. While recent research has shown that deliberate practice accounts for only 18-26% of skill variation—meaning other factors like timing, genetics, and learning environment matter significantly—the core insight remains valid: mastery requires sustained, focused engagement over years, not months.

But the pharmaceutical quality context adds layers of complexity that make the expertise timeline even more demanding. Unlike chess players or musicians who can practice their craft continuously, quality professionals must develop expertise within regulatory frameworks that change, across technologies that evolve, and through organizational transitions that reset context. The “hours” of meaningful practice are often interrupted by compliance activities, reorganizations, and role changes that fragment the learning experience.

More importantly, quality expertise isn’t just about individual skill development—it’s about understanding systems. Deming’s System of Profound Knowledge emphasizes that effective quality management requires appreciation for a system, knowledge about variation, theory of knowledge, and psychology. This multidimensional expertise cannot be compressed into abbreviated timelines, regardless of individual capability or organizational urgency.

The research on mastery learning provides additional insight. True mastery-based approaches require that students achieve deep understanding at each level before progressing to the next. In quality systems, this means that process owners must genuinely understand the current state of their processes—including their failure modes, sources of variation, and improvement potential—before they can effectively drive transformation.

The Hidden Complexity of Process Ownership

Many of our organizations struggle with “iceberg phenomenon”: the visible aspects of process ownership—procedure compliance, metric reporting, incident response—represent only a small fraction of the role’s true complexity and value.

Effective process owners develop several types of knowledge that accumulate over time:

  • Tacit Process Knowledge: Understanding the subtle indicators that precede process upsets, the informal workarounds that maintain operations, and the human factors that influence process performance. This knowledge emerges through repeated exposure to process variations and cannot be documented or transferred through training.
  • Systemic Understanding: Comprehending how their process interacts with upstream and downstream activities, how changes in one area create ripple effects throughout the system, and how to navigate the political and technical constraints that shape improvement opportunities. This requires exposure to multiple improvement cycles and organizational changes.
  • Regulatory Intelligence: Developing nuanced understanding of how regulatory expectations apply to their specific context, how to interpret evolving guidance, and how to balance compliance requirements with operational realities. This expertise emerges through regulatory interactions, inspection experiences, and industry evolution.
  • Change Leadership Capability: Building the credibility, relationships, and communication skills necessary to drive improvement in complex organizational environments. This requires sustained engagement with stakeholders, demonstrated success in previous initiatives, and deep understanding of organizational dynamics.

Each of these knowledge domains requires years to develop, and they interact synergistically. The process owner who has lived through equipment upgrades, regulatory inspections, organizational changes, and improvement initiatives develops a form of professional judgment that cannot be replicated through rotation or abbreviated assignments.

The Deming Connection: Systems Thinking Requires Time

Deming’s philosophy of continuous improvement provides a crucial framework for understanding why process ownership requires sustained engagement. His approach to quality was holistic, emphasizing systems thinking and long-term perspective over quick fixes and individual blame.

Consider Deming’s first point: “Create constancy of purpose toward improvement of product and service.” This isn’t about maintaining consistency in procedures—it’s about developing the deep understanding necessary to identify genuine improvement opportunities rather than cosmetic changes that satisfy short-term pressures.

The PDCA cycle that underlies Deming’s approach explicitly requires iterative learning over multiple cycles. Each cycle builds on previous learning, and the most valuable insights often emerge after several iterations when patterns become visible and root causes become clear. Process owners who remain with their systems long enough to complete multiple cycles develop qualitatively different understanding than those who implement single improvements and move on.

Deming’s emphasis on driving out fear also connects to the tenure question. Organizations that constantly rotate process owners signal that deep expertise isn’t valued, creating environments where people focus on short-term achievements rather than long-term system health. The psychological safety necessary for honest problem-solving and innovative improvement requires stable relationships built over time.

The Current Context: Why Stick-to-itness is Endangered

The pharmaceutical industry’s current talent management practices work against the development of deep process ownership. Organizations prioritize broad exposure over deep expertise, encourage frequent role changes to accelerate career progression, and reward visible achievements over sustained system stewardship.

This approach has several drivers, most of them understandable but ultimately counterproductive:

  • Career Development Myths: The belief that career progression requires constant role changes, preventing the development of deep expertise in any single area. This creates professionals with broad but shallow knowledge who lack the depth necessary to drive breakthrough improvement.
  • Organizational Impatience: Pressure to demonstrate rapid improvement, leading to premature conclusions about process owner effectiveness and frequent role changes before mastery can develop. This prevents organizations from realizing the compound benefits of sustained process ownership.
  • Risk Aversion: Concern that deep specialization creates single points of failure, leading to policies that distribute knowledge across multiple people rather than developing true expertise. This approach reduces organizational vulnerability to individual departures but eliminates the possibility of breakthrough improvement that requires deep understanding.
  • Measurement Misalignment: Performance management systems that reward visible activity over sustained stewardship, creating incentives for process owners to focus on quick wins rather than long-term system development.

The result is what I observe throughout the industry: sophisticated quality systems managed by well-intentioned professionals who lack the deep process knowledge necessary to drive genuine improvement. We have created environments where people are rewarded for managing systems they don’t truly understand, leading to the elaborate compliance theater that satisfies auditors but fails to protect patients.

Building Genuine Process Ownership Capability

Creating conditions for deep process ownership requires intentional organizational design that supports sustained engagement rather than constant rotation. This isn’t about keeping people in the same roles indefinitely—it’s about creating career paths that value depth alongside breadth and recognize the compound benefits of sustained expertise development.

Redefining Career Success: Organizations must develop career models that reward deep expertise alongside traditional progression. This means creating senior individual contributor roles, recognizing process mastery in compensation and advancement decisions, and celebrating sustained system stewardship as a form of leadership.

Supporting Long-term Engagement: Process owners need organizational support to sustain motivation through the inevitable plateaus and frustrations of deep system work. This includes providing resources for continuous learning, connecting them with external expertise, and ensuring their contributions are visible to senior leadership.

Creating Learning Infrastructure: Deep process ownership requires systematic approaches to knowledge capture, reflection, and improvement. Organizations must provide time and tools for process owners to document insights, conduct retrospective analyses, and share learning across the organization.

Building Technical Career Paths: The industry needs career models that allow technical professionals to advance without moving into management roles that distance them from process ownership. This requires creating parallel advancement tracks, appropriate compensation structures, and recognition systems that value technical leadership.

Measuring Long-term Value: Performance management systems must evolve to recognize the compound benefits of sustained process ownership. This means developing metrics that capture system stability, improvement consistency, and knowledge development rather than focusing exclusively on short-term achievements.

The Connection to Jobs-to-Be-Done

The Jobs-to-Be-Done tool I explored iprovides valuable insight into why process ownership requires sustained engagement. Organizations don’t hire process owners to execute procedures—they hire them to accomplish several complex jobs that require deep system understanding:

Knowledge Development: Building comprehensive understanding of process behavior, failure modes, and improvement opportunities that enables predictive rather than reactive management.

System Stewardship: Maintaining process health through minor adjustments, preventive actions, and continuous optimization that prevents major failures and enables consistent performance.

Change Leadership: Driving improvements that require deep technical understanding, stakeholder engagement, and change management capabilities developed through sustained experience.

Organizational Memory: Serving as repositories of process history, lessons learned, and contextual knowledge that prevents the repetition of past mistakes and enables informed decision-making.

Each of these jobs requires sustained engagement to accomplish effectively. The process owner who moves to a new role after 18 months may have learned the procedures, but they haven’t developed the deep understanding necessary to excel at these higher-order responsibilities.

The Path Forward: Embracing the Long View

We need to fundamentally rethink how we develop and deploy process ownership capability in pharmaceutical quality systems. This means acknowledging that true expertise takes time, creating organizational conditions that support sustained engagement, and recognizing the compound benefits of deep process knowledge.

The choice is clear: continue cycling process owners through abbreviated assignments that prevent the development of genuine expertise, or build career models and organizational practices that enable deep process ownership to flourish. In an industry where process failures can result in patient harm, product recalls, and regulatory action, only the latter approach offers genuine protection.

True process ownership isn’t something we implement because best practices require it. It’s a capability we actively cultivate because it makes us demonstrably better at protecting patients and ensuring product quality. When we design organizational systems around the jobs that deep process ownership accomplishes—knowledge development, system stewardship, change leadership, and organizational memory—we create competitive advantages that extend far beyond compliance.

Organizations that recognize the value of sustained process ownership and create conditions for its development will build capabilities that enable breakthrough improvement and genuine competitive advantage. Those that continue to treat process ownership as a rotational assignment will remain trapped in the cycle of elaborate compliance theater that satisfies auditors but fails to serve the fundamental purpose of pharmaceutical manufacturing.

Process ownership should not be something we implement because organizational charts require it. It should be a capability we actively develop because it makes us demonstrably better at the work that matters: protecting patients, ensuring product quality, and advancing the science of pharmaceutical manufacturing. When we embrace the deep ownership paradox—that mastery requires time, patience, and sustained engagement—we create the conditions for the kind of breakthrough improvement that our industry desperately needs.

In quality systems, as in life, the most valuable capabilities cannot be rushed, shortcuts cannot be taken, and true expertise emerges only through sustained engagement with the work that matters. This isn’t just good advice for individual career development—it’s the foundation for building pharmaceutical quality systems that genuinely serve patients and advance human health.

Further Reading

Kausar, F., Ijaz, M. U., Rasheed, M., Suhail, A., & Islam, U. (2025). Empowered, accountable, and committed? Applying self-determination theory to examine work-place procrastination. BMC Psychology13, 620. https://doi.org/10.1186/s40359-025-02968-7

Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC12144702/

Kim, A. J., & Chung, M.-H. (2023). Psychological ownership and ambivalent employee behaviors: A moderated mediation model. SAGE Open13(1). https://doi.org/10.1177/21582440231162535

Available at: https://journals.sagepub.com/doi/full/10.1177/21582440231162535

Wright, T. A., & Bonett, D. G. (2002). The moderating effects of employee tenure on the relation between organizational commitment and job performance: A meta-analysis. Journal of Applied Psychology87(6), 1183-1190. https://doi.org/10.1037/0021-9010.87.6.1183

Available at: https://pubmed.ncbi.nlm.nih.gov/12558224/

Risk Blindness: The Invisible Threat

Risk blindness is an insidious loss of organizational perception—the gradual erosion of a company’s ability to recognize, interpret, and respond to threats that undermine product safety, regulatory compliance, and ultimately, patient trust. It is not merely ignorance or oversight; rather, risk blindness manifests as the cumulative inability to see threats, often resulting from process shortcuts, technology overreliance, and the undervaluing of hands-on learning.

Unlike risk aversion or neglect, which involves conscious choices, risk blindness is an unconscious deficiency. It often stems from structural changes like the automation of foundational jobs, fragmented risk ownership, unchallenged assumptions, and excessive faith in documentation or AI-generated reports. At its core, risk blindness breeds a false sense of security and efficiency while creating unseen vulnerabilities.

Pattern Recognition and Risk Blindness: The Cognitive Foundation of Quality Excellence

The Neural Architecture of Risk Detection

Pattern recognition lies at the heart of effective risk management in quality systems. It represents the sophisticated cognitive process by which experienced professionals unconsciously scan operational environments, data trends, and behavioral cues to detect emerging threats before they manifest as full-scale quality events. This capability distinguishes expert practitioners from novices and forms the foundation of what we might call “risk literacy” within quality organizations.

The development of pattern recognition in pharmaceutical quality follows predictable stages. At the most basic level (Level 1 Situational Awareness), professionals learn to perceive individual elements—deviation rates, environmental monitoring trends, supplier performance metrics. However, true expertise emerges at Level 2 (Comprehension), where practitioners begin to understand the relationships between these elements, and Level 3 (Projection), where they can anticipate future system states based on current patterns.

Research in clinical environments demonstrates that expert pattern recognition relies on matching current situational elements with previously stored patterns and knowledge, creating rapid, often unconscious assessments of risk significance. In pharmaceutical quality, this translates to the seasoned professional who notices that “something feels off” about a batch record, even when all individual data points appear within specification, or the environmental monitoring specialist who recognizes subtle trends that precede contamination events.

The Apprenticeship Dividend: Building Pattern Recognition Through Experience

The development of sophisticated pattern recognition capabilities requires what we’ve previously termed the “apprenticeship dividend”—the cumulative learning that occurs through repeated exposure to routine operations, deviations, and corrective actions. This learning cannot be accelerated through technology or condensed into senior-level training programs; it must be built through sustained practice and mentored reflection.

The Stages of Pattern Recognition Development:

Foundation Stage (Years 1-2): New professionals learn to identify individual risk elements—understanding what constitutes a deviation, recognizing out-of-specification results, and following investigation procedures. Their pattern recognition is limited to explicit, documented criteria.

Integration Stage (Years 3-5): Practitioners begin to see relationships between different quality elements. They notice when environmental monitoring trends correlate with equipment issues, or when supplier performance changes precede raw material problems. This represents the emergence of tacit knowledge—insights that are difficult to articulate but guide decision-making.

Mastery Stage (Years 5+): Expert practitioners develop what researchers call “intuitive expertise”—the ability to rapidly assess complex situations and identify subtle risk patterns that others miss. They can sense when a investigation is heading in the wrong direction, recognize when supplier responses are evasive, or detect process drift before it appears in formal metrics.

Tacit Knowledge: The Uncodifiable Foundation of Risk Assessment

Perhaps the most critical aspect of pattern recognition in pharmaceutical quality is the role of tacit knowledge—the experiential wisdom that cannot be fully documented or transmitted through formal training systems. Tacit knowledge encompasses the subtle cues, contextual understanding, and intuitive insights that experienced professionals develop through years of hands-on practice.

In pharmaceutical quality systems, tacit knowledge manifests in numerous ways:

  • Knowing which equipment is likely to fail after cleaning cycles, based on subtle operational cues rather than formal maintenance schedules
  • Recognizing when supplier audit responses are technically correct but practically inadequate
  • Sensing when investigation teams are reaching premature closure without adequate root cause analysis
  • Detecting process drift through operator reports and informal observations before it appears in formal monitoring data

This tacit knowledge cannot be captured in standard operating procedures or electronic systems. It exists in the experienced professional’s ability to read “between the lines” of formal data, to notice what’s missing from reports, and to sense when organizational pressures are affecting the quality of risk assessments.

The GI Joe Fallacy: The Dangers of “Knowing is Half the Battle”

A persistent—and dangerous—belief in quality organizations is the idea that simply knowing about risks, standards, or biases will prevent us from falling prey to them. This is known as the GI Joe fallacy—the misguided notion that awareness is sufficient to overcome cognitive biases or drive behavioral change.

What is the GI Joe Fallacy?

Inspired by the classic 1980s G.I. Joe cartoons, which ended each episode with “Now you know. And knowing is half the battle,” the GI Joe fallacy describes the disconnect between knowledge and action. Cognitive science consistently shows that knowing about biases or desired actions does not ensure that individuals or organizations will behave accordingly.

Even the founder of bias research, Daniel Kahneman, has noted that reading about biases doesn’t fundamentally change our tendency to commit them. Organizations often believe that training, SOPs, or system prompts are enough to inoculate staff against error. In reality, knowledge is only a small part of the battle; much larger are the forces of habit, culture, distraction, and deeply rooted heuristics.

GI Joe Fallacy in Quality Risk Management

In pharmaceutical quality risk management, the GI Joe fallacy can have severe consequences. Teams may know the details of risk matrices, deviation procedures, and regulatory requirements, yet repeatedly fail to act with vigilance or critical scrutiny in real situations. Loss aversion, confirmation bias, and overconfidence persist even for those trained in their dangers.

For example, base rate neglect—a bias where salient event data distracts from underlying probabilities—can influence decisions even when staff know better intellectually. This manifests in investigators overreacting to recent dramatic events while ignoring stable process indicators. Knowing about risk frameworks isn’t enough; structures and culture must be designed specifically to challenge these biases in practice, not simply in theory.

Structural Roots of Risk Blindness

The False Economy of Automation and Overconfidence

Risk blindness often arises from a perceived efficiency gained through process automation or the curtailment of on-the-ground learning. When organizations substitute active engagement for passive oversight, staff lose critical exposure to routine deviations and process variables.

Senior staff who only approve system-generated risk assessments lack daily operational familiarity, making them susceptible to unseen vulnerabilities. Real risk assessment requires repeated, active interaction with process data—not just a review of output.

Fragmented Ownership and Deficient Learning Culture

Risk ownership must be robust and proximal. When roles are fragmented—where the “system” manages risk and people become mere approvers—vital warnings can be overlooked. A compliance-oriented learning culture that believes training or SOPs are enough to guard against operational threats falls deeper into the GI Joe fallacy: knowledge is mistaken for vigilance.

Instead, organizations need feedback loops, reflection, and opportunities to surface doubts and uncertainties. Training must be practical and interactive, not limited to information transfer.

Zemblanity: The Shadow of Risk Blindness

Zemblanity is the antithesis of serendipity in the context of pharmaceutical quality—it describes the persistent tendency for organizations to encounter negative, foreseeable outcomes when risk signals are repeatedly ignored, misunderstood, or left unacted upon.

When examining risk blindness, zemblanity stands as the practical outcome: a quality system that, rather than stumbling upon unexpected improvements or positive turns, instead seems trapped in cycles of self-created adversity. Unlike random bad luck, zemblanity results from avoidable and often visible warning signs—deviations that are rationalized, oversight meetings that miss the point, and cognitive biases like the GI Joe fallacy that lull teams into a false sense of mastery

Real-World Manifestations

Case: The Disappearing Deviation

Digital batch records reduced documentation errors and deviation reports, creating an illusion of process control. But when technology transfer led to out-of-spec events, the lack of manually trained eyes meant no one was poised to detect subtle process anomalies. Staff “knew” the process in theory—yet risk blindness set in because the signals were no longer being actively, expertly interpreted. Knowledge alone was not enough.

Case: Supplier Audit Blindness

Virtual audits relying solely on documentation missed chronic training issues that onsite teams would likely have noticed. The belief that checklist knowledge and documentation sufficed prevented the team from recognizing deeper underlying risks. Here, the GI Joe fallacy made the team believe their expertise was shield enough, when in reality, behavioral engagement and observation were necessary.

Counteracting Risk Blindness: Beyond Knowing to Acting

Effective pharmaceutical quality systems must intentionally cultivate and maintain pattern recognition capabilities across their workforce. This requires structured approaches that go beyond traditional training and incorporate the principles of expertise development:

Structured Exposure Programs: New professionals need systematic exposure to diverse risk scenarios—not just successful cases, but also investigations that went wrong, supplier audits that missed problems, and process changes that had unexpected consequences. This exposure must be guided by experienced mentors who can help identify and interpret relevant patterns.

Cross-Functional Pattern Sharing: Different functional areas—manufacturing, quality control, regulatory affairs, supplier management—develop specialized pattern recognition capabilities. Organizations need systematic mechanisms for sharing these patterns across functions, ensuring that insights from one area can inform risk assessment in others.

Cognitive Diversity in Assessment Teams: Research demonstrates that diverse teams are better at pattern recognition than homogeneous groups, as different perspectives help identify patterns that might be missed by individuals with similar backgrounds and experience. Quality organizations should intentionally structure assessment teams to maximize cognitive diversity.

Systematic Challenge Processes: Pattern recognition can become biased or incomplete over time. Organizations need systematic processes for challenging established patterns—regular “red team” exercises, external perspectives, and structured devil’s advocate processes that test whether recognized patterns remain valid.

Reflective Practice Integration: Pattern recognition improves through reflection on both successes and failures. Organizations should create systematic opportunities for professionals to analyze their pattern recognition decisions, understand when their assessments were accurate or inaccurate, and refine their capabilities accordingly.

Using AI as a Learning Accelerator

AI and automation should support, not replace, human risk assessment. Tools can help new professionals identify patterns in data, but must be employed as aids to learning—not as substitutes for judgment or action.

Diagnosing and Treating Risk Blindness

Assess organizational risk literacy not by the presence of knowledge, but by the frequency of active, critical engagement with real risks. Use self-assessment questions such as:

  • Do deviation investigations include frontline voices, not just system reviewers?
  • Are new staff exposed to real processes and deviations, not just theoretical scenarios?
  • Are risk reviews structured to challenge assumptions, not merely confirm them?
  • Is there evidence that knowledge is regularly translated into action?

Why Preventing Risk Blindness Matters

Regulators evaluate quality maturity not simply by compliance, but by demonstrable capability to anticipate and mitigate risks. AI and digital transformation are intensifying the risk of the GI Joe fallacy by tempting organizations to substitute data and technology for judgment and action.

As experienced professionals retire, the gap between knowing and doing risks widening. Only organizations invested in hands-on learning, mentorship, and behavioral feedback will sustain true resilience.

Choosing Sight

Risk blindness is perpetuated by the dangerous notion that knowing is enough. The GI Joe fallacy teaches that organizational memory, vigilance, and capability require much more than knowledge—they demand deliberate structures, engaged cultures, and repeated practice that link theory to action.

Quality leaders must invest in real development, relentless engagement, and humility about the limits of their own knowledge. Only then will risk blindness be cured, and resilience secured.

The Expertise Crisis: Why AI’s War on Entry-Level Jobs Threatens Quality Excellence

As pharmaceutical and biotech organizations rush to harness artificial intelligence to eliminate “inefficient” entry-level positions, we are at risk of creating a crisis that threatens the very foundation of quality expertise. The Harvard Business Review’s recent analysis of AI’s impact on entry-level jobs reads like a prophecy of organizational doom—one that quality leaders should heed before it’s too late.

Research from Stanford indicates that there has been a 13% decline in entry-level job opportunities for workers aged 22 to 25 since the widespread adoption of generative AI. The study shows that 50-60% of typical junior tasks—such as report drafting, research synthesis, data cleaning, and scheduling—can now be performed by AI. For high-quality organizations already facing expertise gaps, this trend signals a potential self-destructive path rather than increased efficiency.

Equally concerning, automation is leading to the phasing out of some traditional entry-level professional tasks. When I started in the field, newcomers would gain experience through tasks like batch record reviews and good documentation practices for protocols. However, with the introduction of electronic batch records and electronic validation management, these tasks have largely disappeared. AI is expected to accelerate this trend even further.

Everyone should go and read “The Perils of Using AI to Replace Entry-Level Jobs” by Amy C. Edmondson and Tomas Chamorro-Premuzic and then come back and read this post.

The Apprenticeship Dividend: What We Lose When We Skip the Journey

Every expert in pharmaceutical quality began somewhere. They learned to read batch records, investigated their first deviations, struggled through their first CAPA investigations, and gradually developed the pattern recognition that distinguishes competent from exceptional quality professionals. This journey, what the Edmondson and Chamorro-Premuzic call the “apprenticeship dividend”, cannot be replicated by AI or compressed into senior-level training programs.

Consider commissioning, qualification, and validation (CQV) work in biotech manufacturing. Junior engineers traditionally started by documenting Installation Qualification protocols, learning to recognize when equipment specifications align with user requirements. They progressed to Operational Qualification, developing understanding of how systems behave under various conditions. Only after this foundation could they effectively design Performance Qualification strategies that demonstrate process capability.

When organizations eliminate these entry-level CQV roles in favor of AI-generated documentation and senior engineers managing multiple systems simultaneously, they create what appears to be efficiency. In reality, they’ve severed the pipeline that transforms technical contributors into systems thinkers capable of managing complex manufacturing operations.

The Expertise Pipeline: Building Quality Gardeners

As I’ve written previously about building competency frameworks for quality professionals, true expertise requires integration of technical knowledge, methodological skills, social capabilities, and self-management abilities. This integration occurs through sustained practice, mentorship, and gradual assumption of responsibility—precisely what entry-level positions provide.

The traditional path from Quality specialist to Quality Manager to Quality Director illustrates this progression:

Foundation Level: Learning to execute quality methods methods, understand requirements, and recognize when results fall outside acceptance criteria. Basic deviation investigation and CAPA support.

Intermediate Level: Taking ownership of requirement gathering, leading routine investigations, participating in supplier audits, and beginning to see connections between different quality systems.

Advanced Level: Designing audit activities, facilitating cross-functional investigations, mentoring junior staff, and contributing to strategic quality initiatives.

Leadership Level: Building quality cultures, designing organizational capabilities, and creating systems that enable others to excel.

Each level builds upon the previous, creating what we might call “quality gardeners”—professionals who nurture quality systems as living ecosystems rather than enforcing compliance through rigid oversight. Skip the foundation levels, and you cannot develop the sophisticated understanding required for advanced practice.

The False Economy of AI Substitution

Organizations defending entry-level job elimination often point to cost savings and “efficiency gains.” This thinking reflects a fundamental misunderstanding of how expertise develops and quality systems function. Consider risk management in biotech manufacturing—a domain where pattern recognition and contextual judgment are essential.

A senior risk management professional reviewing a contamination event can quickly identify potential failure modes, assess likelihood and severity, and design effective mitigation strategies. This capability developed through years of investigating routine deviations, participating in CAPA teams, and learning to distinguish significant risks from minor variations.

When AI handles initial risk assessments and senior professionals review only the outputs, we create a dangerous gap. The senior professional lacks the deep familiarity with routine variations that enables recognition of truly significant deviations. Meanwhile, no one is developing the foundational expertise needed to replace retiring experts.

The result is what is called expertise hollowing, organizations that appear capable on the surface but lack the deep competency required to handle complex challenges or adapt to changing conditions.

Building Expertise in a Quality Organization

Creating robust expertise development requires intentional design that recognizes both the value of human development and the capabilities of AI tools. Rather than eliminating entry-level positions, quality organizations should redesign them to maximize learning value while leveraging AI appropriately.

Structured Apprenticeship Programs

Quality organizations should implement formal apprenticeship programs that combine academic learning with progressive practical responsibility. These programs should span 2-3 years and include:

Year 1: Foundation Building

  • Basic GMP principles and quality systems overview
  • Hands-on experience with routine quality operations
  • Mentorship from experienced quality professionals
  • Participation in investigations under supervision

Year 2: Skill Development

  • Specialized training in areas like CQV, risk management, or supplier quality
  • Leading routine activities with oversight
  • Cross-functional project participation
  • Beginning to train newer apprentices

Year 3: Integration and Leadership

  • Independent project leadership
  • Mentoring responsibilities
  • Contributing to strategic quality initiatives
  • Preparation for advanced roles

As I evaluate the organization I am building, this is a critical part of the vision.

Mentorship as Core Competency

Every senior quality professional should be expected to mentor junior colleagues as a core job responsibility, not an additional burden. This requires:

  • Formal Mentorship Training: Teaching experienced professionals how to transfer tacit knowledge, provide effective feedback, and create learning opportunities.
  • Protected Time: Ensuring mentors have dedicated time for development activities, not just “additional duties as assigned.”
  • Measurement Systems: Tracking mentorship effectiveness through apprentice progression, retention rates, and long-term career development.
  • Recognition Programs: Rewarding excellent mentorship as a valued contribution to organizational capability.

Progressive Responsibility Models

Entry-level roles should be designed with clear progression pathways that gradually increase responsibility and complexity:

CQV Progression Example:

  • CQV Technician: Executing test protocols, documenting results, supporting commissioning activities
  • CQV Specialist: Writing protocols, leading qualification activities, interfacing with vendors
  • CQV Engineer: Designing qualification strategies, managing complex projects, training others
  • CQV Manager: Building organizational CQV capabilities, strategic planning, external representation

Risk Management Progression:

  • Risk Analyst: Data collection, basic risk identification, supporting formal assessments
  • Risk Specialist: Facilitating risk assessments, developing mitigation strategies, training stakeholders
  • Risk Manager: Designing risk management systems, building organizational capabilities, strategic oversight

AI as Learning Accelerator, Not Replacement

Rather than replacing entry-level workers, AI should be positioned as a learning accelerator that enables junior professionals to handle more complex work earlier in their careers:

  • Enhanced Analysis Capabilities: AI can help junior professionals identify patterns in large datasets, enabling them to focus on interpretation and decision-making rather than data compilation.
  • Simulation and Modeling: AI-powered simulations can provide safe environments for junior professionals to practice complex scenarios without real-world consequences.
  • Knowledge Management: AI can help junior professionals access relevant historical examples, best practices, and regulatory guidance more efficiently.
  • Quality Control: AI can help ensure that junior professionals’ work meets standards while they’re developing expertise, providing a safety net during the learning process.

The Cost of Expertise Shortcuts

Organizations that eliminate entry-level positions in pursuit of short-term efficiency gains will face predictable long-term consequences:

  • Expertise Gaps: As senior professionals retire or move to other organizations, there will be no one prepared to replace them.
  • Reduced Innovation: Innovation often comes from fresh perspectives questioning established practices—precisely what entry-level employees provide.
  • Cultural Degradation: Quality cultures are maintained through socialization and shared learning experiences that occur naturally in diverse, multi-level teams.
  • Risk Blindness: Without the deep familiarity that comes from hands-on experience, organizations become vulnerable to risks they cannot recognize or understand.
  • Competitive Disadvantage: Organizations with strong expertise development programs will attract and retain top talent while building superior capabilities.

Choosing Investment Over Extraction

The decision to eliminate entry-level positions represents a choice between short-term cost extraction and long-term capability investment. For quality organizations, this choice is particularly stark because our work depends fundamentally on human judgment, pattern recognition, and the ability to adapt to novel situations.

AI should augment human capability, not replace the human development process. The organizations that thrive in the next decade will be those that recognize expertise development as a core competency and invest accordingly. They will build “quality gardeners” who can nurture adaptive, resilient quality systems rather than simply enforce compliance.

The expertise crisis is not inevitable—it’s a choice. Quality leaders must choose wisely, before the cost of that choice becomes irreversible.

Navigating the Evidence-Practice Divide: Building Rigorous Quality Systems in an Age of Pop Psychology

I think we all have a central challenge in our professional life: How do we distinguish between genuine scientific insights that enhance our practice and the seductive allure of popularized psychological concepts that promise quick fixes but deliver questionable results. This tension between rigorous evidence and intuitive appeal represents more than an academic debate, it strikes at the heart of our professional identity and effectiveness.

The emergence of emotional intelligence as a dominant workplace paradigm exemplifies this challenge. While interpersonal skills undoubtedly matter in quality management, the uncritical adoption of psychological frameworks without scientific scrutiny creates what Dave Snowden aptly terms the “Woozle effect”—a phenomenon where repeated citation transforms unvalidated concepts into accepted truth. As quality thinkers, we must navigate this landscape with both intellectual honesty and practical wisdom, building systems that honor the genuine insights about human behavior while maintaining rigorous standards for evidence.

This exploration connects directly to the cognitive foundations of risk management excellence we’ve previously examined. The same systematic biases that compromise risk assessments—confirmation bias, anchoring effects, and overconfidence—also make us vulnerable to appealing but unsubstantiated management theories. By understanding these connections, we can develop more robust approaches that integrate the best of scientific evidence with the practical realities of human interaction in quality systems.

The Seductive Appeal of Pop Psychology in Quality Management

The proliferation of psychological concepts in business environments reflects a genuine need. Quality professionals recognize that technical competence alone cannot ensure organizational success. We need effective communication, collaborative problem-solving, and the ability to navigate complex human dynamics. This recognition creates fertile ground for frameworks that promise to unlock the mysteries of human behavior and transform our organizational effectiveness.

However, the popularity of concepts like emotional intelligence often stems from their intuitive appeal rather than their scientific rigor. As Professor Merve Emre’s critique reveals, such frameworks can become “morality plays for a secular era, performed before audiences of mainly white professionals”. They offer the comfortable illusion of control over complex interpersonal dynamics while potentially obscuring more fundamental issues of power, inequality, and systemic dysfunction.

The quality profession’s embrace of these concepts reflects our broader struggle with what researchers call “pseudoscience at work”. Despite our commitment to evidence-based thinking in technical domains, we can fall prey to the same cognitive biases that affect other professionals. The competitive nature of modern quality management creates pressure to adopt the latest insights, leading us to embrace concepts that feel innovative and transformative without subjecting them to the same scrutiny we apply to our technical methodologies.

This phenomenon becomes particularly problematic when we consider the Woozle effect in action. Dave Snowden’s analysis demonstrates how concepts can achieve credibility through repeated citation rather than empirical validation. In the echo chambers of professional conferences and business literature, unvalidated theories gain momentum through repetition, eventually becoming embedded in our standard practices despite lacking scientific foundation.

The Cognitive Architecture of Quality Decision-Making

Understanding why quality professionals become susceptible to popularized psychological concepts requires examining the cognitive architecture underlying our decision-making processes. The same mechanisms that enable our technical expertise can also create vulnerabilities when applied to interpersonal and organizational challenges.

Our professional training emphasizes systematic thinking, data-driven analysis, and evidence-based conclusions. These capabilities serve us well in technical domains where variables can be controlled and measured. However, when confronting the messier realities of human behavior and organizational dynamics, we may unconsciously lower our evidentiary standards, accepting frameworks that align with our intuitions rather than demanding the same level of proof we require for technical decisions.

This shift reflects what cognitive scientists call “domain-specific expertise limitations.” Our deep knowledge in quality systems doesn’t automatically transfer to psychology or organizational behavior. Yet our confidence in our technical judgment can create overconfidence in our ability to evaluate non-technical concepts, leading to what researchers identify as a key vulnerability in professional decision-making.

The research on cognitive biases in professional settings reveals consistent patterns across management, finance, medicine, and law. Overconfidence emerges as the most pervasive bias, leading professionals to overestimate their ability to evaluate evidence outside their domain of expertise. In quality management, this might manifest as quick adoption of communication frameworks without questioning their empirical foundation, or assuming that our systematic thinking skills automatically extend to understanding human psychology.

Confirmation bias compounds this challenge by leading us to seek information that supports our preferred approaches while ignoring contradictory evidence. If we find an interpersonal framework appealing, perhaps because it aligns with our values or promises to solve persistent challenges, we may unconsciously filter available information to support our conclusion. This creates the self-reinforcing cycles that allow questionable concepts to become embedded in our practice.

Evidence-Based Approaches to Interpersonal Effectiveness

The solution to the pop psychology problem doesn’t lie in dismissing the importance of interpersonal skills or communication effectiveness. Instead, it requires applying the same rigorous standards to behavioral insights that we apply to technical knowledge. This means moving beyond frameworks that merely feel right toward approaches grounded in systematic research and validated through empirical study.

Evidence-based management provides a framework for navigating this challenge. Rather than relying solely on intuition, tradition, or popular trends, evidence-based approaches emphasize the systematic use of four sources of evidence: scientific literature, organizational data, professional expertise, and stakeholder perspectives. This framework enables us to evaluate interpersonal and communication concepts with the same rigor we apply to technical decisions.

Scientific literature offers the most robust foundation for understanding interpersonal effectiveness. Research in organizational psychology, communication science, and related fields provides extensive evidence about what actually works in workplace interactions. For example, studies on psychological safety demonstrate clear relationships between specific leadership behaviors and team performance outcomes. This research enables us to move beyond generic concepts like “emotional intelligence” toward specific, actionable insights about creating environments where teams can perform effectively.

Organizational data provides another crucial source of evidence for evaluating interpersonal approaches. Rather than assuming that communication training programs or team-building initiatives are effective, we can measure their actual impact on quality outcomes, employee engagement, and organizational performance. This data-driven approach helps distinguish between interventions that feel good and those that genuinely improve results.

Professional expertise remains valuable, but it must be systematically captured and validated rather than simply accepted as received wisdom. This means documenting the reasoning behind successful interpersonal approaches, testing assumptions about what works, and creating mechanisms for updating our understanding as new evidence emerges. The risk management excellence framework we’ve previously explored provides a model for this systematic approach to knowledge management.

The Integration Challenge: Systematic Thinking Meets Human Reality

The most significant challenge facing quality professionals lies in integrating rigorous, evidence-based approaches with the messy realities of human interaction. Technical systems can be optimized through systematic analysis and controlled improvement, but human systems involve emotions, relationships, and cultural dynamics that resist simple optimization approaches.

This integration challenge requires what we might call “systematic humility“—the recognition that our technical expertise creates capabilities but also limitations. We can apply systematic thinking to interpersonal challenges, but we must acknowledge the increased uncertainty and complexity involved. This doesn’t mean abandoning rigor; instead, it means adapting our approaches to acknowledge the different evidence standards and validation methods required for human-centered interventions.

The cognitive foundations of risk management excellence provide a useful model for this integration. Just as effective risk management requires combining systematic analysis with recognition of cognitive limitations, effective interpersonal approaches require combining evidence-based insights with acknowledgment of human complexity. We can use research on communication effectiveness, team dynamics, and organizational behavior to inform our approaches while remaining humble about the limitations of our knowledge.

One practical approach involves treating interpersonal interventions as experiments rather than solutions. Instead of implementing communication training programs or team-building initiatives based on popular frameworks, we can design systematic pilots that test specific hypotheses about what will improve outcomes in our particular context. This experimental approach enables us to learn from both successes and failures while building organizational knowledge about what actually works.

The systems thinking perspective offers another valuable framework for integration. Rather than viewing interpersonal skills as individual capabilities separate from technical systems, we can understand them as components of larger organizational systems. This perspective helps us recognize how communication patterns, relationship dynamics, and cultural factors interact with technical processes to influence quality outcomes.

Systems thinking also emphasizes feedback loops and emergent properties that can’t be predicted from individual components. In interpersonal contexts, this means recognizing that the effectiveness of communication approaches depends on context, relationships, and organizational culture in ways that may not be immediately apparent. This systemic perspective encourages more nuanced approaches that consider the broader organizational ecosystem rather than assuming that generic interpersonal frameworks will work universally.

Building Knowledge-Enabled Quality Systems

The path forward requires developing what we can call “knowledge-enabled quality systems“—organizational approaches that systematically integrate evidence about both technical and interpersonal effectiveness while maintaining appropriate skepticism about unvalidated claims. These systems combine the rigorous analysis we apply to technical challenges with equally systematic approaches to understanding and improving human dynamics.

Knowledge-enabled systems begin with systematic evidence requirements that apply across all domains of quality management. Whether evaluating a new measurement technology or a communication framework, we should require similar levels of evidence about effectiveness, limitations, and appropriate application contexts. This doesn’t mean identical evidence—the nature of proof differs between technical and behavioral domains—but it does mean consistent standards for what constitutes adequate justification for adopting new approaches.

These systems also require structured approaches to capturing and validating organizational knowledge about interpersonal effectiveness. Rather than relying on informal networks or individual expertise, we need systematic methods for documenting what works in specific contexts, testing assumptions about effective approaches, and updating our understanding as conditions change. The knowledge management principles discussed in our risk management excellence framework provide a foundation for these systematic approaches.

Cognitive bias mitigation becomes particularly important in knowledge-enabled systems because the stakes of interpersonal decisions can be as significant as technical ones. Poor communication can undermine the best technical solutions, while ineffective team dynamics can prevent organizations from identifying and addressing quality risks. This means applying the same systematic approaches to bias recognition and mitigation that we use in technical risk assessment.

The development of these systems requires what we might call “transdisciplinary competence”—the ability to work effectively across technical and behavioral domains while maintaining appropriate standards for evidence and validation in each. This competence involves understanding the different types of evidence available in different domains, recognizing the limitations of our expertise across domains, and developing systematic approaches to learning and validation that work across different types of challenges.

From Theory to Organizational Reality

Translating these concepts into practical organizational improvements requires systematic approaches that can be implemented incrementally while building toward more comprehensive transformation. The maturity model framework provides a useful structure for understanding this progression.

Cognitive BiasQuality ImpactCommunication ManifestationEvidence-Based Countermeasure
Confirmation BiasCherry-picking data that supports existing beliefsDismissing challenging feedback from teamsStructured devil’s advocate processes
Anchoring BiasOver-relying on initial risk assessmentsSetting expectations based on limited initial informationMultiple perspective requirements
Availability BiasFocusing on recent/memorable incidents over data patternsEmphasizing dramatic failures over systematic trendsData-driven trend analysis over anecdotes
Overconfidence BiasUnderestimating uncertainty in complex systemsOverestimating ability to predict team responsesConfidence intervals and uncertainty quantification
GroupthinkSuppressing dissenting views in risk assessmentsAvoiding difficult conversations to maintain harmonyDiverse team composition and external review
Sunk Cost FallacyContinuing ineffective programs due to past investmentDefending communication strategies despite poor resultsRegular program evaluation with clear exit criteria

Organizations beginning this journey typically operate at the reactive level, where interpersonal approaches are adopted based on popularity, intuition, or immediate perceived need rather than systematic evaluation. Moving toward evidence-based interpersonal effectiveness requires progressing through increasingly sophisticated approaches to evidence gathering, validation, and integration.

The developing level involves beginning to apply evidence standards to interpersonal approaches while maintaining flexibility about the types of evidence required. This might include piloting communication frameworks with clear success metrics, gathering feedback data about team effectiveness initiatives, or systematically documenting the outcomes of different approaches to stakeholder engagement.

Systematic-level organizations develop formal processes for evaluating and implementing interpersonal interventions with the same rigor applied to technical improvements. This includes structured approaches to literature review, systematic pilot design, clear success criteria, and documented decision rationales. At this level, organizations treat interpersonal effectiveness as a systematic capability rather than a collection of individual skills.

DomainScientific FoundationInterpersonal ApplicationQuality Outcome
Risk AssessmentSystematic hazard analysis, quantitative modelingCollaborative assessment teams, stakeholder engagementComprehensive risk identification, bias-resistant decisions
Team CommunicationCommunication effectiveness research, feedback metricsActive listening, psychological safety, conflict resolutionEnhanced team performance, reduced misunderstandings
Process ImprovementStatistical process control, designed experimentsCross-functional problem solving, team-based implementationSustainable improvements, organizational learning
Training & DevelopmentLearning theory, competency-based assessmentMentoring, peer learning, knowledge transferCompetent workforce, knowledge retention
Performance ManagementBehavioral analytics, objective measurementRegular feedback conversations, development planningMotivated teams, continuous improvement mindset
Change ManagementChange management research, implementation scienceStakeholder alignment, resistance management, culture buildingSuccessful transformation, organizational resilience

Integration-level organizations embed evidence-based approaches to interpersonal effectiveness throughout their quality systems. Communication training becomes part of comprehensive competency development programs grounded in learning science. Team dynamics initiatives connect directly to quality outcomes through systematic measurement and feedback. Stakeholder engagement approaches are selected and refined based on empirical evidence about effectiveness in specific contexts.

The optimizing level involves sophisticated approaches to learning and adaptation that treat both technical and interpersonal challenges as part of integrated quality systems. Organizations at this level use predictive analytics to identify potential interpersonal challenges before they impact quality outcomes, apply systematic approaches to cultural change and development, and contribute to broader professional knowledge about effective integration of technical and behavioral approaches.

LevelApproach to EvidenceInterpersonal CommunicationRisk ManagementKnowledge Management
1 – ReactiveAd-hoc, opinion-based decisionsRelies on traditional hierarchies, informal networksReactive problem-solving, limited risk awarenessTacit knowledge silos, informal transfer
2 – DevelopingOccasional use of data, mixed with intuitionRecognizes communication importance, limited trainingBasic risk identification, inconsistent mitigationBasic documentation, limited sharing
3 – SystematicConsistent evidence requirements, structured analysisStructured communication protocols, feedback systemsFormal risk frameworks, documented processesSystematic capture, organized repositories
4 – IntegratedMultiple evidence sources, systematic validationCulture of open dialogue, psychological safetyIntegrated risk-communication systems, cross-functional teamsDynamic knowledge networks, validated expertise
5 – OptimizingPredictive analytics, continuous learningAdaptive communication, real-time adjustmentAnticipatory risk management, cognitive bias monitoringSelf-organizing knowledge systems, AI-enhanced insights

Cognitive Bias Recognition and Mitigation in Practice

Understanding cognitive biases intellectually is different from developing practical capabilities to recognize and address them in real-world quality management situations. The research on professional decision-making reveals that even when people understand cognitive biases conceptually, they often fail to recognize them in their own decision-making processes.

This challenge requires systematic approaches to bias recognition and mitigation that can be embedded in routine quality management processes. Rather than relying on individual awareness or good intentions, we need organizational systems that prompt systematic consideration of potential biases and provide structured approaches to counter them.

The development of bias-resistant processes requires understanding the specific contexts where different biases are most likely to emerge. Confirmation bias becomes particularly problematic when evaluating approaches that align with our existing beliefs or preferences. Anchoring bias affects situations where initial information heavily influences subsequent analysis. Availability bias impacts decisions where recent or memorable experiences overshadow systematic data analysis.

Effective countermeasures must be tailored to specific biases and integrated into routine processes rather than applied as separate activities. Devil’s advocate processes work well for confirmation bias but may be less effective for anchoring bias, which requires multiple perspective requirements and systematic questioning of initial assumptions. Availability bias requires structured approaches to data analysis that emphasize patterns over individual incidents.

The key insight from cognitive bias research is that awareness alone is insufficient for bias mitigation. Effective approaches require systematic processes that make bias recognition routine and provide concrete steps for addressing identified biases. This means embedding bias checks into standard procedures, training teams in specific bias recognition techniques, and creating organizational cultures that reward systematic thinking over quick decision-making.

The Future of Evidence-Based Quality Practice

The evolution toward evidence-based quality practice represents more than a methodological shift—it reflects a fundamental maturation of our profession. As quality management becomes increasingly complex and consequential, we must develop more sophisticated approaches to distinguishing between genuine insights and appealing but unsubstantiated concepts.

This evolution requires what we might call “methodological pluralism”—the recognition that different types of questions require different approaches to evidence gathering and validation while maintaining consistent standards for rigor and critical evaluation. Technical questions can often be answered through controlled experiments and statistical analysis, while interpersonal effectiveness may require ethnographic study, longitudinal observation, and systematic case analysis.

The development of this methodological sophistication will likely involve closer collaboration between quality professionals and researchers in organizational psychology, communication science, and related fields. Rather than adopting popularized versions of behavioral insights, we can engage directly with the underlying research to understand both the validated findings and their limitations.

Technology will play an increasingly important role in enabling evidence-based approaches to interpersonal effectiveness. Communication analytics can provide objective data about information flow and interaction patterns. Sentiment analysis and engagement measurement can offer insights into the effectiveness of different approaches to stakeholder communication. Machine learning can help identify patterns in organizational behavior that might not be apparent through traditional analysis.

However, technology alone cannot address the fundamental challenge of developing organizational cultures that value evidence over intuition, systematic analysis over quick solutions, and intellectual humility over overconfident assertion. This cultural transformation requires leadership commitment, systematic training, and organizational systems that reinforce evidence-based thinking across all domains of quality management.

Organizational Learning and Knowledge Management

The systematic integration of evidence-based approaches to interpersonal effectiveness requires sophisticated approaches to organizational learning that can capture insights from both technical and behavioral domains while maintaining appropriate standards for validation and application.

Traditional approaches to organizational learning often treat interpersonal insights as informal knowledge that spreads through networks and mentoring relationships. While these mechanisms have value, they also create vulnerabilities to the transmission of unvalidated concepts and the perpetuation of approaches that feel effective but lack empirical support.

Evidence-based organizational learning requires systematic approaches to capturing, validating, and disseminating insights about interpersonal effectiveness. This includes documenting the reasoning behind successful communication approaches, testing assumptions about what works in different contexts, and creating systematic mechanisms for updating understanding as new evidence emerges.

The knowledge management principles from our risk management excellence work provide a foundation for these systematic approaches. Just as effective risk management requires systematic capture and validation of technical knowledge, effective interpersonal approaches require similar systems for behavioral insights. This means creating repositories of validated communication approaches, systematic documentation of context-specific effectiveness, and structured approaches to knowledge transfer and application.

One particularly important aspect of this knowledge management involves tacit knowledge: the experiential insights that effective practitioners develop but often cannot articulate explicitly. While tacit knowledge has value, it also creates vulnerabilities when it embeds unvalidated assumptions or biases. Systematic approaches to making tacit knowledge explicit enable organizations to subject experiential insights to the same validation processes applied to other forms of evidence.

The development of effective knowledge management systems also requires recognition of the different types of evidence available in interpersonal domains. Unlike technical knowledge, which can often be validated through controlled experiments, behavioral insights may require longitudinal observation, systematic case analysis, or ethnographic study. Organizations need to develop competencies in evaluating these different types of evidence while maintaining appropriate standards for validation and application.

Measurement and Continuous Improvement

The application of evidence-based approaches to interpersonal effectiveness requires sophisticated measurement systems that can capture both qualitative and quantitative aspects of communication, collaboration, and organizational culture while avoiding the reductionism that can make measurement counterproductive.

Traditional quality metrics focus on technical outcomes that can be measured objectively and tracked over time. Interpersonal effectiveness involves more complex phenomena that may require different measurement approaches while maintaining similar standards for validity and reliability. This includes developing metrics that capture communication effectiveness, team performance, stakeholder satisfaction, and cultural indicators while recognizing the limitations and potential unintended consequences of measurement systems.

One promising approach involves what researchers call “multi-method assessment”—the use of multiple measurement techniques to triangulate insights about interpersonal effectiveness. This might include quantitative metrics like response times and engagement levels, qualitative assessment through systematic observation and feedback, and longitudinal tracking of relationship quality and collaboration effectiveness.

The key insight from measurement research is that effective metrics must balance precision with validity—the ability to capture what actually matters rather than just what can be easily measured. In interpersonal contexts, this often means accepting greater measurement uncertainty in exchange for metrics that better reflect the complex realities of human interaction and organizational culture.

Continuous improvement in interpersonal effectiveness also requires systematic approaches to experimentation and learning that can test specific hypotheses about what works while building broader organizational capabilities over time. This experimental approach treats interpersonal interventions as systematic tests of specific assumptions rather than permanent solutions, enabling organizations to learn from both successes and failures while building knowledge about what works in their particular context.

Integration with the Quality System

The ultimate goal of evidence-based approaches to interpersonal effectiveness is not to create separate systems for behavioral and technical aspects of quality management, but to develop integrated approaches that recognize the interconnections between technical excellence and interpersonal effectiveness.

This integration requires understanding how communication patterns, relationship dynamics, and cultural factors interact with technical processes to influence quality outcomes. Poor communication can undermine the best technical solutions, while ineffective stakeholder engagement can prevent organizations from identifying and addressing quality risks. Conversely, technical problems can create interpersonal tensions that affect team performance and organizational culture.

Systems thinking provides a valuable framework for understanding these interconnections. Rather than treating technical and interpersonal aspects as separate domains, systems thinking helps us recognize how they function as components of larger organizational systems with complex feedback loops and emergent properties.

This systematic perspective also helps us avoid the reductionism that can make both technical and interpersonal approaches less effective. Technical solutions that ignore human factors often fail in implementation, while interpersonal approaches that ignore technical realities may improve relationships without enhancing quality outcomes. Integrated approaches recognize that sustainable quality improvement requires attention to both technical excellence and the human systems that implement and maintain technical solutions.

The development of integrated approaches requires what we might call “transdisciplinary competence”—the ability to work effectively across technical and behavioral domains while maintaining appropriate standards for evidence and validation in each. This competence involves understanding the different types of evidence available in different domains, recognizing the limitations of expertise across domains, and developing systematic approaches to learning and validation that work across different types of challenges.

Building Professional Maturity Through Evidence-Based Practice

The challenge of distinguishing between genuine scientific insights and popularized psychological concepts represents a crucial test of our profession’s maturity. As quality management becomes increasingly complex and consequential, we must develop more sophisticated approaches to evidence evaluation that can work across technical and interpersonal domains while maintaining consistent standards for rigor and validation.

This evolution requires moving beyond the comfortable dichotomy between technical expertise and interpersonal skills toward integrated approaches that apply systematic thinking to both domains. We must develop capabilities to evaluate behavioral insights with the same rigor we apply to technical knowledge while recognizing the different types of evidence and validation methods required in each domain.

The path forward involves building organizational cultures that value evidence over intuition, systematic analysis over quick solutions, and intellectual humility over overconfident assertion. This cultural transformation requires leadership commitment, systematic training, and organizational systems that reinforce evidence-based thinking across all aspects of quality management.

The cognitive foundations of risk management excellence provide a model for this evolution. Just as effective risk management requires systematic approaches to bias recognition and knowledge validation, effective interpersonal practice requires similar systematic approaches adapted to the complexities of human behavior and organizational culture.

The ultimate goal is not to eliminate the human elements that make quality management challenging and rewarding, but to develop more sophisticated ways of understanding and working with human reality while maintaining the intellectual honesty and systematic thinking that define our profession at its best. This represents not a rejection of interpersonal effectiveness, but its elevation to the same standards of evidence and validation that characterize our technical practice.

As we continue to evolve as a profession, our ability to navigate the evidence-practice divide will determine whether we develop into sophisticated practitioners capable of addressing complex challenges with both technical excellence and interpersonal effectiveness, or remain vulnerable to the latest trends and popularized concepts that promise easy solutions to difficult problems. The choice, and the opportunity, remains ours to make.

The future of quality management depends not on choosing between technical rigor and interpersonal effectiveness, but on developing integrated approaches that bring the best of both domains together in service of genuine organizational improvement and sustainable quality excellence. This integration requires ongoing commitment to learning, systematic approaches to evidence evaluation, and the intellectual courage to question even our most cherished assumptions about what works in human systems.

Through this commitment to evidence-based practice across all domains of quality management, we can build more robust, effective, and genuinely transformative approaches that honor both the complexity of technical systems and the richness of human experience while maintaining the intellectual honesty and systematic thinking that define excellence in our profession.