By Michael Haycock, Sr. BRC Consultant
During the holidays last year (2013) I watched almost a full day of “Mayday”. This is an hour long series where a particular “air crash” is reviewed to understand the cause. You might think for someone with close to a million miles in the air this would be bothersome but it is interesting and instructional in the detail that is taken to understand the causes of these accidents. One in particular was instructional – regardless the nature of your work – especially for service.
On May 25, 1979 American Airlines Flight 191 took off from Chicago’s O’Hare Airport. Just as the DC-10 reached air speed the left engine (pilot side) separated from the aircraft wing. While it was able to lift off, it was in the air less than a minute before it crashed – killing all 271 on the aircraft and 2 additional people on the ground. A number of other factors were complicit in the crash, but if the engine hadn’t come off, the crash would not have occurred.
Long story, short – the root cause for the failure was determined to be the maintenance. The recommended procedure from the manufacturer (MD) recommended the engine be removed from the pylon, and then the pylon was to be removed. (If removed and replaced as a complete unit, all at once, there was greater potential for structural damage.) In the interest of saving time (about 200 less hours) the engine and pylon were removed by airline maintenance as a complete unit. This was determined to have damaged the pylon mounts during the most recent maintenance – and then it was just a matter of time. (American Airlines was eventually fined $500,000 by the U.S. govt for improperly following maintenance procedures.)
While this introduction is somewhat longer than intended, there is a purpose. Procedures can keep you safe or not. Procedures must be appropriate, adequate and known…and expected to be followed.
Back on Sept 20, 2013, a passenger boarding an aircraft in Edmonton was found to have a pipe bomb in his carry on. (A fuse was running through this substantial pipe, already filled with gunpowder). After the original discovery in the bag – it wasn’t clear if he would be allowed to keep the bomb (WHAT!?) and was eventually allowed to board the plane by the CATSA (security people) without it . The RCMP was notified 4 days later (WHAT!?) of the incident. He was picked up on return flight – fined $100.00 and put on probation. While this apparently worked out OK, this is so wrong on so many levels. For security who will remove a few ounces of hand gel, something’s wrong here. There are undoubtedly procedures and supporting documentation for carrying out the security in Canadian airports. This was an obvious case of not only the documents not being followed – but of multiple pieces of a system that apparently had NO clue what the actual mission of this service was. There is an obvious need for continual review to ensure the organizations’ functions will always be carried out in the defined and structured manner expected. While there is no doubt this is a challenging service to provide, there is also no doubt that this is a service that when there is anything less than perfection – the potential outcome is disaster.
A QMS based on ISO 9001 is the ideal means to address service activities and concerns. The system would address:
- Appropriate documentation, up to date, in place, available and known.
- Required training with a required review for effectiveness.
- Periodic management review to confirm that that system is working as expected.
- Planning, to support the service.
- Clear understanding of work responsibilities.
- Objectives (I know, 100% bombs off a plane).
- Preventive actions and continual improvement
- Methods to deal with nonconformity (it is not clear what was done with the bomb – until the RCMP was contacted – 4 days later!!!).
While most service organizations are not responsible for such critical operations, the actual service provision can be almost immediate – such that a Quality System has the potential for even more value.
Some years ago I was appointed as the first division Quality Manager for a large multi-national distributor. Historically, Quality Managers had only been resident in our manufacturing divisions. (The story of why is too long to tell, but trust me it was not well received). I took the job very seriously and while searching for what was new, I came upon this “ISO” thing. I started taking training, learning and trying to understand if there was any benefit for us. The system seemed like a natural for any organization. Unfortunately the implementation process never occurred because our headquarters was closed. (Not my fault.) It would have been a great challenge because most of the management team believed quality systems were not necessary for service organizations.
Some years later while conducting audits for a registrar, I was assigned to do a “service registration” for a “TEMP” agency in a very specialized business, with Design. Because of my work with a distributor I was one of the few auditors with service experience. While most of the wording of ISO 9001 had a manufacturing connotation and still does, I had a good team mate to work with and with a little logic, we worked it out, had a great audit and left the agency with a system that was very functional for them.
Quality activities have been typically been focused on manufacturing. Tangible product lent itself to inspection and test – and – tangible defects required a tangible response. Manufacturers were forced to focus on defects because if product doesn’t work, we mostly know and it’s usually obvious (mostly). Most manufacturing and production organizations had a similar ability to determine and confirm product characteristics, with similar or comparable inspection and test equipment. If and when there was a customer complaint, the nature of the complaint could be confirmed and agreed to.
Why not quality system activities for organizations who provide a service? While there has been emphasis on registration of systems, even if using the standard as an operational tool, the service organization would find value from implementing the system from the clarity and discipline that would come from completing this activity (even if not registered). This could include banks, hospitals and health care services, municipalities, government departments, hotels, accounting firms, insurance agencies, airports, airlines, car rental agencies and even restaurant chains.
Unless, of course, services organizations always work in a state of perfection.
Ever know a bank to make a mistake?
How many medical errors are there in a year?
How often do airlines overbook?
How often do airlines leave late and arrive late?
Luggage lost? (I was on a flight with one other passenger – she had carry on. They lost my bag!)
How many store pricing errors?
How many credit card errors?
How many hotel booking errors?
How many phone billing errors?
Does your city, town, municipality ever ask you, when you pay your taxes, what services are important to you and that you’re willing to pay for?
You could add your own here…
There is actually so much opportunity for service improvement that the benefit could be exponential improvement for service organizations – compared to manufacturing. A study was done some years go that said 96% of the time, we as customers do not complain – we just look for alternatives. In simple English, it means that often we just go away and do not go back to that service provider.
I once picked up shirts at the dry cleaners – and after getting them home found they weren’t mine. Upon returning the clerk assured me they were – and had the signed receipt with my signature. I pointed out they were monogrammed – and while I’m sure quite expensive – the initials just didn’t happen to be mine. I filed a complaint with the clerk and a request for my shirts and left the shirts I had initially picked up. When I returned, to find a new clerk, I was informed they had no evidence of my complaint – and it was “good that I returned” when I had – or they were prepared to dispose of my “monogrammed” shirts. I never returned to them or any of the other stores in that chain. With cut-off sleeves, the monogrammed shirts were actually OK for work around the house.
What is the cost of a medical error? Potentially millions of dollars plus unknown suffering.
Aside from the tragic loss of life, the cost has been millions if not billions of dollars. So much of this lacks of recognition of the cost of not doing it right in the first place and then, being forced to spend multiples of the original cost to fix the problem after the fact.
What could be the value of an internal, operational audit that would bring some of these things to light?
In the mid-90’s, there was a flurry of registration activity in service type organizations. Temp agencies, a number of banks, printing shops, government services, even a municipality were registered. It appeared that service organizations were actually seeing the value in confirming their ability to carry out specified requirements. While manufacturing industry continued to see the value, with expectations even being increased, compared to manufacturing the implementation in the service sector has been limited compared to the potential.
Back to our ISO requirements. It is a methodology of common sense. It is a methodology of deciding what you need to do, doing what you’ve agreed to and then confirming that it has been done. Common sense is what is found most often, to be uncommon.
Can we get our hospitals and municipal governments to be registered? The Children’s Hospital in Toronto has actually had a ISO 13485 registration (medical devices) since 2006. Some cities are, but I suspect except in the case of those most forward thinking – registration is the exception, not the rule. But WE do have every right to set our expectations, have our service organizations define service level agreements, and then meet them. Even if not registered, the value to any organization from a standard, is a “best practices” operating system where clear expectations are identified. Quality should never be an accident.
If we accept less than what has been agreed to, we are as much at fault as the service provider. At a time when cost is an issue in every organization and we in particular as individuals – we should expect that what needs to be done – will be done right – the first time. Whether in business or personally, expect what was agreed, to be done. When we accept nothing less, service organizations wishing to survive will do what is necessary. Effectiveness and efficiency comes from not having to do over what should have been done correctly the first time.
For service organizations – whether commercial, government or not for profit – there should be recognition of the “opportunity cost” when failures occur. A defined and disciplined system never prevented anyone from being creative or doing what was necessary to be done. If anything, responsibilities and authority are clarified and work is done correctly the first time. To set up a system, you are forced to know who you are and who you want to be. Structure provides clarity.
Let us support and encourage our service providers, but let us be clear, especially with service organizations, “…they have to be running”. Running? They have to be sprinting!!