Process Approach and Risk-based thinking

 

Organizations plan its processes and their interactions when they use the process approach. ISO9001:2015 Quality Management systems-Requirements states “The process approach involves the systematic definitions and management of processes, and their interactions, so as to achieve the intended results….and can be achieved using the PDCA cycle with an overall focus on risk-based thinking aimed at…..and preventing undesirable results.”

To conform to this International standard, “an organization needs to plan and implement actions to address risks and opportunities,….establishes a basis for increasing the effectiveness of the quality management system, achieving improved results and preventing negative effects.”

Although there is no requirement (stated in this Standard) for formal methods for risk management or a documented risk management process, Organizations can and should decide whether or not to develop a more extensive risk management methodology than is required by this International Standard.

One such methodology or technique of risk-based analysis is the potential Failure Mode and Effects Analysis (FMEA). This technique was first used in the aerospace industry in the mid-1960s because the effect of a failure is too severe and costly to bear as human lives are at stake. Later, this technique was also used in the automotive industry.

Studies have shown that using the FMEA as a disciplined technique to identify and eliminate potential concerns is as important as ever, especially when the consequence of a failure is severe and catastrophic in nature. To be effective in using this technique, a team of knowledgeable individuals should be assembled (those with expertise in various functions) to take on this responsibility to prevent problems. One of the most important factors for the successful implementation of a FMEA program is timeliness, i.e. it is meant to be a “before-the-event” action, not an “after-the-fact” exercise.

Problem Solving: The Poka Yoke Way

 
All traditional and technical problem-solving techniques have failed to solve human behavioral issues. Why is it so hard to change human behaviors and habits?

In an organization context, some ‘carrot-and-stick’ programs may work in the short term to change habits and behaviors, but change won’t be permanent. As the famous saying goes: old habits die hard. Organizations either have to choose to live with their hardcore workers who refuse to change or just fire and replace them.

When human behavioral issues are the root-causes to many societal problems, society suffers. Nothing would or could change people’s habits and behaviours unless their brains could be ‘washed’ or reset. There is a famous Chinese proverb: 江山易改，本性难移, meaning “it’s easier to change the mountain than to change behavior”, which remains very true till today. 

Take the case of our continuing efforts to nudge people to return their trays and crockery after eating at public hawker centres. The latest observation survey showed that only 30% or less of the people return their trays despite the many educational campaigns in the past 3 decades. Why is it so damn tough to get people to return their trays after eating? Everyone from government agencies to civil groups know the real issue lies in people’s mindset and attitude of “I don’t really care!”

No ‘carrot-and-stick’ solution could work for such social problem as ‘carrots’ need funding (nobody wants to dig into their pockets) and the ‘stick’ means legislations and constant monitoring and enforcement in every public eating places. They are simple non-sustainable in the long term.

Studies in human psychology and neuroscience have shown that people change their behaviour only when the change brings relief to their pains, i.e. no pain no change. So in conclusion, to cause change in behaviour and habits, we must create pains. This is the only viable and workable strategy to our decades-old problems nobody has managed to solve. Deploying this “No Pain No Gain” approach with a smart and a simple ‘fool-proof’ engineering design, such behavioral problems could easily be solved as shown in this example here. There is really no need for any expensive and advanced technological solutions. One just needs to determine the root-cause(s) to the problem and think and dig deeper for a workable solution. When we need to deal with ‘fools’, we just need to find a fool-proofing method(s) to counter them.

This is the Poka-Yoke Way, only remaining way to solving behavioral problems (originally called fool-proofing in Japan but was later changed to mistake-proofing to avoid being offensive).  

Effective Problem Solving vs Biased Solutions

 

Does simple problem ends up with complex solution?

Very often. It’s people that make simple problems looked complicated and solutions complex.

Problems can end up with biased solutions as decision makers have ‘hidden agenda’ and mindsets of their own. More often than not, they have already jumped to the solutions before identifying and defining the problem clearly.

How the problem is defined often ‘molds’ the solutions to be implemented.

Take the example of low-wage workers in every country and how this problem is defined:

1)  Low-wage workers cannot get out of poverty because their jobs’ productivity is low in their low-level jobs shunned by many.

2)  Low-wage workers cannot keep up with the rising cost of living that are beyond their controls.  

Do you see the difference and possible outcomes?

When executives and management do not define the problem clearly, often they ended up implementing biased solutions. This misstep is known as Biased Problem-Solving.   

Thus, the key to effective problem solving is its first-step in defining the problem clearly before proceeding to the next step. 

Management of Change: What model to use?

The Straits Times 07Feb2021: 5 doses of Covid-19 vaccine given to S'pore National Eye Centre worker due to human error

It was reported that a staff member at the Singapore National Eye Centre (SNEC) has been mistakenly given the equivalent of five doses of the Pfizer-BioNTech Covid-19 vaccine. This occurred during a vaccination exercise on Jan 14, and was due to human error resulting from a lapse in communication among members of the vaccination team, said SNEC on Saturday (Feb 6).  It said it has been following up closely with the staff member, who remains well.

SNEC said the worker in charge of diluting the vaccine had been called away to attend to other matters before it was done.

A second staff member had then mistaken the undiluted dose in the vial to be ready for administering. The error was discovered within minutes after the vaccination.

As a safety measure, the vaccination exercise at SNEC was stopped immediately upon detection of the error, and the rest of the staff were vaccinated at SGH.

The centre is not involved in the vaccination of other groups.

The SNEC has apologised to the affected staff member and the worker’s family, said Professor Wong Tien Yin, the medical director of the centre. “SNEC takes a very serious view of this incident. The safety of those receiving the vaccination during our staff vaccination exercise is of our utmost priority,” he added.

He said that the centre has done a thorough review of its internal processes, and taken steps to tighten them so that such lapses do not occur again.

This isn’t the first time blunders made by public hospitals and health institutions like this have been reported. Many, I believe went un-reported.

This event is just another example to illustrate the importance of managing change in the workplaces and organizations. Deploying an reactive approach towards managing change could be fatal at times. Some may question: shouldn’t ‘a thorough review of internal processes’ be conducted prior to the implementation of change? The short answer is probably YES! Again, this depends on the competencies and skills of the change management team and the change approach or model deployed in this hospital.

There are many change management models designed by many authors. Some models are relatively complex to understand without an in-depth knowledge of its benefits, pitfalls and implementation difficulties. The simplest change management model is the 5M Approach (copyrighted) as depicted here. This change management model can be used to suit every situation and in various change categories: financial, operations, quality, environmental, workplace safety and health aspect.

For more information and training on the use of this change management model, kindly contact us.