Quality and Excellence: Two sides of the same coin

Quality is predicated on Caring.
High Performance, also called "Excellence",  first requires people to Care about their results.

They are related through the Feedback Loop of Continuous Improvement, also known as O-O-D-A (Observe, Orient, Decide, Act) and Plan-Do-Check-Act (from W. Edwards Deming).

The Military take OODA another level with After-Action-Reviews or After-Action-Reports (AAR's), a structured approach to acquiring "Lessons Learned".

High Performance has two aspects: work-rate and consistency.
It's not enough to produce identical/consistent goods or results everytime, but you have to do it with speed.

There's an inviolate Quality Dictum:
You can't Check your own work.

For Organisations, this Dictum becomes:
 Objective assessment requires an Independent Expert Body.

From which follows the necessity for an External Auditor:
  Only Independent persons/bodies can check an Organisation and its people/processes for compliance and performance.

For around 80 years, Aviation has separated the roles of Investigation, or Root Cause Analysis, from Regulation, Compliance and Consequences. In the USA the NTSB Investigates and the FAA Regulates. This has led to consistent, demonstrable improvement in both Safety and Performance. Profitability is linked to Marketing, Financial Management and Administration, not just Performance.

All of which leads to the basic Professional Test for individuals:
 "Never Repeat, or allow to be repeated, Known Errors, Faults and Failures".

And the Raison d'ĂȘtre of Professional Associations or Bodies:
 To collect, preserve and disseminate Professional Learnings of Successes, Failures, Discovery and Invention.

Barry Boehm neatly summaries the importance of the Historical Perspective as:
Santayana half-truth: “Those who cannot remember the past are condemned to repeat it”

Don’t remember failures?
  • Likely to repeat them
Don’t remember successes?
  • Not likely to repeat them

All these statements are about Organisations as Adaptive Control Systems.

To effect change/improvement, there has to be reliable, objective measures of outputs and the means to effect change: Authority, the Right to Direct and Control, the ability to adjust Inputs or Direct work.

Which points the way as to why Outsourcing is often problematic:
  The Feeback Loop is broken because the hirer gives up Control of the Process.

Most Organisations that Outsource critical functions, like I.T., completely divest themselves of all technical capability and, from a multitude of stories, don't contract for effective Quality, Performance or Improvement processes.

They give up both the capability to properly assess Outputs and Processes and Control mechanisms to effect change. Monthly "management reports" aren't quite enough...


Business Metrics and "I.T. Event Horizons"

Is there any reason the "Public Service", as we call paid Government Administration in Australia, isn't the benchmark for good Management and Governance??

Summary: This piece proposes 5 simple metrics that reflect, but are not in themselves pay or performance measures for, management effectiveness and competence:
  • Meeting efficiency and effectiveness,
  • Time Planning/Use and Task Prioritisation,
  • Typing Speed,
  • Tool/I.T. Competence: speed and skill in basic PC, Office Tools and Internet tools and tasks, and
  • E-mail use (sent, read, completed, in-progress, pending, never resolved, personal, social, other).

As a taxpayer, in a world of White Collar Desktop Automation, I'd expect some quantitative metrics for "efficiency" and "effectiveness" as required of Agency heads in s44 of the FMAA (Financial Management and Accountability Act, 1997), not just some hand-waving, bland reassurance by those Heads and the Audit Office that "we're World's Best Practice, Trust Us".

We know that "what you measure is what you get" (or is maximised) and that career bureaucrats are:
  • risk adverse (C.Y.A. at all times),
  • "very exact", they follow black-letter rules/regulations to the precise letter, and
  • very adept at re-interpreting rules to their advantage.
Unanticipated outcomes abound, the least of which is using reasonable rules to fire or move-on challenging and difficult people,  such as "whistle-blowers", innovators, high-performers (showing up others is "career suicide") or those naively enquiring "why is this so?". 

These "challenging" behaviours are exactly those required under s44 of the FMAA to achieve:
 "Efficient, Effective and Ethical use of Commonwealth Resources",
yet they are almost universally considered anathema by successful bureaucrats.

This bureaucratic behaviour also extinguishes and punishes exactly the elements of "Star Performers" identified in the research of Robert E. Kelley.
Done in the mid-90's, the lack of take-up, or penetration, of this research in the Public Service leads to other questions: Why Not?

In the Bureaucratic world, asking for one thing gets precisely the opposite result.
Something is missing, wrong or perverted... But this has been the essential nature of large bureaucracies since the Roman Empire.

There's a double- or triple-failure going on here:
  • The desired outcomes are not being achieved,
  • This isn't being detected by the Reporting and Review mechanism's: Agency Annual Reports or Audit Office reports, and
  • a culture of non-performance is built, reinforced and locked-in.
An aside:
  If any Agency is truly managed to the minimum standards required by the FMAA, the three-E's, how could there ever be any whistle-blowing??

That there are whistle-blowers such as Andrew Wilke,  is proof of systemic, perhaps systematic, failures, and worse, at many levels.

Simple mindedly imposing minimum "standards" across-the-board would not only be a waste of time, but would be massively counter-productive within this environment.

So what might work??

"Events Horizons" in the world of Information Technology may point the way.

Between 1990 and 1995, using {Intel 486, 256Mbit RAM chips, twisted-pair Ethernet LANs, and Windows Desktop plus File and Print Servers}, PC Desktops made their way onto the bulk of clerical desktops. Usage was mainly "Productivity Applications", mainframe access and a little in-house messaging. Cheaper and Faster paper-and-pencils plus zero-delay transfer-to-next-in-process:  Automated Manual processing, with simple fall-back to actual manual processes.

From 1995 to 2000, Internet use took off and Office Desktops went from being expensive/Leading Edge items to low-end commodity units.  Usage focused more on e-mail, Intranets and some office tools. "Client-Server" became the buzz-word. New processes arose that weren't just Automated Manual processing.

After 2000, and the forced upgrades for Y2K, there was a 3-5 year technology plateau/recovery followed by an up-tick in both penetration, usage and integration of I.T. tools and facilities.
File/Print and Office Tools "on the Network" are now taken "as a given", as is high-speed Internet links, good Security, "Standard PC images" and centralised I.T. purchasing, admin and support.
E-mail and Web access are ubiquitous and inter-system compatibility is a necessity.

From 1990 to the present, Government Agencies have moved from having all backend processing automated, to the majority of front-end processes and work tasks being dependent on I.T. Automation:  Desktops, Networks and Services.

Telephony systems are increasingly being moved to the common network, becoming less robust and less reliable in the process. We are yet to see the full impact of this trend and it's reversal for critical services.

Now, when a large Agency has a major computer room malfunction or upgrade glitch, most or all office staff are sent home until all critical systems are restored.

This didn't happen only 10 years ago:
 the loss or slowing of back-end systems didn't halt all Agency work,  an effect unremarked and unreported by both Agencies and their oversight organisations, Finance and the Audit Office.

There are real End Service-Delivery implications of this current Event Horizon and they aren't being addressed or even acknowledged. Nor do these avoidable costs and employee time losses constitute efficient or effective management.

We've passed the Event Horizon of Dependence of Front Office Operations on I.T. [The next is complete dependence, there after "invisibly dependent", like water, gas and electricity.]

The bell can't be "unrung", we now have to manage our efforts in this context. Wanting to go back to "simpler times" is not an option for many and complex reasons. Even if it were possible or desirable...

Can we use this insight to define some universal metrics related to the use ("efficiency") and outputs ("effectiveness") of the technology and whose measurement has insignificant staff impact?

An aside:
  • Measuring values and analysing data, "instrumentation", always costs: money, time, complexity.
    This process/proposition is not free or trivial.
    Nor is the valid interpretation of read-outs always simple and obvious.
  • You wouldn't think of flying a 747 without instrumentation and that wall of switches-and-displays are the minimum needed for "Safe and Effective" aviation (we know this from the constantly improving safety/performance metrics from the ATSB etc).
    Why do Managers and Boards think the larger, more complex, more costly machines we call "organisations" need little or no instrumentation?

Some Metrics

Business tasks, perhaps as well the stock-in-trade of Managers, "decisions", have four major internal dimensions:
  • Degree-of-Difficulty
  • Size
  • Urgency
  • Importance (and/or Security Classification)
And four related external dimensions:
  • Time: Deadline, timeliness or elapsed time
  • Minimum Acceptable "Quality"
  • Input Effort (work-time or staff-days)
  • Cost
All tasks, projects and process have Inputs as well:
 Resources, Plant, Equipment, Tools, Information, Energy, Licences, etc
and, for well-defined tasks/projects, defined measurable Outputs.

When measuring Inputs vs tasks completed, actions taken or messages communicated, classification by Internal dimensions is necessary for "Like-with-Like" ("really-same", not "about-same") comparisons.
  • Are Urgent tasks/enquiries dealt with as appropriate?
  • Are Important tasks/projects completed? On time, On Budget, To Spec?
  • How many tasks of what size/difficulty are reasonable to expect?
  • Do staff find the work rewarding and motivating or not?
    Are they engaged, stimulated and developed through the work or demotivated, unproductive and either leaving or Time-Serving until they can ("golden handcuffs" of superannuation or other benefits).
With E-mail, both the inputs and outputs are available to be analysed.
Individual and Group Outputs can be assessed according to the External dimensions.
  • Were budgets (costs, deadline, effort, resources) met for a matrix of different task classes (urgency, importance, size, difficulty)?
  • Were Quality targets met per task matrix?
  • Where were Staff Effort and Resources expended?
    Was this optimal or desired?
Measuring Realised Benefits and "Expectations vs Outcomes", the very heart of the matter, is beyond the scope of this piece.

Having generic I.T. tools available on every desktop and used for every task implies three metrics related to mastery of basic tools and skills:
  • Typing Speed,
  • Tool/I.T. Competence: speed and skill in basic PC, Office Tools and Internet tools and tasks, and
  • E-mail use (sent, read, completed, in-progress, pending, never resolved, personal, social, other).
There are two basic work-practice skills, where the I.T. systems gather data necessary for analysis:
  • Meeting efficiency and effectiveness
  • Time Planning/Use and Task Prioritisation
After 5 decades of availability of definitive solutions in, and widespread training and consulting firms offering services, these basic and critical Business Processes, there is no excuse for poor meeting skills or undue waste of staff-time in meetings.

Nor of incompetent time management/task prioritisation and the associated waste of staff-time, idleness and under- or non-achievement of goals.

"Meetings, The Practical Alternative to Work" (or now, "Email, T-P-A-t-W"), is not "that's how it is here" or just amusing, it is an indictment of poor and ineffective management and failed governance systems.

So we hit an inherent contradiction:
 We need to measure basic performance metrics to affect improvement, but if we try to use those metrics to achieve improvement, we can only create the opposite effect.

If tying Performance Metrics to pay, bonuses or "Consequences" isn't useful, why measure and report?

Jerry Landsbaum in his 1992 book, "Measuring and Motivating Maintenance Programmers" definitively answered this question.

Just by measuring and publicly posting individual resource usage, he was able to achieve radical changes in habits (and costs) without imposing penalties or instuiting any formal process.

Reasonable people given timely, objective feedback will modify their behaviour appropriately.
Landsbaum went on to provide a suite of tools to his staff providing various code metrics.
Without direction, they consistently and deliberately improved the measured "quality" of their code.

As a side-effect, Landsbaum was able to quantify for his management considerable savings and productivity improvements. Most importantly, in a language and form they could understand:
 an Annual Report with year-on-year financial comparisons.

This approach is backed up by Dr. Brent James, Executive Director of Intermountain Health Care in Salt Lake City, Utah, described in "Minimising Harm to Patients in Hospitals", broadcast in October 2000.

Dr James and his team spent time discovering exactly what caused the most harm to patients under their care, then prioritising and addressing those areas.

The major cause of "adverse events" (harm to patients) wasn't Human Error, but injuries due to Systems failures, by a factor of 80:1 (eighty times).

Charles Perrow calls these "Normal Accidents", whilst James T. Reason, author of "Human Error" and the "Swiss Cheese Model" of accidents, calls them "Organisational Accidents".

Perrow and Reason's work is the underpinning of the last 5 decades improvement in Aviation and Nuclear safety. It's based a sound theory that works in practice, based on real, verifiable evidence.

Dr James said the approach: "could save as much as 15% to 25% of our total cost of operations" whilst delivering much reduced Adverse Events and better, more consistent, patient outcomes.

An unanticipated benefit of Dr James work was identifying the occasional "bad physicians and nurses":
"If we see active criminal behaviour, if we see patterns of negligence or malfeasance, we will react.".

(Because there was) "less noise in the system. It’s easier to see them.
And I have to tell you that was startling when we first encountered that.
We knew we needed to go after the 95% of the system’s failures
but as we started to take down those rates we also knew that there were some bad physicians,
it was just hard to find them,
and suddenly, there they were,
and we were able to take appropriate action."

Bundaberg 2005: Dr Jayant Patel

In Dr James' hospitals, Jayant Patel would have been quickly noticed and dealt with.

If you lived in Bundaberg, you might be asking why their systems didn't detect Patel: 5 years after Dr James' public broadcast in Australia?
Is there an excuse the management at Bundaberg ignored Dr James proven, effective, methods?
Especially as he'd documented substantial savings as well as fewer injuries and better patient outcomes from his approach. All the self-described goals of every Health system in the country.

Queensland Health's performance fails the basic Professional Test:
 "Repeat, or allow to be repeated, Known Errors, Faults and Failures".
And seemingly without timely, direct or personal consequences to anyone.

Whilst Patel is seen to be "the one bad apple", his being charged and held to account is not timely nor will it improve the standard of care for others, or cause lasting change where "it can't happen again".

Just what did those lives lost and needlessly destroyed, and the ruining of Patel buy the community?
Seemingly, very little.
Retribution leaves ashes in the mouth, and "playing the Blame Game" only increases workplace fear and risk-adverse management decisions. None of which drives useful or lasting organisaitonal change.

In Bundaberg, the culprit is "The System" that let Patel firstly pratice at all, then get away with bad performances for an extended period. I won't go into the poor treatment of the nurses that tried to address the situation and who eventually managed to get media attention.
It's all the same Organisational Failure.

Other 2005 events: Lockhart River aircrash and the sinking of the Malu Sara.

Where is the routine investigation and transparent, public reporting by an independent expert body akin to CASA/FAA, as for  the 2005 Lockhard River crash that killed 15 and led to the demise or deregistration of two companies. This same crash led to a Senate Inquiry critical of the oversight bodies: the coronial inquest and CASA. "Who watches the Watchers?" The Senate, for one.

Patel was linked to 87 deaths, six times more that the crash, though only convicted of the manslaughter of 3. In spite of the size of this "oops" and the overwhelming evidence of the power and effectiveness of the NTSB/FAA system in Aviation, there are no moves to effect this sort of change.

This isn't an isolated organisational condition or limited to any one level of Government or area of practice.

Consider the 2005 deaths of all five on-board the "Malu Sara", specified, purchased and operated by the Department of Immigration. Sinking 6 weeks after going into service.
The 2008 Coroner's Report, is cited by a 2010 SBS programme, around 12 months after the Coronial Inquest, as saying:
... Queensland's coroner ruled it was a totally avoidable disaster, caused by the incompetence and indolence of senior Immigration official ...
The SBS programme claims:
  • "No charges were laid after a 2007 police investigation."
  • The senior Immigration official "avoided departmental disciplinary proceedings by retiring from immigration - with his full entitlements."
  • "The federal work place regulator ... is prosecuting Immigration over the deaths.
    The maximum penalty - a $240,000 fine."
  • "So far, all the families have received from authorities is an apology from Immigration and, in January, the department named two rooms in its Canberra headquarters after the deceased (departmental) officers."
The formal words of the Coroner, "incompetence and indolence",  should alarm anyone reading them, especially those with oversight of the Department or responsible for Good Governance.

This behaviour is never justifiable in a well managed and is completely inconsistent with the Three-E's required of Agency Heads. That one senior officer failed their basic performance requirements and was either undetected or known and allowed to continue, is a failure of Governance and oversight.

One major event like this is complete proof of failing under s44 of the FMAA.

The Audit Office has not investigated the matter, nor has Finance, the administrators of the FMAA, taken an interest.

A Senate question was asked in May 2007 about the investigation:
In July/August 2006, more Senate questions were asked in relation to AusSAR.
Is the Department’s report on the Malu Sara incident a document that the Committee can have access to? If not, why?
The Department’s report was provided to the Coroner at the directions hearing on 15 February 2007. The Coroner, on his own motion, made an order that prohibits the publication of the report other than to the formal parties to the proceeding.
There was an independent ATSB inquiry and report released in May 2006 (No 222) and a supplemental report (MO-2009-007) released in September 2009, reopening the investigation after the Coroners Report.

In late 2009, ComCare issued a media release saying they would be launching court action against the Department and the boat builder.

The Head of Immigration in the 2008-9 Annual Report commented:
The department has since made changes and improvements to its procedures to ensure that such a tragedy could never occur again,...
It seems all Agencies involved in the matter are unaware of the Quality dictum:
 You cannot check your own work.

Organisationally, this equates to:
  Performance and Compliance can only be assessed by an Independent Expert Body.

Organisations can't investigate their own problems, nor categorically state, as Immigration has, "We fixed it, it can't happen again. Trust Us".

Since the 1926 formation in the US of the dual-body model used in Aviation, one to investigate causes (NTSB) and another to form and enforce regulations and issue non-compliance penalties (FAA), has shown itself to be an effective, possibly a definitive solution to Organisation Safety and Quality improvement.

From the steady improvement in aviation performance figures, an unintended effect of the dual-body system is that it may also improve Performance and Efficiency/Effectiveness for free.

Why is there this blindspot, especially as the NTSB/FAA model is so well known and respected throughout the commercial and public sectors, and in political and judicial circles?

Wrapping up Performance Metrics

Putting real numbers out in Public enables good people to lift their game while exposing poor performers and worse (malfeasance, misfeasance, nonfeasance, negligence, incompetence, indolence, ...)

Formalising the measurement of basic management outcome metrics and tying them to rewards and punishments can only result in disaster. Mangers will devote themselves to doing whatever it takes to get promotion or reward, not achieving their mission: good taxpayer outcomes and good governance.

Providing good data to taxpayers and their proxies, journalists and researchers, will provide enough leverage to see real, lasting change.

But this approach is not "sexy", big or expensive - and certainly can't be used as a punitive political weapon, either for career bureaucrats or their political masters.

Why wouldn't you do this if the whole Output of Government was dependent on the use of I.T. and you cared about "the efficient, effective and ethical use and management of public money and public property"?

So who will champion this idea?

Who has something to gain from real change? [Not the major Political Parties, not incumbent Bureaucrats, not existing oversight bodies: the status quo works for all them.]

Who has the Motivation, Authority and Will to make real change happen?
That's the real question here...