Friday, August 16, 2013
Slowly Sliding to Mediocrity or Worse
|First Nations vs. Canadian Military at the 1990 Oka Crisis|
The Oka Crisis and other events prompted Canada's Federal Government to re-consider its policies towards the First Nations' people. A Royal Commission on Canada's Aboriginals was formed in 1991, which outlined many serious problems in their 4,000 page report of 1996, and the recommended solutions.
One Federal Department that the Royal Commission found negligent was Health Canada. Health Canada agreed with the findings of the Royal Commission, and was told to fix it.
To find out how well Health Canada had responded to the problems identified by the Royal Commission, Canada's Auditor General ("AG") did an audit on Health Canada in 1997. The AG was disappointed by the lack of effort and results that Health Canada had achieved in the year after the Royal Commission's report. The AG made many recommendations to help Health Canada to get back on track and make progress on the problems identified by the Royal Commission.
The AG gave Health Canada another 3 years to get these 1997 AG recommendations completed, then did a follow-up audit on Health Canada in Year 2000.
I recently had occasion to read the Year 2000 Auditor General's followup report on Health Canada. Health Canada had accepted and committed to implement the AG's recommendations, but unfortunately little or no progress on the AG recommendations had occurred in this second follow-up audit. The AG did another followup audit in 2004 (same problem again), and another follow-up again with a 2006 followup audit (same problem again).
Just how many chances does Health Canada get?
It's good to see that the AG does followup. Too often, there is a 15 minute flash of infamy to an AG report or other negative story, then the government, the press, and the public are distracted to something else, and things quickly go back to "business as usual", with no significant change having occurred. Followup and historic memory within organizations (or their watchdogs) is a sign of both excellence and effectiveness.
More recently, 2012 academic research paper has been written about the ongoing abuse of the prescription drug plan for First Nations people, and its continuation for the last 16 years, still the same or similar to the 1996 Royal Commission finding.
It seems that Health Canada moves significantly slower than a glacier. In spite of the many caring people who work at Health Canada, perhaps they are close to being a truly fossilized bureaucracy.
I assume that the government's intent behind the providing of prescription drugs to First Nation people is to help them.
Providing excessive amounts of psychotropic drugs (eg. opiates such as Oxycodone, Percoset and other addictive narcotics) to anybody is clearly not helping. Why government would enable and encourage addiction and illegal trafficking in narcotics by providing these drugs for free and without adequate controls to prevent abuse is hard to explain. Could Health Canada not see this coming? Did they not think about unintended consequences from their plans, or were these risks known and too easily dismissed?
Did Health Canada use known, effective tools such as FTA (Fault Tree Analysis), or FMEA (Failure Mode Effect Analysis)? PQA used these techniques in a detailed risk management report we did for Health Canada on Hepatitis C around that time, so I know some people at Health Canada were aware of these techniques.
Knowing that most First Nations communities have significantly lower income and standard of living as compared to main stream society, then dropping huge quantities of addictive, free, high value prescription drugs into these impoverished communities seems like gross negligence, or worse.
The overall result is the government forcibly takes money away from taxpayers so that the government can use it to create bigger, more expensive problems (eg. chronic addictions, trafficking, illegal activities, social and familial dysfunction, etc.) in First Nation communities. The government needs a new program to fix the unintended consequences from the previous program. Talk about a make-work project!
While Health Canada has made some small improvements over the last 1.5 decades, they would seem to have been distracted or working half-hearted to take 16 years, and still haven't fully addressed the Royal Commissions recommendations, nor the AG's recommendations.
Unfortunately, it isn't just Health Canada who fails to change their mediocre ways.
Over the last 35 years of my career, I have seen too many other organizations fall into the same trap as Health Canada and the AG. Everybody has problems. However, it is the response to those problems that separates the excellent from the mediocre.
I have seen that problems were identified, but people then stepped over those problems every day, or swept them under the carpet so they could be out of sight and out of mind. Management usually allowed this corporate blindness to occur, and continue. Neither the workers nor management wanted to address these messy problems, so they didn't. After 20 years of this behaviour, you have an organizational swamp filled with unresolved problems that taints the drinking water of everybody downstream.
What is the solution? How do we avoid this natural human frailty?
You hire and enable an Auditor General for your organization. Somebody who is outside of the normal channels who is paid to hire excellent auditors to help identify the polluted swamps, encouraging you to drain them, find the rotting festering problems, and get them taken care of in a timely and effective manner. If your organization isn't fortunate enough to have an AG today, pick up the phone now and call somebody to get the help you need.
Allowing 3 years to elapse between follow-up audits, as demonstrated by AG and Health Canada, isn't effective either. Organizations often need help in getting started and keeping it going. That's where a good facilitator comes in. Both Health Canada and the Auditor General can learn from this tragedy for Canada's First Nations people. You can learn from their mistakes too.
If you don’t call somebody for help right now, but wait another 15 minutes, the pangs of guilt about the festering swamp in your organization will soon pass. Call now, operators are standing by to receive your call.
If you choose not to call, you may already be on a slow slide towards mediocrity or worse.
Glenn Black P.Eng. CQE CQA
Process Quality Associates Inc.