Category Archives: Irish IQ Trainwrecks

A process problem with the trains…

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Information can take many forms. Ultimately, it is the ‘message’ that is communicated between two people (or systems or processes).

This story from today’s Irish Examiner shows the importance of checking that the message being communicated is accurate and timely. It’s a trainwreck because it relates to trains, there was a problem and it will cost the Irish rail operator €10,000 to compensate people for a miscommunication and an error in the presentation of information.

The summary of the article is that

  1. Over 300 people were waiting for the train from one of Ireland’s flagship railway stations.
  2. A visually impaired passenger was helped by the Station Controller on to the train
  3. The signal for the train to depart was given, while 300+ people stood on the platform.
  4. The people at the station had to take a different train (leading no doubt to over crowding), which made an unscheduled stop to link up with a special shuttle train transfer that brought them to their final destination.

Inaccurate information was given to the train driver and guard (or perhaps they interpreted information incorrectly) who followed the procedure when that signal was given – they started the train up and left the platform (and the 300 people) behind it.
How might this have been avoided? As ever in these cases an investigation is underway.

A minor trainwreck… the importance of quality info on live TV

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From the blog section of the Irish Times…

http://www.ireland.com/blogs/presenttense/2007/10/08/youve-won-nothing/

 ‘Tubridy Tonight’ is a popular weekly TV show on Ireland’s national broadcaster RTE.  On Saturday last, the presenter was giving away a holiday to Chicago along with an amount of spending money. A caller to the show simply had to answer a question correctly… the question was “Which actress won an Oscar for her role in the movie Chicago?”.

The caller answered “Renée Zellwegger”, one of the female leads in the 2002 movie and was congratulated on giving the correct answer (and got a fanfare from the house band). A few seconds later the hapless presenter had to correct himself (and the caller) and inform her that she had given the wrong answer and hadn’t actually won the prize but had received a lesser consolation prize instead.

My guess is that the presenter, perhaps believing the question to be so trivally easy that no-one could get it wrong, went on auto-pilot and didn’t perform the much needed vital check of accuracy before opening his mouth and putting at least one foot firmly in….

The lesson… a control check on the quality  of information (such as accuracy or ‘correctness’) needs to not just exist but needs to be actually operated in order to prevent embarrassment, injury or loss.  Having the mechanisms of a control in place but not operating it is a recipe for a trainwreck.

For the record, both Catherine Zeta-Jones and Renée Zellwegger were nominated for Oscars for Chicago. Zeta-Jones won for Best Supporting Actress. Zellwegger missed out for Best Actress, but did win a Golden Globe.

“Problems with the quality of the data” cause process traffic jam

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Hundreds of Irish motorists  (this author included) have technically driving uninsured because of delays with the National Car Test (the Irish equivalent of the UK MOT). This was reported by the Sunday Business Post on the 19th of August.

The Irish Road Safety Authority has confirmed that some motorists may not have been informed that their car was due its NCT. In Ireland you can’t insure your car with out a valid NCT certificate and not having an NCT certificate that verifies your vehicle’s roadworthiness could invalidate your insurance policy.

The root cause is identified by the company that operates the testing in Ireland as being “problems with the quality of the data” which resulted in them not getting details of all vehicles due for testing.

 Apparently the first that the company that adminsters the NCT knew of the problem was when people started to phone them asking them where their reminder letters where and seeking to make appointments.

The knock-on affect is that there is now a back log of a number of weeks for an appointment to get an NCT test. The Sunday Business Post refers to the testing centre in Donegal with a wait period of 6 weeks. My experience in the South East of Ireland has been a wait of over 2 months.

The NCT certificate on our car expired in July but due to my wife’s persistence on the phone we eventually got a test date in late August. I wonder if we would be insured if we were in a crash during that month?  Strictly speaking we would not have been as the vehicle would not have been certified as road-worthy.

In Ireland it is an offence to drive a vehicle that doesn’t have a valid NCT certificate. This offence carries with it a penalty of 5 ‘points’ on your drivers licence. 12 points results in your licence being taken away from you.  The impacts of this IQ Trainwreck were potentially significant.

Leading Private Hospital ordered to cease Breast cancer Services

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The Irish Examiner Newspaper reports today that Barrington’s Hospital, one of the leading private hospitals in the West of Ireland, has been ordered by the Irish Minister for Health to cease all Breast Cancer services on foot of concerns from her Chief Medical Officer and the Health Information & Quality Authority about the

“adequacy of the management and care of 10 women who attended the breast disease services within the last four years”

This story is also carried by Ireland’s national broadcaster, RTE.

The background to this closure is the misdiagnosis of breast cancer in the case of a woman who had been given the ‘all clear’ on two seperate occasions, resulting in a delay of 18 months in starting treatment.

So, does this count as an IQ Trainwreck?

  1. Information did not meet or exceed expectations – when a hospital test is performed on us we expect the results to support correct and timely diagnosis of illness and enable early and effective treatment. Two incorrect ‘all clear’ results and an 18 month delay in treatment falls short of that expectation
  2. There has been a significant impact on the ‘information consumer’, the patient at the centre of the concerns. Her health has probably suffered further and she and her family have likely experienced much trauma and upset.
  3. There has been a significant impact on the faith people have in the ability of our health care professionals to make us better (or at least no worse).
  4. The Government has stepped in and, as a result, there is now a further curtailment of available services for breast cancer screening in Ireland.

Yup.. that looks like an IQ Trainwreck to me.

Any thoughts?

What’s in a name?

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The Irish national broadcaster RTE has this story on their website this morning…

The wrong prisoner was let out of one of Ireland’s main prisons yesterday because he had the same name as another prisoner who was due for release.  It seems that there were two Mark Kennys in the prison, one serving a short sentence for a minor offence, the other serving a longer sentence for a serious offence.

For the sake of clarity and a bad pun I’ll refer to the Kenny with the minor sentence as “Mark 1” and the other as (inevitably) “Mark 2”.

“Mark 1” had been granted temporary release. “Mark 2” was the prisoner released. Nobody noticed for 20 minutes. One can only assume that the error was identified by “Mark 1” enquiring when he was going to be let out.

This is a case of a process failure triggered by poor quality management of information which resulted in a serious criminal being released in error who will now have to be tracked down and re-arrested by police (the Gardaí as they are called in Ireland).

An investigation into how this came to happen has been ordered by the Director of the Irish Prison Service. Which is a bit like locking the stable door after the prisoner has bolted.

A healthcare trainwreck

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Following on from cases of people having stomachs removed in error last year, we find the following story from the Irish Healthcare system where the quality of information used to tell women whether they had or didn’t have breast cancer didn’t meet or exceed expectations (was plain wrong) and now all tests have to be reviewed.

This is an illness that, if caught early, is treatable but if it is left to take hold the treatment becomes more invasive (maestectomy) and the risk of the cancer spreading to other parts of the body increases.

The cost and risk of non-quality information here is immense.

More people registered to vote than live in Ireland

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The background

An Irish Sunday Newspaper broke the story in 2006 that there were up to 860,000 more people registered to vote in the Irish Republic than actually lived there. To put that in perspective, the number of persons resident in Ireland who were of an age to vote was only approximately 2.6 million or so. This represented a significant issue.

The approach of the Irish Government to the issue was to dispatch personnel to go door to door checking voter registrations. This was a form of scrap and rework. It was conducted over a period of approximately 3 months in late 2006. The work practices involved in this review varied betweenlocal government areas . In the electoral constituency of the Minister for the Environment (who has ultimate responsiblity for the Electoral Register) at least one entire housing estate (of a few hundred houses) ‘disappeared’ off the Electoral Register.

The litany of issues is too long to go into here… check out my personal blog site for some more background.

Why is this a trainwreck?

There are a variety of reasons why this is an Information Quality Trainwreck:

  1. It has a fundamental effect on a key process in democracy.
  2. It would appear that divergent processes, poorly defined processes and a failure to define and manage processes in a way that reflect ‘life events’ that might change the electoral register was part of the root cause for the problem.
  3. There was a focus on scrap and rework to address the issue. There has been no substantive or tangible official review of the root causes for these problems. There are some anecdotes however of Electoral Register clerks in some parts of the country using the Obituary pages from local papers to identify people to be taken off the Register as they didn’t know that there was a central register of Deaths who could provide them that information.
  4. The ‘tone from the top’ was one of creating fear and spreading blame. The Government Minister in charge berated local authorities for not doing a good enough job. However it seems that there was a fundamental failure to provide the local authorities with the tools and processes they needed to do that job.

Current State

In Ireland we are less than a month away from a General Election. Our Electoral Register is now known to be flawed and innaccurate. The root causes have not been addressed and whatever ‘clean-up’ was achieved through the manual scrap and rework will have degraded as it is now over 6 months old.

The information does not meet or exceed our expectation and there is a fundamental risk to the quality of our elections.