Friday, August 10, 2012

Box unticked

Or how to turn an honest mistake into a complete debacle

Loving the Olympics, and more regular bloggage will resume after they are done, but I was a bit surprised this week to find as aspect of it I can actually professionally comment on. I figure its as close as I'll get to ever competing so I'm running with it anyway :)

The whole fiasco of Valerie Adams turning up to her event to find out she wasn't entered due to a paperwork botch got my interest, because a big part of my job is making sure documentation practice is up to snuff, whether it's creating docs, completing them or reviewing them. My company can't manufacture or sell our materials without it (those materials being cGMP pharmaceutical ingredients), and if I was teaching a QA course I’d use this as a relatable example of what can happen if you don’t do it right.

So how does an athlete (including a current Olympic title holder) turn up to the Olympics, a moment they have been anticipating for years, only to find they aren’t actually entered in their event?

From my outsiders perspective going by what has been related in the media, it sounds like little failures compounding each other to make a big one. A step got missed, maybe because it wasn't prominent enough, or just got forgotten about, it didn't get checked, and no-one noticed until it was almost too late to do anything about it (technically it actually was).

The whole situation apparently arising because a box wasn't ticked is interesting, because from a good documentation practice point of view, that possibility shouldn't be there, or at least minimised as much as practicable. Bad form design is a great enabler of muck-ups, and if not ticking a single box as claimed can have this kind of outcome (and I’d think “is your representative planning to compete?” would be a pretty fundamental aspect), then barring incompetence or misunderstanding from the person filling it out, it might be a bit flawed. 

I’d love to see the document in question and confirm if that hunch is correct or not (it's sad, but after years of being in the industry, form design is a pet obsession :) ). Single answer tick boxes aren’t great for these kind of things since you can’t tell if it wasn’t ticked on purpose, or just forgotten. In my line of work a big no-no is to leave spaces blank, for exactly this reason; it's ambiguous. What’s better is something that requires a definite action, like using “YES / NO” and requiring one to be circled and the other crossed out. If neither has been circled or crossed you know that section has been missed when you review it. Another way to help prevent this kind of thing would be to remove the question: assume the person IS competing, and require a declaration if they aren’t, or use a form specifically for competitors only. You can’t make documentation that requires user input completely foolproof, but there are ways to engineer out traps, and make sure the information you really need to be recorded is. It's all about minimising ambiguity and room for misinterpretation.

That said, the documentation should have been checked both when it was completed, and when it was submitted. Designing a form well is no good if people don’t fill it out properly anyway (which happens surprisingly often, even when they are specifically trained to do it right). When important things are riding on the documentation process, you get someone other than the person filling it out to check it, both at the time, and when the process is complete. I find it weird that the documentation that you know, enables your athletes to actually register in the competition doesn’t seem to have been overseen.

The management says their document practice will be reviewed, and it should be, because at this level this is something that simply should not happen. No excuses. It’s arguable if it cost Adams the gold medal, but it certainly didn’t help.

Post Script:
Ultimately it didn't cost her the medal; the winner on the day failed drug testing and was stripped of the gold

More story and reaction from Adams here :).


Maureen said...

Wow. It seems strange that there would even be an option for not competing. If that's the case, then what is the purpose of filling out the paperwork? I feel bad for the woman who made the mistake. Now everyone knows it was her. Poor lady.

Off-Black said...

Yeah, a few things struck me as odd from a Quality perspective, hence the post :). I had a bit written about the whole naming thing, but redacted it as it didn't quite fit. Even if she honourably came forward herself, the manner as described in which her name was dropped (as an unprompted aside to a journalist from the chef de mission) is inexcusable, and very uncool; poor and cowardly leadership. Short of deliberate malice, the buck stops at the top.

As a postscript the Silver has now been upgraded to Gold anyway, after the winner on the day failed doping tests: