Quality Management is more than simply a collection of processes and tools that lead to better efficiency and customer satisfaction. It’s a perspective that must change the way everyone in an organization views the way they do their jobs and the way they process information. It’s not enough for an organization to have Quality software; it must also listen to every voice in the organization to identify weaknesses in the overall QMS, no matter how slight they may appear. As we’ll see below, negative events are not always big, dramatic cataclysms, but are often found hiding in the furthest reaches of even the best Quality Management Systems.
In 2008, Canadians in several provinces reported illnesses that were eventually diagnosed as listeriosis, a type of food poisoning related to the listeria monocytogenes bacterium. A total of 57 people became seriously ill and 22 people died. The source of the bacteria was eventually traced to the Bartor Road Maple Leaf Foods plant in Toronto, Canada. An independent investigator determined that the outbreak was a result of contamination of the slicing machines in the plant and not the cooking or preparation process.[i] Maple Leaf Foods engaged in an extensive decontamination of the plant in early September of that year. The administrative costs of the recall for Maple Leaf Foods were approximately $20 million. In December 2008, Maple Leaf Foods settled several class action lawsuits for $27 million.
The investigation revealed that Maple Leaf Foods had an exemplary record for safety, with a proactive approach to meeting the compliance regulations put forth by the Federal Government of Canada. The Bartor Road plant undertook immediate corrective actions with any positive tests for listeria contamination. However, the care with which each corrective action was taken gave employees a false sense of security that the issue had been addressed. Employees were collecting data on each incident of contamination, but no one was given the responsibility of conducting a trend analysis to determine if there existed any patterns that would lead to an underlying cause of the contaminations, and the data was never passed on to the office of the Chief Executive Officer.
Investigators determined that two meat slicing machines, despite having had all surfaces thoroughly cleaned, had meat residue lodged deeply inside the internal workings, which allowed listeria to grow unchecked over a long period of time and provided the “ground zero” source of the contamination. In this case, the day-to-day attention the employees paid to the health and safety procedures was not enough to diagnose a contamination that would only have been revealed by long-term trend analysis of the incidents as a series.
Two other Quality factors played significant roles in this event. First, Maple Leaf Foods had created a low-sodium version of its products to meet the request of its larger hospital and long-term care facility customers. Reducing sodium increases the risk of listeria growth, but Maple Leaf Foods did not adjust its procedures to mitigate against this increased risk.
Second, Maple Leaf Foods did not disclose the presence of listeria to inspectors at the Canadian Food Inspection Agency prior to the contamination outbreak. Although there was no requirement for Maple Leaf Foods to volunteer this information, it meant that they missed another opportunity to spot a pattern and engage in trend analysis of the previous outbreaks.
This event provides an example of the way in which Quality must become a mindset and culture that permeates every level of an organization, from the floor worker to the Chief Executive Officer. Floor workers cannot be expected to engage in long-term trend analysis, so the exercise must become an essential process stage at a managerial or executive level. Quality is both a big-picture and an on-the-ground way of life, and even a superlative Quality program, such as that of Maple Leaf Foods, is prone to failure without this type of thinking.
[i] Report of the Independent Investigator into the 2008 Listeriosis Outbreak, Chapter 5 (July 2009), accessed March 9, 2018, http://publications.gc.ca/collections/collection_2009/agr/A22-508-2009E.pdf.