Book Talk: Mistake Proofing

Mistake proofing, also known as poka-yoke or error proofing, is an important lean tool, based on the principle that the best way to reduce errors is to prevent them from happening in the first place.

We publish several books about mistake proofing. To understand the fundamental concept, you might read Zero Quality Control: Source Inspection and the Poka-Yoke System by one of the original lean thinkers, Shigeo Shingo.

For a how-to guide, try Poka-Yoke: Improving Product Quality by Preventing Defects. We also have a good guide in our Shopfloor series, Mistake-Proofing for Operators: The ZQC System. The book is also available as part of a learning package.

Another good book is Make No Mistake!: An Outcome-Based Approach to Mistake-Proofing by C. Martin Hinckley. (Last year when I vacationed in Alaska, the title of that book prompted me to buy a notepad I found showing a moose grilling meat, with the caption, “Make No Moosteak.” It still makes me smile.)

A concept related to mistake proofing is FMEA, failure mode and effect analysis. We have two books discussing that concept: The Basics of FMEA: Second Edition by Robin E. McDermott; Raymond J. Mikulak; Michael R. Beauregard, and Strategic Error-Proofing: Achieving Success Every Time with Smarter FMEAs by John J. Casey.

If your organization has not thoroughly utilized mistake proofing in the past, then I strongly recommend you add some of these books to your library.

Do you have a question or comment about a book(s) that you would like addressed in Book Talk? Email me directly at Ralph.bernstein@taylorandfrancis.com.


Interviews with Healthcare Author George Halvorson

For those following the debate over health care reform, George Halvorson, CEO of Kaiser Permanente and author of Health Care Will Not Reform Itself, has several interviews coming up.

On Sunday Nov. 1, as part of Health Care Under a Microscope, he appears in a special on NBC News at 7p.m. in local markets.

Then on Thursday, Nov. 5, he will be on Minnesota Public Radio at 9 a.m.


Study: Patients Suffer When Surgeons are Tired

I’ve written before about efforts to limit the numbers of hours doctors (or at least medical residents) are required to work. But because all of today’s doctors went through residencies that required long hours, it is difficult to convince them there is anything wrong with the system. I noted that the New England Journal of Medicine had published an editorial arguing that there hadn’t been any studies proving bad things happen when doctors are tired.

Fortunately, some forward-thinking doctors decided more research was in order. In a recent issue of the Journal of the American Medical Association, a team at Brigham and Women’s Hospital in Boston led by Jeffrey M. Rothschild, MD, reported on a study of whether complications are more likely from surgery when the surgeon is sleep-deprived.

Guess what? They are!

Overall, procedures performed the day after attending physicians worked overnight were not associated with significantly increased complication rates, although there was an increased rate of complications among post-nighttime surgical procedures performed by physicians with sleep opportunities of less than 6 hours.

An article from Physician Leadership News contains a quote about the required next step.

In a media briefing Tuesday, Rothschild said the study findings "raise the importance of professionalism and the need for physicians to step up to the plate. If they feel tired or they find a colleague is tired, to find another way to approach this problem."

I hope others in the profession listen to him. Especially the New England Journal of Medicine.


Microsoft Opens Its Windows to Let Lean In

Is it possible Microsoft has actually learned something about lean?

I don’t believe anyone has ever referred to Microsoft as a lean company. I’ve never heard of the company adopting a lean strategy or tactics, and the fact that Windows has always been a bloated, error-laden product – meaning lacking in quality – suggests considerable room for improvement.

But Microsoft has also often been a company that, at least to some degree, can learn from its mistakes.

By now you are undoubtedly aware of the release of Windows 7, the latest version of Microsoft’s operating system. The reviews of Windows 7 have been pretty good, certainly better than the much-reviled Windows Vista.

I came across a fascinating article on CNN.com describing the process that went into the development of Windows 7. Amazingly, Microsoft apparently has some new-found respect for its supply chain partners, and a stronger focus on customer value.

This time around, though, Microsoft shared its earliest plans, sought input, and held regular meetings with the PC makers. In addition, it dedicated engineering teams to work with each of the biggest computer makers to help them work through any issues specific to their designs…

When finally asked for their early input, computer makers were not shy with their ideas for how Microsoft could do better. Indeed, the computer makers' fingerprints can be found all over the product from the way it supports touch input to which features are included in which versions of the product…

Among the changes that came directly from the computer makers was the about-face that Microsoft did with regards to Windows 7 Starter--the entry-level version of the product aimed primarily at Netbooks. Initially, Microsoft wanted to impose a limit of three open applications at a time, in part to distinguish the version from higher-end editions.

PC makers complained loudly that the restriction was too onerous--and might tempt consumers to stick with the older and less secure Windows XP. Microsoft eventually relented and, though it has maintained other limitations, Netbooks with Windows 7 Starter can run as many applications as their limited memory will allow.

Another feature that grew out of discussions with computer makers and business customers is the addition of an "XP Mode"--an option that allows Windows 7 users to run a free, virtualized copy of Windows XP to run older applications that aren't compatible with newer operating systems. In some cases, one incompatible program was keeping businesses from even considering a move off Windows XP.

Microsoft also had harsh messages for the PC companies. The vast amounts of preinstalled software that they were shipping on consumer machines, so-called "crapware" were slowing down systems and hurting the PC's image.

The computer makers and Microsoft began looking at each piece of software, whether it came from the PC manufacturers or a third party, and measuring its impact on the system. Those that were bogging things down were told to fix their software or else got pulled from new PCs.

The result is that Windows 7, in many cases, can boot up more quickly and go in and out of sleep in a matter of seconds. Consumers will also notice they get systems that are a lot less cluttered, in some cases with nothing more than a recycle bin on their desktop when they first boot their PC.

What Microsoft has done is just a few small steps in the direction of lean – and lean is a term that is probably still unfamiliar to most executives there.

Still, it is nice to hear that even such a large company can begin to change its mindset.


Book Talk: Healthcare Delivery in the USA

With growing interest in applying lean concepts to healthcare, one trend we’ve seen is that people from other industries who have lean knowledge are being hired for healthcare jobs.

But every industry has its own issues and terminology, and when you are switching industries, you need to know the issues and terminology necessary for your new job.

Healthcare Delivery in the U.S.A.: An Introduction to Hospitals, Health Systems and Other Providers of Care by Margaret Schulte is the guide you need. It provides a much-needed orientation to the broader healthcare work environment for those working in hospitals or as vendors and manufacturers.

And it provides that orientation in the context of current healthcare issues – financial, legal, regulatory and workforce.

Schulte is an associate professor in the Graduate Program in Health Administration at Grand Valley State University in Grand Rapids, Michigan, and she serves as editor for Frontiers in Health Services Management, a publication of the American College of Healthcare Executives.

Do you have a question or comment about a book(s) that you would like addressed in Book Talk? Email me directly at Ralph.bernstein@taylorandfrancis.com.


The Best Sources of Information About the Toyota Production System

A question posted recently on LinkedIn asked about sources of information regarding the Toyota Production System.

I was pleased to see 20 responses to the question, with the recommendations including several books we publish.

The Productivity Press books suggested include Toyota Production System by Taiichi Ohno, Lean Production Simplified, Second Edition by Pascal Dennis, Value Stream Management by Don Tapping, Tom Luyster and Tom Shuker, several of the books by Shigeo Shingo, and even Today and Tomorrow by Henry Ford. And there were more.

Other recommendations (beyond our books) featured works by Jeffrey Liker, James Womack, Daniel Jones, John Shook, Richard Schonberger, and several others.

I thought I would ask the question of those of you who read this blog (which presumably includes people knowledgeable about lean).

What is your best source of information about lean or the Toyota Production System? I’ll even divide that into a couple of more specific questions: What is your best source of information on the concepts and principles, and what is your best source of how-to or training material?

Please join the discussion by posting your comments below.


Radiation Overdoses Highlight Process Flaws

A disturbing case of process failure is being reported out of Los Angeles, with word that CT scans with eight times the normal dose of radiation were given to 206 stroke patients at Cedars-Sinai Hospital over an 18-month period.

As reported in the Los Angeles Times, the overdoses should never have occurred because, with any given scan, the dose of radiation is displayed on a computer screen facing the technician.

The FDA and the state Department of Public Health are still investigating the overdoses. Cedars-Sinai has released only basic information, saying the overdoses stemmed from an error made when the hospital reconfigured a scanner to improve doctors' ability to see blood flow in the brain.
The CT machine in question performed several types of scans, each with its own set of computerized instructions, or protocols. To change the instructions for brain perfusion scans, the hospital had to bypass the protocol that came installed on the machine. Other types of scans were not affected.

In a statement issued Monday, hospital officials said they have "added double-checks to our process whenever a protocol is changed" -- raising questions about why such checks were not already in place.

Experts said it was just as worrisome that the hospital apparently missed opportunities to catch the mistake as possible stroke victims continued to be overdosed.

Asked how CT technicians could have missed the dosage levels on their screens, spokesman Richard Elbaum said that will be part of the hospital's investigation…

"There are other places where the techs might be operating more as button-pushers," said Dr. Geoffrey Rubin, a professor of radiology at Stanford University. "The user becomes a little blind to these numbers."

I haven’t seen any information yet as to what ill effects, if any, the patients may have suffered as a result of the radiation overdoses.

Clearly, the process needs to be addressed, with new safeguards built in – particularly when it comes to bypassing the scanner’s protocols. But I’m a little concerned about one comment in the Times article.

Najmedin Meshkati, a professor of industrial and systems engineering at USC, said the airline industry experienced a similar problem with the advent of automated cockpits. The operator must trust the machine, and "sometimes this trust may be misplaced," he said.

Meshkati said the overdoses point to a problem well-documented in medicine over the last decade -- the need for multiple backup systems to catch mistakes.

I’m not sure what he means by “backup systems.” It seems to me there may be a fairly simple solution. Recent news reports have described how some hospitals have reduced surgical errors through use of a surgical-room checklist, to make sure nothing is forgotten. (Can you say 'standard work'?)

How about a radiology checklist – including checking the radiation dose?

What are your suggestions?


How Outsourcing Undermines U.S. Industry

I recently made fun of a couple of articles on the Harvard Business Review website. So it seems only fair that now I want to praise a different one of their articles.

This one has to do with outsourcing, which lean advocates have long criticized. We argue that outsourcing in search of cheap manufacturing often ends up not saving money because of additional costs and problems it creates. We also contend that a total commitment to a lean strategy can streamline your company to the point where you can compete effectively with cheap overseas competitors.

But there is another, possibly more important argument against outsourcing – that it undermines a company’s – and an industry’s – strengths and core essence. That argument is articulated extremely well in an HBR article by Gary P. Pisano.

The culprit is the outsourcing of development and manufacturing work to specialists abroad. The result: a damaging deterioration in the collective capabilities that serve high tech. This industrial commons includes not just suppliers of advanced materials, production equipment, and components, but also R&D know-how, advanced process development and engineering skills, and manufacturing competencies.

Making matters even worse is something that has been largely ignored: In addition to undermining the ability of the U.S. to manufacture high tech products, the erosion of the industrial commons has seriously damaged the country's ability to invent new ones (original emphasis).

The prevailing view of the past 25 years has been that the U.S. can thrive as a center of innovation and leave the manufacturing of the products it invents and designs to others. Nothing could be further from the truth.

This logic is predicated on utterly false assumptions about the divisibility of R&D and manufacturing and basic competitive dynamics.

In many cases, R&D and manufacturing are tightly intertwined. Unless you know how to manufacture a product, you often cannot design it. And, to understand how to manufacture it, you have to have manufacturing competencies and experience. The notion that you can design a product in the serene world of the R&D laboratory without any knowledge of the rough and tumble world of production is ridiculous.

To innovate, you need great two-way feedback. You need to transfer knowledge from R&D into production, but you also need to move knowledge from production back to R&D. The act of production creates knowledge about the process and the product design.

I agree completely.

However, if you’d like to read a different point of view, check out another HBR article, this one by David B. Yoffie.


Book Talk: Total Productive Maintenance

Total Productive Maintenance probably doesn’t get as much attention as it deserves. It is a critically important part of a lean strategy, but it is not as exciting or dramatic as some other aspects of lean. However, TPM – when properly implemented – can produce significant benefits of reduced downtime, lower maintenance or repair costs, and increased capacity.

We publish numerous books about TPM and the TPM-related metric of Overall Equipment Effectiveness (OEE). If machines are an important part of your operations, then TPM should be as well, and you may want to consider one or more of these books:

In addition, our Shopfloor series of training manuals includes books on TPM, autonomous maintenance and focused equipment improvement, some of which come in versions for supervisors and/or learning packages.

We also have a new book coming out next year, The OEE Primer: Understanding Overall Equipment Effectiveness, Reliability, and Maintainability .

Do you have a question or comment about a book(s) that you would like addressed in Book Talk? Email me directly at Ralph.bernstein@taylorandfrancis.com.


A New Lean Insider Group on LInkedIn

I’ve created a new Lean Insider group on LinkedIn. The postings from this blog feed to the group. However, anyone who joins the group is welcome to post and/or discuss lean news items from any source.

Please join this new group.


John Muir: The Original Lean Advocate?

Before Toyota, before Henry Ford, there was… John Muir?

Muir, of course, is well-known as a naturalist and environmentalist, who fought for creation of national parks in the United States and founded the Sierra Club.

Beyond that, I knew little about him. I learned a little more recently when I began watching the marvelous new documentary television series by Ken Burns about our national parks. As I watched the program, which discusses Muir in detail, I was surprised to hear a passing reference to the fact that, as a young man, Muir was an inventor, worked in a factory, and found ways to improve production.

After a little research online, I came across an article on the website of The Canadian Friends of John Muir. Written by Bruce Cox, the article describes Muir’s experience in an area of Canada known as Trout Hollow, near Meaford, Ontario.

Muir lived with William H. Trout and his family, working from 1864 to 1866 at a sawmill and factory Trout operated with his partner Charles Jay. Cox writes that Muir found ways to significantly increase the factory’s production of rakes and broom handles.

In 1866 William H. conceded when he had done all he could to improve the tool manufacture, "Muir easily took it further". Peter Trout, in his unpublished memoirs, put it this way: "My brother William H. was an inventor, but for original ideas, he was nowhere with John Muir."
To be specific, Muir succeeded in improving the machinery by paying close attention to the organization and sequence of all the steps in the production process. This is how it was arranged. Logs were elevated above the factory floor, slabbed and rounded, and cut into proper lengths for handles. Then in an assembly line they were fed down to be turned on a lathe and stacked in inventory. William H. recounts;
He began with our self-feeding lathe for turning rake, fork and broom handles and similar articles, which I considered nearly perfect; by rendering this more completely automatic he nearly doubled the output of broom handles. He placed one handle in position while the other was being turned. It required great activity for him to put away the turned handle and place the new one in position during the turning process. When he could do this there would be eight broom handles turned in a minute.

Putting the steps of production in the right sequence? Eliminating waste from the process? Creating an assembly line? Shades of Henry Ford! That sure sounds like a lean approach to me.


Boeing’s Problems: Lean Lessons Unlearned

You have undoubtedly heard about the latest developments in the Boeing soap opera, most recently the announcement of a delay in the first flight of the 747-8.

In his FlightBlogger blog, Jon Ostrower has done a good job of analyzing what when wrong. He attributes it to “resource constraints driven by the engineering responsibilities diverted by the 787 program.”

He also quotes one engineer as saying that, with the 787 Dreamliner, "workers are adjusting to building a new airplane. A lot of them have been moved around...so their work lacks continuity which leads to production errors."

What I find most interesting is Jon’s descriptions of problems stemming from early decisions about planning (or not planning).

Boeing decided against a full systems integration lab (SIL) for the 747-8 derivative aircraft, due to the influence of the legacy systems on the current design. However, because a SIL was unavailable, says a second 747-8 program engineer, many of the system level issues were encountered on the aircraft, rather than being caught in the lab.
In addition, without a universal computer model derived from Dassault Systemes CATIA v5 software, Boeing has found itself "trying to bridge the gap between 1969 and 2009," says a veteran engineer based at one of Boeing's 747-8 suppliers.
For example, the new wing design and enlarged empennage were designed through CATIA v5, while a portion of of the internal fuselage structure and other parts of the aircraft were built using legacy engineering drawings.
Some parts and their associated engineering drawings, the engineer says, have not changed since the 747-100, which in some instances has led to a loss of tolerance control in some areas.

All of this is very sad news about a company that knows as much about lean as Boeing. While following lean strategies and tactics might not, by itself, have been enough to avoid everything that has happened, certainly a greater attention to value stream mapping and management might have helped.

A lot of what Boeing learned over the years about lean seems to have been unlearned. Maybe when Alan Mulally is done at Ford he can return to Boeing.


Book Talk: Training Within Industry

You may have heard of the Training Within Industry program, developed by the U.S. during World War II. Its four modules – Job Instruction, Job Methods, Job Relations and Program Development – have been used by Toyota for decades.

While the program pre-dates lean, it embodies lean concepts for measurable continuous improvement because it sets a baseline, then establishes a framework for efficiency and innovation.

We publish two books about TWI. The first, by Donald Dinero and entitled Training Within Industry: The Foundation of Lean, gave the TWI concepts renewed popularity when it was published four years ago. It subsequently won the 2006 Shingo Prize for Excellence in Manufacturing Research.

We then published The TWI Workbook: Essential Skills for Supervisors by Patrick Graupp and Robert J. Wrona. This manual teaches supervisors how to apply the TWI concepts with examples and exercises. It won the Shingo research prize in 2007.

Both of these books can be valuable resources to help you address your training needs.

Do you have a question or comment about a book(s) that you would like addressed in Book Talk? Email me directly at Ralph.bernstein@taylorandfrancis.com.


Productivity Press is on Facebook (Again)

I’ve created a new version of our Facebook page, which should be a little easier to find for anyone searching Facebook.

I hope that many of you will become fans of our page. And feel free to visit my personal profile. I welcome your friend requests.


Private Equity Investors: Ignorant About Lean – and Destructive

The core principle of lean production is to focus on creating value for customers – because creating value for customers is essential to success. A cautionary tale appearing in The New York Times this week describes how large numbers of companies have been damaged or destroyed by private equity investors who have no understanding of that principle.

The article, by Julie Creswell, focuses on the Simmons mattress company, a 133-year-old firm with a well-known brand. Simmons is set to file for bankruptcy and will be sold – for the seventh time in two decades. Stockholders and bondholders of Simmons will lose most of their money, and hundreds of employees have lost their jobs.

But the private equity firms buying and selling Simmons have done just fine.

Thomas H. Lee Partners of Boston has not only escaped unscathed, it has made a profit. The investment firm, which bought Simmons in 2003, has pocketed around $77 million in profit, even as the company’s fortunes have declined. THL collected hundreds of millions of dollars from the company in the form of special dividends. It also paid itself millions more in fees, first for buying the company, then for helping run it. Last year, the firm even gave itself a small raise.

Wall Street investment banks also cashed in. They collected millions for helping to arrange the takeovers and for selling the bonds that made those deals possible. All told, the various private equity owners have made around $750 million in profits from Simmons over the years…

Every step along the way, the buyers put Simmons deeper into debt. The financiers borrowed more and more money to pay ever higher prices for the company, enabling each previous owner to cash out profitably.

But the load weighed down an otherwise healthy company. Today, Simmons owes $1.3 billion, compared with just $164 million in 1991.

Simmons is not an isolated case.

Simmons is one of hundreds of companies swept up by private equity firms in the early part of this decade, during the greatest burst of corporate takeovers the world has ever seen. Many of these deals, cut in good times, left little or no margin for error — let alone for the Great Recession.

A disproportionate number of the companies that were acquired during that frenzy are now struggling with the enormous debts. More than half the roughly 220 companies that have defaulted on their debt in some form this year were either owned at one time or are still controlled by private equity firms, according to analysts at Standard & Poor’s. Among them are household names like Harrah’s Entertainment and Six Flags, the theme park operator.

The private equity folks are quoted in the story as saying Simmons was destroyed by the recession, not by its debt.

Yeah, right.

Private equity firms have no customers. Their sole reason for existence is to enrich their investors. It seems that many of them pursue that with little or no regard to what it really takes to sustain a business, undermining the company’s ability to serve customers.

I’m sure there are good private equity firms – “good” meaning they actually do try to help the businesses they buy create value for customers, without overloading them with debt. I’ve even heard of private equity firms hiring lean experts to help analyze and work with their purchased companies.

But that requires people who can transition from the pure-profit mindset of an equity firm to the customer-service orientation of a manufacturer, and I suspect those people are few and far between.

Too many of them are the kinds of people who run the firms that bought and sold Simmons – predators who ultimately don’t care whether their acquisitions succeed or fail.

I have nothing but contempt for these people. And I am confident that in the long run, they will be seen for who they are, and will fail. It is unfortunate they cause so much damage along the way.


HBR Writers Are Rediscovering Some Lean Ideas

I always smile a little bit when I see business writers singing the praises of supposedly newly discovered truths that, in fact, have been known for some time to people familiar with lean concepts. The most recent examples are a couple of articles I came across on the website of the Harvard Business Review.

One is by author and economist Sylvia Ann Hewlett, discussing research related to her most recent book, Top Talent: Keeping Performance Up When Business Is Down (Harvard Business Press). She talks about the importance of having employees engaged.

It's impossible to understate the importance of having a sense of community at work, especially in these turbulent times. After enduring wave after wave of job cuts, plant closings, and corporate bankruptcies, employees uniformly say that what enables them to keep going is being able to talk to others who listen to and understand their concerns.

As an example, she talks about technology company EMC and its use of social networking tools to create an online forum for collaboration and discussion – which led to a wide range of successful cost-saving ideas.

I have no argument with anything Hewlett is saying or with her use of EMC as an example. But I’m not surprised. For years, lean advocates have known the value of employee engagement and how it can be encouraged through cross-functional teams, the sharing of information and other tactics. EMC’s use of social networking is relatively new, but that’s just a tool to support a well-established strategy.

The other article is by Vineet Hayar, CEO of IT services company HCL Technologies. He champions the need for collaboration rather than competition with supply chain partners, particularly customers, to achieve success in today’s marketplace.

Where have I heard this before? Oh yes, I wrote about it recently in regard to hospitals learning to deal with engaged patients. (That wasn’t exactly what Hayar discusses, but it is a form of collaboration with customers.) And my post was not groundbreaking, but discussing concepts that have been around for a long time.

Hewlett and Hayar promote sound ideas, and that’s a good thing. It would be nice if their work didn’t treat those ideas as new, but gave credit to the thinking – particularly lean thinking – that preceded them.


Book Talk: Supply Chain Project Management

The devil may be in the details, and for those whose job is managing and optimizing their supply chains, Supply Chain Project Management, Second Edition: A Structured Collaborative and Measurable Approach is a book that can help tackle that devil.

Written and updated by James Ayers, a member of the Project Management Institute and the Council of Supply Chain Management Professionals, the book covers how to implement project management best practices in ways that will encourage continual improvement of the supply chain. It encompasses supply chain foundation concepts, ways to define supply chain and supply chain management, and effective SCM project processes.

It also highlights examples of how collaboration can reduce material and process costs. This book is scheduled for publication later this month.

Do you have a question or comment about a book(s) that you would like addressed in Book Talk? Email me directly at Ralph.bernstein@taylorandfrancis.com.


Upcoming Lean Conferences

Fall is conference season, and several good lean conferences are on the calendar.

Journey to Greatness, the annual conference of the Association for Manufacturing Excellence, is taking place Oct. 19-23 in Covington, Kentucky. Under an arrangement with Productivity Press, you can get a 15 percent discount on registration by using the discount code PRODP.

A week later, Oct. 26-29, the Institute of Industrial Engineers is holding its Operational Excellence Conference and Expo in St. Louis, Missouri.

And a week after that, our friends at Productivity, Inc. (a separate company) are sponsoring Lean in the Process Industry – Beyond TPM. That event is scheduled for Nov. 2-5 in Houston, Texas.

Conferences can be a great opportunity to learn and network. While conference spending is often one of the first areas to be cut back in tough times, the insights and connections you can gain at a conference may be just what you need to move ahead of the competition. I hope you can find away to attend one of these events.