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.
Another good book is Make No Mistake!: An Outcome-Based Approach to Mistake-Proofingby 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.)
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.
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 ina 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.
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 afterattending physicians worked overnight were not associated withsignificantly increased complication rates, although there wasan increased rate of complications among post-nighttime surgicalprocedures performed by physicians with sleep opportunitiesof less than 6 hours.
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.
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.
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.
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 GrandValleyStateUniversity in Grand Rapids, Michigan, and she serves as editor for Frontiers in Health Services Management, a publication of the AmericanCollege 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.
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.
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-SinaiHospital 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 StanfordUniversity. "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?
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.
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.
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.
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.
