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Six Sigma Tools & Templates Poka Yoke How Mistake Proof Are Your Processes?

How Mistake Proof Are Your Processes?

It was a Japanese manufacturing engineer named Shigeo Shingo who developed the concept that revolutionized the quality profession in Japan. Originally called “fool proofing” and later changed to “mistake proofing” and “fail safing” so employees weren’t offended, poka yoke (pronounced “poh-kah yoh-kay”) translates into English as to avoid (yokeru) inadvertent errors (poka). The result is a business that wastes less energy, time and resources doing things wrong in the future.

What Is Poka Yoke?

Poka yoke is one of the main components of Shingo’s Zero Quality Control (ZQC) system – the idea being to produce zero defective products. One way this was achieved is through the use of poka yoke; a bunch of small devices that are used to either detect or prevent defects from occurring in the first place. These poka yoke methods are simple ways to help achieve zero defects.

Who Develops Poka Yokes?

Here’s the beauty of the methods…anyone, from manager to line supervisor to line employee can develop a poka yoke. (Alright for you transaction people out there…anyone, from regional sales manager to sales associate to document specialist). All it takes is the empowerment of employees, as well as a little instruction around what makes a good poka yoke.

What Does a Poka Yoke Look Like?

Poka yoke looks different in each situation. I’ll try to present a few different scenarios for poka yoke use. Let’s take a transactional situation and analyze a few parts of it. Say, for instance, we’re at the signing of a bank loan by a lucky couple closing the mortgage on their first home.

Example 1:
The lucky couple picks up the pen to sign, but when they depress the top of the pen to extend the writing part it malfunctions because the spring is missing. A poka yoke could have prevented this situation. If all pieces of the pen were presented to the assembler in a dish, a simple poka yoke would be for the assembler to visually inspect the dish for any remaining parts once the pen was assembled. (Ok, I lied about this being only a transactional process!)

Example 2:
The lucky couple bypasses the signature part of the process because their bank is really high-technology focused. In fact, they signed a writing pad and their signature was recorded electronically. The bank also needed to collect four additional pieces of information before the entire package of information is sent to the processing department. A simple poka yoke to add to this process is to require all fields to be filled in (including the loanee signature) before allowing the form to be sent to processing. This prevents the processing department from reviewing an incomplete document, sending back to the loan department, delaying the processing of paperwork…you get the idea.

Example 3:
Once the complete paperwork is submitted to the processing department and it is printed, it then needs to be filed with the city and state. In order for this to occur, papers need to be filled out (the city and state are not high-technology enabled) and attached to the form. A poka yoke used by the city is a simple check-sheet at the top of the form. This allows the person submitting the form to ensure that all additional information and payments are attached. As in example 2 above, this prevents the city/state from reviewing an incomplete document, sending back the document to the sender, delaying the processing of paperwork…again, you get the idea.

Conclusion

Is there any rocket science to poka yoke? I don’t think so either. So what’s the big deal? Well, the big deal involves execution within your business. Bright ideas are a dime a dozen, it’s the execution that’s the hard part. First, you need to educate your workforce on the concept of poka yoke (call it mistake proofing for ease). Second, you need to empower your employees to make a bunch of small improvements to their processes – continuously. What you will end up with a business that wastes less energy, time and resources doing things wrong in the future.

User Test – Real World Scenario

I was recently reading a newspaper article entitled “Surgeon operates on wrong side of man’s head.” An excerpt is below:

Providence, Rhode Island, USA – A surgeon at Rhode Island Hospital operated on the wrong side of a man’s brain after a CAT scan was placed the wrong way round on an X-ray viewing box, the hospital told the state Health Department.

The patient had bleeding on the right side of his brain but the reversed scan made it look as if the bleeding was on the left. In addition, the patient’s incision site had not been marked with a pen, as recommended by error-prevention experts.

You’re probably thinking the same thing as me…WOW, how could this happen with all the procedures, mistake proofing, quality systems, etc.? It just amazes me. The good news is that the patient lived after the doctor repeated the procedure on the right side and the blood was drained. It turns out that wrong-side surgery tops a list of 27 serious, preventable events says the National Quality Forum, which promotes a strategy for measuring healthcare quality.

So what can we do about it? Well, let’s help the medical system out. Post your thoughts in the comments section below.

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Comments

Baqar Hasan 29-04-2010, 17:31

A simple check by two doctors of the scan could have prevented the operation on the wrong side of the brain.

In other words one doctors checks it and the other verifies it.

Reply
Anna 28-01-2012, 19:14

When you have 2 doctors doing a check, you are creating over inspection, which is waste. Do it right the first time and there’s no need for inspection.

Reply
Dave 04-05-2010, 02:03

What about a standardized symbol on only the right side of every x-ray. That way, it is put on the xray light-board only one way. Or an a-symetrical xray film that only fits the xray light-board one way? or maybe a osset of pins that only allow the film to fit one way?

Reply
Laura 22-05-2010, 20:15

I don’t know if this is possible, but how about x ray film that can only be viewed from one side. If it is turned around it is not able to be viewed properly.

Reply
Little Box 31-01-2012, 14:08

This would be the greatest solution. Even though a little expensive, because that kind of film needs a layer of polarized material, that lets the light cross only from one of it’s sides.

Reply
Nomer 05-06-2010, 11:50

I suggest a label on all xray film which is right and which is left or “this side up” label to ensure that the scan will not be reversed (if scan will be reversed then the R (right) and L (left) label will be reversed as well) =) sense and simplicity

Reply
Gail 07-06-2010, 12:04

It is also questionable – why did the team not mark the incision with a pen as recommended? Were other key preparation steps skipped and why? I agree that the xray being reversed is part of the problem but there seems to be other quality checks that were overridden here.

Reply
Louie00 15-06-2010, 15:41

This was complete lack of attention by physicians and staff members. Radiologic Technologist place markers on the Xray image while shooting the images. The MARKERS consist of a two letters “L” and “R”. The markers are clearly displayed on all images and serve as a reference point for technologist and physicians.

Reply
SD 06-07-2010, 19:37

I know when they amputate some legs at some hospitals they mark it “TAKE ME” as in the past they have sadly mistaken and amputated the wrong leg. Same here, why not mark the head? Sounds ridiculous but hey who knows what’s going on in there most of the time? NURSES!!!

Reply
kavs 30-07-2010, 11:00

I am aware that left eye was operated insted of the right eye one to patient as per the TV news and patient went to court.

I heard that a patient was operated for stomach pain ,the surgeon left a pair of scissors in the belly while in operation and noticed in the susequent Xray ..The patient was reoperated to remove the scissors.

Reply
jennifer 27-09-2010, 18:54

how about just a reality check before a doctor numbly ambles his or her way through a life altering surgery! this should be a wake up call that surgeries can not become routine or mistakes are made. We need fresh eyes and double check systems–come on wake up!

Reply
kamlesh pandey 12-01-2011, 12:52

simply the poka yoke is doing job as stoper in the door when you open first you operate the stopper.

Reply
Brad R. 15-02-2011, 20:04

Ahh, but then there’s always Grave’s Law – make something idiot proof and the world will create a smarter idiot.

Reply
Paul 06-04-2011, 22:21

How about designing the xray film to have the wording ‘THIS WAY UP’ pre printed onto the film. The operator could take the xray in the orientation stated on the film and then the doctors could place the xray light board ‘THIS WAY UP’.

Reply
David 07-09-2011, 18:31

I think it is due our education system. For not teaching the students in class to always check and even double check there work before starting or finishing a job. No one thinks that quality matters until a life hangs in the balance. Specially when it is there own.
If students are taught from the time they start high school or even college it will be some thing that they will carry with them for the rest of there life. Six Sigma is some thing that is a way of life in Japan that is practice in their homes and at work.

Reply
David 07-09-2011, 18:32

I think it is due our education system. For not teaching the students in class to always check and even double check there work before starting or finishing a job. No one thinks that quality matters until a life hangs in the balance. Specially when it is there own.
If students are taught from the time they start high school or even college it will be some thing that they will carry with them for the rest of there life. Six Sigma is some thing that is a way of life in Japan that is practice in their homes and at work.

Reply
David 07-09-2011, 18:32

I think it is due our education system. For not teaching the students in class to always check and even double check there work before starting or finishing a job. No one thinks that quality matters until a life hangs in the balance. Specially when it is there own.
If students are taught from the time they start high school or even college it will be some thing that they will carry with them for the rest of there life. Six Sigma is some thing that is a way of life in Japan that is practice in their homes and at work.

Reply
David 07-09-2011, 18:33

I think it is due our education system. For not teaching the students in class to always check and even double check there work before starting or finishing a job. No one thinks that quality matters until a life hangs in the balance. Specially when it is there own.
If students are taught from the time they start high school or even college it will be some thing that they will carry with them for the rest of there life. Six Sigma is some thing that is a way of life in Japan that is practice in their homes and at work.

Reply
David 07-09-2011, 18:35

I think it is due our education system. For not teaching the students in class to always check and even double check there work before starting or finishing a job. No one thinks that quality matters until a life hangs in the balance. Specially when it is there own.
If students are taught from the time they start high school or even college it will be some thing that they will carry with them for the rest of there life. Six Sigma is some thing that is a way of life in Japan that is practice in their homes and at work.

Reply
Tracy Morrison 30-06-2012, 19:02

Mark the patient! The surgeon may not have control over the placement (correct or not) of the X-ray in the viewer. Two people should review the X-ray in the presence of the patient and mark the correct side of the patient with a pen. If the patient is alert, even better. They can confirm.

Reply
sakshi 16-11-2012, 10:40

May be the X-Ray holder should have a structure like our mobile sim cards (a little cut from one side), where there is no way of placing it incorrectly.

Reply

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