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Presented byPresented byTodd Hatley, CEO Todd Hatley, CEO

Integral Performance SolutionsIntegral Performance Solutions

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Where does this fit?

DFSS

DMAICLean DFSS

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Market

Serv

ice

Existing

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stin

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Error Proofing EMS

Original Content Developed By:A. Blanton Godfrey, PhD

Timothy G. Clapp, PhD, PENC State UniversityTakeshi Nakajo, PhD

Chuo University, JapanEMSized By:

Todd Hatley, MBA, MHA

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• Poka-Yoke• Mistake proofing• Error proofing• Foolproofization• Murphyizing

By Many NamesBy Many Names

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Murphy’s Law

If something can go wrong it will.

Murphy’s Law

If something can go wrong it will.

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Murphy’s LawThe bread always lands

jelly side down.

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Which Line is longer? a or b

a b

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• Everyone makes errors in every operation.

• Occurrence rate of individual error is very low.

• Human carefulness can be effective only for a short time.

• Bounded Rationality

To Err is HumanTo Err is Human

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FoamDebris

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1. Failing to answer a request for service 2. Overlooking patient’s needs3. Inputting customer’s name/address

incorrectly into cardiac monitor4. Delivering the wrong medication to the

patient5. Failing to appropriately document

patient charges

Examples of Human ErrorsExamples of Human Errors

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1. Developing a re-notification procedure.2. Use a checklist in hand. 3. Provide an armband to each patient

and then using an electronic system4. Color-code drug boxes or tubing. 5. Use overlays to make sure required

info is included.

Examples of Error ProofingExamples of Error Proofing

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What is Error Proofing?• Improvement of work operations, including

materials, machines and methods, with the aim of preventing problems due to human error.

Improve Human Beings

Fit to Work Operations

Improve Work Operations

Fit to Human Beings

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• People have not been well trained in how to solve problems.

• They are not permitted to solve problems without a major hassle.

• An infrastructure is not in place to encourage and reward problem solving.

Reasons We Have So Many Problems

Reasons We Have So Many Problems

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Just because you know how to solve a problem doesn’t mean anything.

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Just because you know how to solve a problem doesn’t

mean anything.

You have to actually do something to get results!

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Three Phases of Error Proofing

• Phase 1• Identifying Potential Errors

• Phase 2• Solution Generation

• Phase 3• Solution Evaluation and Selection

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Phase 1: Identify Potential Risk

• Failure Mode Effect Analysis

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0

00

0

00

0

00

0

00

R. P. N

.

D e t

O c c

S e v

Actions Taken

Responsibility & Target Completion

Date

Recommended

Action(s)

R. P. N

.

D e t e c

Current Process Controls

O c c u r

Potential Cause(s) &

Mechanism(s) of Failure

C l a s s

S e v

Potential Effect(s) of Failure

Potential Failure Mode

Process Function Requirements

Action Results

FMEA Date: Orig. Rev.Core Team:

Prepared By:Key Date: Model:

Page of Process Responsibility:Item:

FMEA Number:

Potential Failure Mode and Effects Analysis (Process FMEA)

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Phase 2: Generate Error Proofing Solutions

Error Proofing Principles and Solution Directions

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Principles of Error ProofingPrinciples of Error Proofing

Minimize the effects of human errors.

Error Proofing

LossesSmall Large

The percentage indicates the ratio of examples corresponding to each principle.

Prevention of OccurrencePrevent the occurrence of human errors

which may cause troubles.

Operations

FunctionsRequired

MemoryPerceptio

MotionErrorTasks

Risks

Elimination Replacement Facilitation Detection7% 26% 48% 14% 5%

Minimization of Effects

Abnorma-lities

Mitigation

Effects

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Principles of Error ProofingPrinciples of Error Proofing

Minimize the effects of human errors.

Error Proofing

LossesSmall Large

The percentage indicates the ratio of examples corresponding to each principle.

Prevention of OccurrencePrevent the occurrence of human errors

which may cause troubles.

Operations

FunctionsRequired

MemoryPerceptio

MotionErrorTasks

Risks

Elimination Replacement Facilitation Detection7% 26% 48% 14% 5%

Minimization of Effects

Abnorma-lities

Mitigation

Effects

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Elimination:Remove operations susceptible to

human error from the process.• Error: Inability of the public

to perform ventilation during CPR.

• EP: Only provide instructions for delivering chest compressions.

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Elimination: Sub-principlesElimination: Sub-principles

Eliminate risks inherent inobjects or objectsthemselves.

Getting information and filling it in a format

Elim

inat

ion

Checking or adjusting objects or schedules …

Verify or Adjust

Eliminate error-prone tasks.

Sub-principlesTasks/Risks to be Eliminated

Hand-offTransferring information or objectsfrom a person to another person

Fill-in

Risks

Task

s TaskElimination

Risk Elimination

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Elimination: ExamplesTask Elimination; Risk Elimination

Error Error Proofing Making error in receiving orders from medical control

Standardize orders and only vary in special circumstances (SD: Trimming, Self Elimination)

Loosing personal items through multiple handling

Reduce number of handling steps. (SD: Trimming)

Making errors in questioning patients

Eliminate duplicate of questions between several service steps. (SD: Trimming)

Making errors obtaining patient history.

Eliminate the acceptance of vital information. (SD: Trimming, Automation)

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Elimination: Notes for Application

In many cases, process/equipment design must be changed drastically.

Elimination solutions can have a great side-effect on cost, productivity and performance. This side-effect must be considered.

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How to Generate Solutions

• The five error proofing principles are useful for understanding various error proofing solutions.

• A tool for systematically generating error proofing solutions is needed, which can attain the change required by each principle for the individual case.

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• Original work of G. Altshullerbeginning in the 1940’s• Patent Clerk and Inventor

• “Theory of Inventive Problem Solving”

• Acronym: “TRIZ” (TIPS) • Web Search: “TRIZ”

Patent-based ApproachPatent-based Approach

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How We Solve Creative Problems Using the Psychological-based

Methods (Trial & Error Method)

How We Solve Creative Problems Using the Psychological-based

Methods (Trial & Error Method)

P roblemSolution 1

Solution 2

Solution 3

Solution N-1

Solution N

Personal Solution Space

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InnovativeSolution

Proven Solution

Direction

“Look” in Proven Solution Directions

“Look” in Proven Solution Directions

P roblemSolution 1

Solution 2

Solution 3

Solution N-1

Solution N

Personal Solution Space

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“Solution Directions”

Direct your mind in provendirections that have been

used repeatedly to “Error Proof” processes

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Solution Directions • Trimming (eliminate part or process step)

• ex. Eliminate manual data entry; eliminate duplicate of questions; eliminate unsafe operations

• Self Elimination (the mistake eliminates itself)• ex. Feedback of status/performance;

broken pills do not roll • Standardization (make things the same)

• ex. Standard forms; one size fits all; make asymmetrical part symmetrical

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Solution Directions • Unique Shapes/Geometry (1D, 2D, or 3D)

• ex. Electrical outlets; symbols• Copying (Redundancy)

• ex. Duplicate forms; barcodes; emergency power generator

• Prior Action• ex. Pre-packaged goods; supplier supplies

100 % inspected goods; pre-printed form

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Solution Directions• Flexible Films or Thin Membranes

• ex. Bottle safety seal; package bag; rubber gloves

• Color• ex. Color-coded documents, shelves,

goods• Combining

• ex. Customer records; a bell on the shop door; order form consisted of one original and three carbon copies

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Solution Directions• Counting

• ex. Count the number of goods; Use a checklist

• Automation• ex. Automatic calculation; electronic

verification (bar code; customer record validation)

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Principles and Solution Directions

Solution Direction

Principle

Trim

min

g (7

%)

Self

Elim

inat

ion

(7%

)St

anda

rdiz

atio

n(2

0%)

Uni

que

Shap

e/G

eom

etry

(2%

)C

opyi

ng(R

edun

danc

y) (5

%)

Prio

r Act

ion

(23%

)

Flex

ible

Film

s or

Thin

Mem

bran

es (2

%)

Col

or (5

%)

Com

bini

ng (2

3%)

Cou

ntin

g (1

%)

Aut

omat

ion

(7%

)

Tota

l

Elimination(7%) 29 12 4 0 0 12 0 0 4 0 1 62

Replacement(26%) 1 0 17 2 7 108 0 1 67 0 25 228

Facilitation(48%) 28 0 104 3 16 55 9 35 107 0 0 357

Detection(14%) 0 44 20 9 0 2 2 0 3 6 24 110

Mitigation(5%) 2 0 13 0 17 7 1 0 0 0 1 41Total 60 56 158 14 40 184 12 36 181 6 51 798

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Questions for Generating Solutions

Elimination1. Trimming - Can we eliminate the error-

prone process or harmful objects?2. Self Elimination - Can the harmful

action or object eliminate itself?3. Prior Action - Can we do something

beforehand to eliminate the error-prone process or harmful objects?

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Exercise 1 Worksheet Error to be Error Proofed Principles Question Solution

Trimming - Can we eliminate the error-prone process or harmful objects?

Self Elimination - Can the harmful action or object eliminate itself?

Eliminate Tasks/Risks

Prior Action - Can we do something beforehand to eliminate the error-prone process or harmful objects?

Automation (Automatic Inspection) - Can we automate the process to solve our problem?

Prior Action - Can we do something beforehand to support human operations?

Replace Error-Prone Human Operations

Combining - Can we combine (bring together/closer) two or more things to automate or support human operations?

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Phase 3: Evaluating and Selecting Solutions

Solution Priority Number(SPN)

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Solution Priority Number (SPN)

• Effectiveness: 1(Ineffective) to 3 (Very Effective)

• Cost: 1(High) to 3(Low)• Implementation: 1(Difficult) to 3(Easy)

Solution Priority Number (SPN) =Effectiveness X Cost X Implementation

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Effectiveness Scoring

Very Effective: The error can be eliminated.

3

Ineffective: The error can not be reduced.

1

Effective: The error can be reduced; however, it is still high.

2

DefinitionScore

Higher

is better

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Cost Scoring

Moderate: Store level budget is

needed.2

High: Branch or cooperate level is

budget if needed.1

Low: Within daily operation budget.

No specific budget is needed.3

DefinitionScore

Higher is better

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Implementation Scoring

Moderate: Training course is needed.

Some resistance is expected. 2

Easy: No training is needed.No resistance is expected.3

Difficult: Culture change is needed.Strong resistance is expected.1

DefinitionScore

Higher is better

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• In most cases, combined solutions are more effective than individual one.

• Take into consideration the multi-effects of a solution to various failure modes.

• Some solutions need time for implementation. Phase in the action plans.

• Clarify the responsibility, time frame, and outcome measure for each action plan.

Implementation of Action PlansImplementation of Action Plans

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• Change your mindset from relying on human behavior to changing work operation.

• Generate solutions for the identified errors using the error proofing principles and the solution directions.

• Evaluate the generated solutions using SPN, describe, and implement action plans.

• Use FMEA or other methods to identify the potential errors in your work operations.

ConclusionsConclusions

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References• Shingo Shigeo, Zero Quality Control: Source Inspection and the Poka-yoke

System, Productivity Press Inc, 1986. • The Productivity Press Development Team, Mistake-Proofing for Operation:

The ZQC System, Productivity Press Inc, 1997.• C. Martin Hinckley, Make No Mistake: An Outcome-Based Approach to

Mistake-Proofing, Productivity Press Inc, 2001.• Chase, R. B, “Make your service fail-safe,” Sloan Management Review, 35-

44, spring 1994. • Takeshi Nakajo and Hitoshi Kume; "The principles of foolproofing and these

application in manufacturing," Reports of Statistical Application Research, JUSE, Vol. 3, No. , pp.10-29, 1985.

• Altshuller, G.S., Creativity as an Exact Science: The Theory of the Solution of Inventive Problems, Golden Breach Science Publishers, 1984.

• John Terninko, Alla Zusman and Boris Zlotin, Systematic Innovation: An Introduction to TRIZ, CRC Press LLC, 1998.

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Contact Information:Todd Hatley, CEO

Integral Performance Solutions, LLC5544 Whisper Creek Lane

Wilmington, NC 28409(919) 656-5700

Todd@onlineIPS.comwww.onlineIPS.com