Berry College

1. Campbell School of Business Berry College • Mistake-Proofing • Your System • Workshop on Best Practices • for Reducing Transfusion Errors • John Grout • jgrout@campbell.berry.edu • www.mistakeproofing.com • 706-238-7877

2. Mistake-Proofing IS • The use of process or design features to prevent errors or their negative impact. • Also known as Poka-yoke, Japanese slang for “avoiding inadvertent errors” which was formalized by Shigeo Shingo. • Inexpensive. • Very effective for manufacturers that are aware of it. • Based on simplicity and ingenuity. • Something you already have in your organization.

3. Mistake-Proofing IS NOT • Rocket science. • A stand-alone technique that will obviate the need for any other responses to error. • Widely known and practiced in manufacturing (even less in services generally, or healthcare specifically).

4. Everyday Examples

5. Mistake-Proofing Tends to Be Very Effective AT&T Power Systems: average outgoing defects reduced by 70% TRW: reduced customer PPM’s from 288 to 2. Federal Mogul:99.6% less customer defects and 60% productivity increase DE-STA-CO: omitted parts 800 to 10 ppm all modes 40,000 to 200 ppm 15-30% productivity increase

6. But Devices Tend to Be Inexpensive... Cost of Poka-Yoke Devices 1 0.9 0.8 0.7 0.6 Frequency of Occurrence 0.5 Proportion Cumulative Proportion 0.4 0.3 0.2 0.1 0 $25 to $100 $25 or less $100 to$250 $250 to $1000 $1000 or more Cost

7. The Paybacks Can Be Substantial • Dana corporation has reported a $500,000 savings resulting from a $6 device • Ortho-Clinical Diagnostics(Johnson & Johnson) saved $75000 annually by discovering a new use of Post-It® notes • AT&T Power Systems (Lucent Technologies) reported net saving of $2545 per device (3300 devices) • Weber Aircraft reports saving $350,000 during their first year of implementation of approximately 300 devices. • GE Aircraft Engines spends a minimum of $500,000 on any in-flight shut-down (IFSD). Spending $10,000 to stop one IFSD yields 50:1 benefit

8. Example: Broselow Tape

9. Example • Error: esophageal intubation (putting a tube into a patient’s stomach which was intended for their lungs) • Poka-Yoke: Squeeze bulb and put on tube. If bulb inflates, the tube is in the lungs. If not, tube is incorrectly placed in the esophagus.

10. In other services 1/3 of customer complaints relate to problems caused by the customer themselves 1998, John R. Grout Healthcare Applications Are Different than Manufacturing • Both service provider and patient errors impact service quality and must be managed • The service provider is blamed for all errors, both those committed by the server and by the patient • traditional quality improvement methods may have limited impact Source: make your service fail-safe. Chase, R. B., And D. M. Stewart. 1994. Sloan management review (spring): 35-44.

11. Task Server Poka-Yokes Treatment Tangibles • Task poka-yokes: • Doing work incorrectly or not requested, wrong order, too slowly • Treatment poka-yokes: • Lack of courteous, professional behavior • Tangible poka-yokes: • Errors in physical elements of service

12. Task Examples Treatment Tangibles • Task poka-yokes: • Cash register buttons labeled by item (instead of price) • Tags to indicate order of arrival • Treatment poka-yokes: • Bell on shop door • Record eye color on bank transaction form (insure eye contact) • Tangible poka-yokes: • Paper strips around towels (indicate clean linens) • Envelope windows

13. Preparation Customer Poka-Yokes Encounter Resolution • Preparation poka-yokes: • Failure to bring necessary materials, understand role, or engage correct service • Encounter poka-yokes: • Inattention, misunderstanding, or memory lapses • Resolution poka-yokes: • Failure to signal service failure, provide feedback, learn what to expect

14. Preparation Examples Encounter Resolution • Preparation poka-yokes: • Appointment reminder calls • Student degree requirement checklist • Encounter poka-yokes: • Height bar in amusement park • ATM using card swipe instead of insertion • Resolution poka-yokes: • Provide premium for completed survey

15. Mistake-proofing Puts “Knowledge in the World”In addition to “Knowledge in the Head” World: • Provide clues about what to do • Change process design: embed the details in the process • Frees mind to consider the “big picture” • Facilitates “knowledge work” Head: • “Improve” SOPs (increasing complexity?) • Retrain • Re-certify skills • Manage & enhance attentiveness John R. Grout

16. Knowledge in the World: Which dial turns on the burner? Stove A Stove B

17. Knowledge in the World: How would you operate these doors? Push or pull? left side or right? How did you know? A C B John R. Grout

18. Knowledge in the World: Whose signature is required? Before: After:

19. No System of Barriers is Perfect… Error Harm Adapted from James Reason’s Managing the Risk of Organizational Accidents

20. No System of Barriers is Perfect……But improvements can be made Error Error Harm Harm Adapted from James Reason’s Managing the Risk of Organizational Accidents

21. Where do I go from here?Mistake-Proofing Resources on CD Instructions: • Put CD in drive (label facing up) • Close the drive (starts automatically) • These presentation PowerPoint slides • Full text book: Mistake-Proofing Designing Errors out by Chase & Stewart (only service oriented book on the topic) • An annotated bibliography of other books • Resource links to the world wide web • A few medical examples and information on how to contribute your organization’s examples. • Contact information John R. Grout

22. Thank You!