IPS

Presented by Presented by
Todd Hatley, CEO Todd Hatley, CEO
Integral Performance Solutions Integral Performance Solutions
IPS
Where does this fit?
DFSS
DMAIC
Lean
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DFSS
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IPS
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Error Proofing EMS
Original Content Developed By:
A. Blanton Godfrey, PhD
Timothy G. Clapp, PhD, PE
NC State University
Takeshi Nakajo, PhD
Chuo University, J apan
EMSized By:
Todd Hatley, MBA, MHA
IPS
Poka-Yoke
Mistake proofing
Error proofing
Foolproofization
Murphyizing
By Many Names
By Many Names
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Murphys Law
If something can go
wrong it will.
Murphys Law
If something can go
wrong it will.
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Murphys Law
The 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 Human
To Err is Human
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Foam
Debris
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1. Failing to answer a request for service
2. Overlooking patients needs
3. Inputting customers name/address
incorrectly into cardiac monitor
4. Delivering the wrong medication to the
patient
5. Failing to appropriately document
patient charges
Examples of Human Errors
Examples 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 system
4. Color-code drug boxes or tubing.
5. Use overlays to make sure required
info is included.
Examples of Error Proofing
Examples 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
doesnt mean anything.
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Just because you know how
to solve a problem doesnt
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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Completion
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Potential
Cause(s) &
Mechanism(
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Potential
Effect(s)
of Failure
Potential
Failure
Mode
Process
Function
Require
ments
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 Proofing
Principles of Error Proofing
Minimize the effects of human errors.
Error Proofing
Losses
Small Large
The percentage indicates the ratio of examples corresponding to each principle.
Prevention of Occurrence
Prevent the occurrence of human errors
which may cause troubles.
Operations
Functions
Required
Memory
Perceptio
Motion
Error
Tasks
Risks
Elimination Replacement Facilitation Detection
7% 26% 48% 14% 5%
Minimization of Effects
Abnorma-
lities
Mitigation
Effects
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Principles of Error Proofing
Principles of Error Proofing
Minimize the effects of human errors.
Error Proofing
Losses
Small Large
The percentage indicates the ratio of examples corresponding to each principle.
Prevention of Occurrence
Prevent the occurrence of human errors
which may cause troubles.
Operations
Functions
Required
Memory
Perceptio
Motion
Error
Tasks
Risks
Elimination Replacement Facilitation Detection
7% 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-principles
Elimination: Sub-principles
Eliminate risks inherent in
objects or objects
themselves.
Getting information and filling it in a format
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Checking or adjusting objects or schedules

Verify or Adjust
Eliminate error-prone tasks.
Sub-principles Tasks/Risks to be Eliminated
Hand-off
Transferring information or objects
from a person to another person
Fill-in
Risks
T
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Task
Elimination
Risk Elimination
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Elimination: Examples
Task 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. Altshuller
beginning in the 1940s
Patent Clerk and Inventor
Theory of Inventive Problem
Solving
Acronym: TRIZ (TIPS)
Web Search: TRIZ
Patent-based Approach
Patent-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 roblem
Solution 1
Solution 2
Solution 3
Solution N-1
Solution N
Personal
Solution
Space
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Innovative
Solution
Proven Solution
Direction
Look in Proven Solution
Directions
Look in Proven Solution
Directions
P roblem
Solution 1
Solution 2
Solution 3
Solution N-1
Solution N
Personal
Solution
Space
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Solution Directions
Direct your mind in proven
directions 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
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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 41
Total
60 56 158 14 40 184 12 36 181 6 51 798
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Questions for Generating
Solutions
Elimination
1. 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
Definition Score
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
Definition Score
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
Definition Score
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 Plans
Implementation 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.
Conclusions
Conclusions
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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.
J ohn 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, LLC
5544 Whisper Creek Lane
Wilmington, NC 28409
(919) 656-5700
Todd@onlineIPS.com
www.onlineIPS.com