Tag: Error Proofing

This Coffee Maker Wasn’t Error Proofed, So I Got a Lousy Cup of Coffee

This Coffee Maker Wasn’t Error Proofed, So I Got a Lousy Cup of Coffee

When I was on vacation, my wife and I rented an apartment in Beaune, France instead of getting a hotel room. At left is a picture from the center of town.

It was nice to be able to wash clothes part way through the 12-day trip. That allowed for a smaller batch suitcase, which allowed us to carry on our bags. We’ve learned the hard way that checked bags can get lost on an international connection, especially when you are switching between “partner airlines.” These are partners that blame each other when something goes wrong, I also learned. We had bags go missing for four days once. So, we’ve eliminated that risk by vowing to never check a bag unless we’re on the way home.

By October 24, 2016 1 Comments Read More →
Toronto Cyclist Error Proofs With a “Pool Noodle” to Improve His Safety

Toronto Cyclist Error Proofs With a “Pool Noodle” to Improve His Safety

This article from the Toronto Star caught my eye the other day:

Cyclist says his pool noodle makes Toronto streets safer for him

There was a law passed in Ontario requiring drivers leave one meter of space between them and cyclists. This doesn’t always happen, as there have been almost 900 collisions between bikes and cars to date this year in Toronto.

By October 21, 2016 5 Comments Read More →
Some Design Flaws are Annoying… Some are Deadly

Some Design Flaws are Annoying… Some are Deadly

I won’t literally be on the beach as the photo at left suggests.

But, I will be away on vacation through October 9, so I was going to take some time away from the blog to enjoy the trip, recharge the ole’ batteries, etc.

By September 27, 2016 0 Comments Read More →
Information Deficits, Visual Indicators, Error Proofing, and Payment Terminals

Information Deficits, Visual Indicators, Error Proofing, and Payment Terminals

Gwendolyn Galsworth is a leading thinker and author on Lean and various aspects of "visuality." One thing she talks about in the workplace is "information deficits."

These Two Things Are Designed Badly, But Nobody Gets Hurt…

These Two Things Are Designed Badly, But Nobody Gets Hurt…

Last Thursday, I flew to Ohio after my 93-year-old grandfather was moved from the hospital to hospice. He passed away peacefully Saturday morning in the company of my dad and his three siblings.

So, I have a heavy heart even though he passed away after a very full and long life. I will probably blog more about him in coming days, as he was the rare combination of an incredibly kind, yet strong, person. That’s why they call his “The Greatest Generation” (although, like many of them, he would modestly reject that phrase). “Ah, baloney,” he would probably say.

#FrontierFail & Frontier Lies… Why Competence is Required Before Lean

#FrontierFail & Frontier Lies… Why Competence is Required Before Lean

I think I’m done complaining about Frontier Communications on Twitter. It’s been a very frustrating week, as I’m on day 6 of a complete internet outage. You can read my long rant about it here on LinkedIn:

The Shared Interests & Goals of Lean and the Patient Safety Movement

The Shared Interests & Goals of Lean and the Patient Safety Movement

Later today and tomorrow, I’ll be attending the annual World Patient Safety, Science & Technology Summit that’s produced by a non-profit called the Patient Safety Movement. If you’re also at the event, please say hi! Follow the event on the hashtag #0X2020.

By January 22, 2016 0 Comments Read More →
The First Ever Instance of “Lean Doesn’t Apply to Us?”

The First Ever Instance of “Lean Doesn’t Apply to Us?”

Lean is, of course, not about a better way to build cars. It's a transferrable philosophy, management system, and methodology that is being applied in many different settings and industries, including healthcare. I'm often told (sometimes by somebody who is being sort of huffy): "Patients are not cars." [...]

By November 11, 2015 3 Comments Read More →
Moving from “Visuals” to “Visual Management” and to Broader Lean Thinking

Moving from “Visuals” to “Visual Management” and to Broader Lean Thinking

I’ve been studying and working with Lean for 20 years now and I love Lean because I’m still learning and getting better at this craft. I love seeing other people get excited about Lean when it’s new to them, when they see the potential for improvement and the power of Lean.

LinkedIn: How These Credit Card Websites Illustrate Lean Mistake Proofing

LinkedIn: How These Credit Card Websites Illustrate Lean Mistake Proofing

Here is my latest article for the LinkedIn “Influencers” series, written for a general audience that might not be as familiar with Lean:

How These Credit Card Websites Illustrate Lean Mistake Proofing

How Has Dr. Jack Billi Achieved 100% Hand Hygiene Compliance Since 2008?

How Has Dr. Jack Billi Achieved 100% Hand Hygiene Compliance Since 2008?

Thanks to my friends in the Michigan Quality System group, the internal Lean group at the University of Michigan Health System.

They shared a video that was put together by Dr. Jack Billi, a long-time student of Lean and advocate for Lean healthcare.  You can listen to my podcast with him from 2011.

An Invention to Prevent Empty Gel or Foam Sanitizer Dispensers in a Hospital

An Invention to Prevent Empty Gel or Foam Sanitizer Dispensers in a Hospital

Every time I am in a hospital or clinic setting, one of the first things I do is get a pump or squirt of gel or foam from a wall-mounted dispenser to clean my hands.

Or, I should say *try* to get hand sanitizer. For one, it’s important to practice proper hand hygiene when entering or leaving a unit, for my sake and the patients (and to practice what I preach, a secondary concern). Secondly, I’m testing to see if the hospital’s support processes work well – is the dispenser actually not empty?

Random Super Bowl XLIX Lean-Like Moments – Katy Perry and GE

Random Super Bowl XLIX Lean-Like Moments – Katy Perry and GE

Following up my earlier post about the “Patriot Way…”

During her halftime extravaganza (video), Katy Perry had a silver strap around her wrist, attached to the microphone. It reminded me of the Nintendo Wii strap that helps prevent throwing the controller (Update: I’m not the only one to think this and it might literally be a Wii strap).

By February 1, 2015 2 Comments Read More →
Guest Post: Poka Yoke… When It’s Personal

Guest Post: Poka Yoke… When It’s Personal

Mark’s Note: Today’s guest post is by Chris Burnham. I invited him to write this after I saw him share his pre-surgical “poka yoke” (or error proofing) on Twitter (caution: picture of feet). I asked him if “anybody was offended” by his abundance of caution and interest in not having the wrong foot operated on.  He replied, “No one was offended at all. I made it a point not to interfere with the point of incision.”

By October 8, 2014 4 Comments Read More →
Toyota’s Blog on Pillars of the Toyota Production System & Lean

Toyota’s Blog on Pillars of the Toyota Production System & Lean

Screen Shot 2014-04-30 at 8.18.49 PM

I didn’t know , until yesterday, that Toyota has an official company blog (at least for Toyota UK).

Even though I’ve learned from Toyota people and many books and classes (and I’ve written books of my own), I always encourage people to get Toyota Production System knowledge directly from the source whenever possible – including the books of Ohno & Shingo and modern-day Toyota people like Pascal Dennis, David Meier, John Shook, and others).

Toyota has a post about 13 “pillars” (principles, really?) of the Toyota Production System. Check it out.

Learning Not to Blame: Baseball Edition

Learning Not to Blame: Baseball Edition

[Morrie Rath, Chicago AL (baseball)]  (LOC)Following up my post about not blaming a bartender, here’s another look at learning to cast aside our old habit of blaming individuals… this time, baseball related.

Modern organizations (in healthcare and business) tend to blame an individual when something goes wrong. It’s commonplace in our societies and it’s, basically, human nature to blame. But, Lean and the Toyota Production System teaches us to NOT blame individuals and to, instead, look at the system. Dr. Deming, who influenced Toyota greatly, said that 94% of problems are due to the system. The exact percentage is unknowable, but the point is to not jump to blame.

So what happened in Major League Baseball last week?

A Whiteboard Accident Waiting to Happen – How to Error Proof?

A Whiteboard Accident Waiting to Happen – How to Error Proof?

Yesterday, Jim Benson and I were facilitating a “Lean for Knowledge Work” class at Geekdom in San Antonio and had a great time with attendees from healthcare and high tech companies.

We facilitated some “Lean Coffee” discussion sessions in a conference room. While the format is facilitated with sticky notes and pens, I noticed the whiteboard in the room had an accident just waiting to happen.

marker

Standardized Work? Why Are NFL Concussion Guidelines Not Always Followed?

Standardized Work? Why Are NFL Concussion Guidelines Not Always Followed?

Mark’s note: Ah, another NFL playoff weekend and time for another football post to follow up my apparent jinxing of the Eagles’ head coach Chip Kelly last week. Today’s guest post from Chad Walters is an intersection between sports, medicine, and Lean.

NFL-footballLast weekend during the NFL playoffs, two players – David Bakhtiari of the Green Bay Packers and Keenan Lewis of the New Orleans Saints – violated the NFL’s concussion protocol by not immediately leaving the field or sideline after being diagnosed with concussions. In fact, Bakhtiari re-entered his game for a play after being diagnosed with a concussion.

“NFL: Two violated concussion rules” (ESPN)

By January 11, 2014 9 Comments Read More →