By Kevin Meyer
Imagine my surprise when an article at the Harvard Business Review of all rags discussed poka yoke. Imagine my further surprise when I found it to be right on target without the usual ivory tower mumbo jumbo.
My favorite anecdote about "design rhetoric" has Japanese manufacturing guru Shigeo Shingo telling Toyota assembly line workers about his clever techniques to make production processes "idiot-proof."
One of the plant's employees burst into tears. "I am not an idiot!" she cried. A stricken Shingo quickly recanted. He scrapped "idiot-proof" in favor of declaring his initiatives essential to making assembly lines "mistake-proof." Genius.
He even has some good things to say about manufacturing, to the deference of his own world. I think.
An Excel miscalculation, a PowerPoint misspelling, or a misplaced email is often all it takes to suck the persuasive energy out of a provocative proposal. Overlook a particular bug in mission-critical software or forget a suture in an endoscopic surgery, and we're accelerating past mistake to malpractice. Shingo's initial factory floor audience notwithstanding, there are likely more idiots in the intelligentsia than there are in the mass production proletariat. What we really want to do is annihilate their dumb(er) mistakes.
But here's where Mr. Schrage really gets it right: the power of simplicity.
In effect, Shingo looked for the simplest, cheapest, and surest way to
eliminate foreseeable process errors. To make sure an assembler uses
three screws, for example, package the screws in groups of three. The
package is a poka-yoke device. Obvious? Perhaps. But "obvious" is often
an underutilized and underappreciated asset. This goes well beyond
"ounce-of-prevention vs. pound-of-cure'" clichés because sometimes
ounces cost more than pounds and, more importantly, constantly looking
for creative ways to minimize mistakes pushes people to rethink the
process. That's healthy. It invites innovation.
Very, very true. How often do we look for a complex solution to what is really a simple problem? Spend a few million on nightmarish ERP software instead of mapping and improving a process to remove complex flows and massive WIP, which will usually show how simple good manufacturing really is. Create a globe-spanning supply chain to focus on supposed labor savings instead of simplifying the internal processes to the point where savings overwhelm labor costs.
The power – and potential impact – of the simple is all around us. Take healthcare.
Just over a decade ago, the Institute of Medicine published its landmark To Err is Human report exploring how many medical tragedies are caused by stupid and preventable mistakes and explaining simple — and inexpensive — steps hospitals were beginning to take to prevent them. Yes, that included washing one's hands and taking extra care to mark the correct arm or leg for surgery.
It doesn't get much simpler than that. No fancy bar codes, germ detectors, or other such nonsense. Just wash your hands and use a Sharpie.
Every manager and executive should perform a "poka-yoke audit": What
are the persistently simple — and simply persistent — dumb mistakes we
make that our technologies can help us catch and destroy? (If you have
trouble coming up with five or six, I'm sure your bosses, colleagues,
subordinates, and even a customer or two might constructively suggest a
Then, what kind of digital, virtual, or even physical "poka-yoke
design" could help make that pathology a thing of our past? This isn't
about fundamentally changing our behavior or our minds; that's too
grand. This is about tapping our internal Shigeo Shingo to
"mistake-proof" the personal — and interpersonal — business processes
Tapping our internal Shingo. Part of living lean.
Bill Waddell says
Most remarkable is that the Harvard Business Review and MIT let Schrage into the club in light of his lack of the right credentials. He holds an undergraduate degree from the University of Illinois in economics – not normally enough to get into the Harvard Business School, let alone write for them.
Wjo knows? The times may be achangin’…
Jim Fernandez says
Thanks. A very timely article for me. We are starting a project to evaluate and fix the root cause of our customer returns. I sent your post to our team members.
david foster says
Michael Schrage is an astute guy. He has also written some worthwhile stuff about the (mis)use of technology in education: my excerpt here: