Posts Tagged ‘mistake-proofing’

What level of human error is acceptable?

September 17, 2013

Even competent humans make mistakes. Mistakes may not result in failures to meet requirements. Some systems evolve to become tolerant of mistakes or some organizations employ their management systems to prevent nonconformity.

The only bad nonconformity it the one we do not know about.

Understanding this fact is the key for leaders and their managers being careful not to create a culture that hides nonconformity.

Even so it is common for managers to demand no mistakes and to react badly to errors.

Leading organizations provide employees with management systems that help them to understand and fulfill the requirements. And servant leaders provide a management system to help their employees to eliminate the causes of nonconformity. They do this gradually, according to the 80:20 (or 50:4) rule, so they always start with the vital few nonconformities that cost the most.

Zero Defects (zero nonconformity actually) has to come with humble managers who take responsibility for their management system causing the nonconformity. Care and respect remain to most powerful parts of such management systems. It should not require courage for employees to talk about problems in doing the right work right.

These organizations welcome nonconformity reports to show where the management system needs further improvement to prevent failures to fulfill requirements. They know the only bad nonconformity is the one that remains hidden.

Prevention of Nonconformity by Design

May 11, 2011

Even competent people make mistakes. Consumers misuse poorly designed products perhaps injuring themselves or others. Competent employees may not operate confusing, boring or complex processes as intended. Human factors should be considered when planning and designing systems, processes, goods and services.

The development, use and improvement of the management system should prevent problems instead of relying on their detection. Relying on warning labels to warn customers is less effective than planning and designing products so they cannot be used or operated wrongly. Verifying services and goods is less effective than designing delivery or manufacture to avoid nonconformity.

Unsustainable wastes arise from poor design failing to protect stakeholders from incurring more and more of these losses. Additional resources used to make good the poor quality further damage the environment and adversely impact sustainability.

The prevention of nonconformity in goods, services and processes is a paradigm change from the control of nonconformity. Sorting bad product from good product is less efficient than prevention to stop the design of nonconformity or situations that cause nonconformity.

Prevention focuses first on reducing complexity in design. The most expensive mistakes can then economically be prevented in delivery or manufacture by mistake-proofing. Remaining causes of variation that result in any defective products may then be eliminated. This progression applies to the design of all products and the processes and tooling necessary to deliver conforming products.

Prevention offers a more robust approach to quality assurance than appraisal. It may require major changes in management philosophy, such as shifting the responsibilities for quality assurance into the operating organizations to remove complexity from designs, mistake-proofing service delivery, mistake-proofing manufacturing, statistical process control and verification. Conventional quality assurance organizations may change or decrease in size and importance in organizations applying the prevention principle.

Hence, design is the only way to prevent nonconformity when creating and delivering goods and services.

An organization preventing nonconformity by design will:

1. Establish the metrics for prevention of nonconformity by design (starting with design simplification criteria);

2. Identify the stakeholders affected by the system, product, its processes and the related outcomes;

3. Determine the needs of the customers and the concerns of other stakeholders;

4. Specify measureable and achievable characteristics of the product;

5. Specify the critical methods, resources and controls (including mistake-proofing as required) for correctly making, delivering and safely using conforming products;

6. Fulfill the system, product and process designs with capable processes.

7. Monitor and measure the design process per the established metrics; and

8. Review the design process against stakeholder satisfaction information.