Tag Archives: visual management

Visual Management and Mistake-Proofing for Prescription Pills

Good ideas often just require some sensible thought to think of an improved approach. Management concepts can help guide such thinking, such as mistake-proofing and visual management.

To apply visual management requires giving a bit of thought to how to make visually obvious what is important for people to know. Mistake proofing is often really mistake-making-more-difficult (for some reason this term of mine hasn’t caught on).

prescription pills packaged together

Image from PillPack, they provide a service to deliver packages based on your prescriptions.

I believe mistake-proofing should put barriers in the process that make a mistake hard. Often what is called mistake-proofing doesn’t really fit that definition. The pill package shown above for example, doesn’t prevent you from continuing past the time on the package (Monday at 8AM) without taking the pills.

To call it mistake-proofing I would like to see something that makes it harder to make the mistake of failing to take the pills: something that blocks progress beyond that time without taking the pills.

Even something as simple as an alert to your smart phone that gets your attention and doesn’t allow the smart phone to be used without indicating you have taken the pills would reach the “mistake-proofing” level in my opinion (for someone that has their phone with them at all times). The Apple Watch could be a good tool to use in this case. Even so those wouldn’t make mistakes impossible (you can say you took the pills even if you didn’t, the phone/watch may lose power…). It would depend on the situation; this smart phone/watch solution is not going to be good for some people.

Another idea is that these pill packages should be tied to the room (in a hospital) and at home if a home care nurse (or even family or others) are responsible for assuring the pills are taken with a big display that perhaps 30 minutes before the pill is due posts a message that says “pills to be taken at 8 AM” and once that time is past it could become more obvious, perhaps after 15 minutes it produces an audio alert. The actual solutions are going to be better from those that know the actual situation than someone like me just thinking up stuff as I type.

But the idea is pretty simple: when you have processes that are important and at risk of failure, design processes with elements to make mistakes hard (and ideas such as mistake-proofing and visual management can help you guide your mind to ways to create better processes).

The entire process needs to be considered. The pill packages are nice, because even in failure modes they provide good feedback: you may still fail to take them at the right time, but you can look at the location where the pill packages are kept and see
if any have a time before right now (in which case you can follow the medical guidance – take the pills right now, contact the doctor, or whatever that advice is). Of course even that isn’t foolproof, you could have put the package into your purse and it is still sitting in their but you forgot.

Still the pill packages seem like a good mistake-making-more-difficult solution. And it seems to me that process has room to make mistakes even more difficult (using a smartphone addition, for example).

Continual improvement requires a continual focus on the process and the end user for ways to increase reliability and value. Each process in question should have engaged people with the proper skills and freedom to act using their knowledge to address weakness in the current process that are most critical.

Failure to take prescriptions as directed in a common problem in health care. Knowing this should make those involved in the process think of how they can use concepts, such as mistake-proofing, to improve the results of the system.

Too often to much focus is on making better pills compared to the effort is put into how to improve results with simple concepts such as visual management and mistake-proofing.

Each small improvement contributes to creating a more robust and effective process. And engaged people should continually access how the containing systems, new processes and new capabilities may allow more small steps to provide value to those relying on your products and services.

Related: Great Visual Instruction Example for Taking PillsVisual Management with Brown M&MsQuick Mistake Proofing Ideas for Preventing Date Entry Error

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Magnetic White-Board Kanban Card Options

Just some quick ideas for Kanban whiteboard magnetic card options from a question I answered on Reddit.

Here is the best lean solution: Trying Out My Agile Kanban Board from Jon Miller.

kanban board with magnetic whiteboad  cards

Magnetic kanban board from Jon Miller.

Why, well mainly I am kidding about it being the best, but if you don’t read his Gemba Panta Rei blog you should! Go add it to your RSS feed reader, before you continue with this post.

Ok, welcome back. In addition to thinking his blog is great the solution from his blog is very flexible and easy – though it isn’t quite a packaged solution (as asked for on Reddit). Also that post provides some good insight into the thinking behind the board (as well as how to create your own).

More links with kanban board options: Magnetic whiteboard cards (50-pack)Physical TaskboardsI think just magnetic symbols (not magnetic white board card) but could use magnet with icon to stick paper to the board

Another silly site, that sells some sort of solution, blocked my access because they don’t sell in the country my computer reported being located in. So I didn’t give them a free plug (assuming their product was decent which it might be?). Very dumb design if you ask me; well even though you didn’t ask, I told you anyway.

Localization that impedes users rather than helping them seems far far too common in my experience. Mapping (and related – find closest…) uses are about the only localization stuff I find useful – country based localization I nearly always find annoying or crippling. And showing my location on a map is totally awesome (especially as I travel around as a tourist – or really in whatever capacity). Such bad design and poor usability decisions cost companies money.

Related: Visual Management with Brown M&MsMaking Data VisibleDeming and Software Development

Not Ambiguous Sign

I like the series of posts by Jon Miller on Ambiguous signs (another example). Here is a sign that got my attention recently and they succeeded in keeping me away (which I think was their intention).

photo of sign showing gunman shooting someone, and warning in 5 languages not to enter

Photo in Johor Bahru, Malaysia near the Royal Palace by John Hunter.

The area is near the Royal Palace in Johor Bahru Malaysia, though I am not certain that is what the restricted area is. It isn’t obvious to me why this location requires shooting trespassers, but I took the idea from the sign to stay out. To me, this sign conveys pretty forcefully that you shouldn’t consider entering if you are not authorized to do so.

Related: Living in Malaysiabear warning sign on hiking trailVisual Instructions Example

Visual Management with Brown M&Ms

When you hear about rock musicians having a clause in their contract that they must have a bowl of M&Ms in their dressing room with all the brown M&Ms removed you could be excused for thinking: what will these crazy celebrities do next. Well it might just be those crazy celebrities are using visual management (granted I think there could be better methods [a bit more mistake proofing where the real problems would be manifest] but it is an interesting idea). Basically if they didn’t have the bowl of M&Ms, or if the brown M&Ms were not removed, they could distrust the thoroughness of the contractors. And they would check to see what other, actually important, contractual requirements were not followed.

Righting The Wrongs: Van Halen and M&Ms

The staff at venues in large cities were used to technically-complex shows like Van Halen’s. The band played in venues like New York’s Madison Square Garden or Atlanta’s The Omni without incident. But the band kept noticing errors (sometimes significant errors) in the stage setup in smaller cities. The band needed a way to know that their contract had been read fully. And this is where the “no brown M&Ms” came in. The band put a clause smack dab in the middle of the technical jargon of other riders: “Article 126: There will be no brown M&M’s in the backstage area, upon pain of forfeiture of the show, with full compensation”. That way, the band could simply enter the arena and look for a bowl of M&Ms in the backstage area. No brown M&Ms? Someone read the contract fully, so there were probably no major mistakes with the equipment. A bowl of M&Ms with the brown candies? No bowl of M&Ms at all? Stop everyone and check every single thing, because someone didn’t bother to read the contract. Roth himself said:

“So, when I would walk backstage, if I saw a brown M&M in that bowl . . . well, line-check the entire production. Guaranteed you’re going to arrive at a technical error. They didn’t read the contract. Guaranteed you’d run into a problem. Sometimes it would threaten to just destroy the whole show. Something like, literally, life-threatening.”

Related: The Importance of Making Problems VisibleVisual Work InstructionsGood Process Improvement PracticesGreat Visual Instruction Example

Touring Factories on Vacation When I Was Young

Growing up, occasionally, a family vacation would include a factory tour related to my Dad’s work. He was providing some management or engineering consulting and took the opportunity to check in on progress and visit the gemba. Here is a photo from one of those tours (in Nigeria, I think). My brother and Mom are visible in the photo.

The tours (which were not a very common occurrence) were quite enjoyable and interesting. Though I really didn’t like how noisy the factories were. Seeing all the machines and vast scale of the systems was quite a change of pace and added some excitement to the vacations (that often were already pretty exciting). I remember we also visited some factories in Kenya (in between seeing the game parks).

photo of factory tour with my family when I was a kid

Factory in Nigeria (I think) that my family toured


On this tour we found a bit of visual management showing which side of a crate should be on the top.
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Communicating with the Visual Display of Data

graphs showing data sets with different looks even though some statistical characteristics are the same
Anscombe’s quartet: all four sets are identical when examined statistically, but vary considerably when graphed. Image via Wikipedia.

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Anscombe’s quartet comprises four datasets that have identical simple statistical properties, yet are revealed to be very different when inspected graphically. Each dataset consists of eleven (x,y) points. They were constructed in 1973 by the statistician F.J. Anscombe to demonstrate the importance of graphing data before analyzing it, and of the effect of outliers on the statistical properties of a dataset.

Of course we also have to be careful of drawing incorrect conclusions from visual displays.

For all four datasets:

Property Value
Mean of each x variable 9.0
Variance of each x variable 10.0
Mean of each y variable 7.5
Variance of each y variable 3.75
Correlation between each x and y variable 0.816
Linear regression line y = 3 + 0.5x

Edward Tufte uses the quartet to emphasize the importance of looking at one’s data before analyzing it in the first page of the first chapter of his book, The Visual Display of Quantitative Information.

Related: Great ChartsSimpson’s ParadoxSeeing Patterns Where None ExistsVisible DataControl ChartsEdward Tufte’s: Beautiful Evidence

The Importance of Making Problems Visible

Great, short, presentation webcast by Jason Yip showing the importance of making problems visible. Anyone interested in software development should watch this, and it is valuable for everyone else, also. Great visuals.

Related: Future Directions for Agile ManagementAgile Software Development SlideshowLeading Lean: Missed OpportunityInformation Technology and ManagementCurious Cat Micro-financiersposts on project managementToyota Institute for Managers

Data Visualization

Data is often displayed poorly, making it difficult to see what is important. When data is displayed well the important facts should leap off the page and into the viewers mind. Edward Tufte is an expert on this topic with great books. If you have not read them, you should: Beautiful Evidence, The Visual Display of Quantitative Information, Envisioning Information and Visual Explanations.

Smashing magazine has some nice examples of good display techniques in Data Visualization: Modern Approaches. I don’t like all the examples they show but it does provide some help by showing some creative ways to display data.

Related: Edward Tufte’s new book: Beautiful EvidenceGreat ChartsData Visualization Example

Visual Instructions Example

Visual Instructions

How to get people to actually use instructions for using your product: make it easy to do so. This blog post illustrates a well designed instruction guide for the Seagate FreeAgent backup drive. Simple pictures make it very obvious what to do (and even includes a time stamp showing how long into the process you are – which shows you the total time it will take at one simple glance 1 minute and 36 seconds).

Such instructions are a great example to guide internal standard work instructions.

Related: Why Isn’t Work Standard?How to Create Visual Work Instructionsblog posts on quality toolsmanagement improvement glossary

Visible Data

Effective visual signals are important for effective management improvement: lean thinking emphasizes such ideas. Top 5 Rules of Effective Measurement Boards is an excellent post on how to make measurement effective.

Take the time to find the important measures and then don’t keep data hidden in some drawer or computer file out of people’s view and therefore out of mind. Post the important data for everyone to see. Review the data as changes are made and see that the changes had the desired result. Update the measures when appropriate (for posting visibly – you will of course be measuring more than the few measures that belong on measurement boards).
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