Tag Archives: mistake-proofing

The Best Form of Fire Fighting is None at All

The best form of problem solving is to avoid problems altogether.

At the point you have a “fire” in your organizaiton you have to fight it. But it is better to create systems that avoid fires taking hold in the first place.*

This is a simple idea. Still many organizations would perform better if they took this simple idea to heart. Many organizations suffer from problems, not that they should solve better, but problems they should have avoided altogether.

By John Hunter, see more of my trip to Rocky Mountain National Park.

A stronger management system based on continual improvement using experimentation based practices (PDSA etc.) while viewing the organization as a system should reduce the need for heroic action to fix problems.

* This idea is sensible for management systems and cities; for forests that have evolved complex ecosystems in which fires play a roll it may well not be a wise strategy (as the US Forest Service has learned).

Add Constraints to Processes Carefully

Take great care in adding constraints to processes to avoid doing so needlessly.

Online you will frequently find forms that have required fields that needn’t be. Certainly if you were designing with focus on what is best for customers those requirements rarely make sense. Occasionally a required field is a sensible constraint on an online form but so often they add unnecessary constraints.

I frequently find those forms even requiring a false answer since a response is required and none of the options are true. Often this is because the organization is thinking of the boxes they expect users to fit themselves into rather than thinking how to create the best user experience.

I wrote previously about a company representative that suggested a customer change their name because the computer system didn’t accept names with 2 characters. Constraints on creating a secure password are a frequent failure of web sites for the last 10 years.

Man without arms denied housing loan due to inability to provide fingerprints

because Wu Jianping has no arms, creditors claimed they could not give him a loan since he was unable to be fingerprinted.

After the case was publicized and there was a great deal of negative publicity on social media the banks modified their process and approved the loan. But your organization shouldn’t have as the mistake-proofing (obviously not mistake-proofing at all) that when the process doesn’t quite work well then rely on a massive social media outcry which is a signal to us to straighten out the issue.

Frequently I see unnecessary constraints creating the edge case excuse. By burdening your process with unnecessary constraints you create edge cases that fail and then use the excuse that each of the edge cases is rare and therefore you can’t justify the expense of fixing them.

But if you designed the process sensibly in the first place the edge case never would have failed and you wouldn’t need special work arounds for such “edge cases.” A simple example of this is unnecessarily complex web page code that fails if to submit a button without javascript. Yes, a small number of users won’t have enabled all javascript to run (today anyway) so it is an “edge case” to deal with if you don’t have the form work without javascript. But there is no decent reason to have it fail in most cases.

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Human Proof Design

Human proof design is design that prevents people from successful using the item.

It is similar to mistake proofing except instead of prevent mistakes it prevents people from using it.

When you see human proof design you will often see signs to tell people how to use the device that has been human proofed. Common instances of this are hotels that have shower designs so opaque they need instructions on how to use a device most people have no problem using if they are not human proofed.

Human proof design is often created by a subset of designers that care about how something looks more than how it is used.

Most people prefer designs that are beautiful without being human proofed. The Design of Everyday Things is a great book on designing beautifully with customer focus.

A sign your design is human proofed is that a sign or manual is needed for people to use it.

Most human proof design can be identified very simply by having regular people try to use the item. Watch what they do and when they struggle to use it, many problems will be very obvious. You can’t use people in this effort that are significantly different from the normal users.

In several areas I see these failures quite often. Hotel rooms are a common source of problems. The light switches are often very odd and I have to search all over to find out how to turn on or off different lights.

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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).

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.

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Practicing Mistake-Promoting Instead of Mistake-Proofing at Apple

Mistake proofing is a wonderful management concept. Design systems not just to be effective when everything goes right but designing them so mistakes are prevented.

I have had several bad customer experiences in the short time I have had my iPad mini. One of the most pitiful is caused by mistake-promoting process design. As the name implies that isn’t a good idea. Mistake-proofing processes is a good practice to strive for; processes that create extra opportunities for failure impacting customers negatively are a bad idea.

My experience below is but one mistake-promoting practice that has caught me in its grips in the short time I have owned my iPad mini. I want to view books on the mini but can’t find any book reader. So I decide, fine I’ll just install the Kindle reader app.

I go to do so (run into additional issues but get through them) and then Apple decides for this free app, on an iPad I just bought with my credit card a week ago, to block me from getting what I need and force me to revalidate my credit card. This is lame enough, but I am used to companies not caring about the customer experience, so fine, what hoops does Apple want to force me through?

But guess what, the unnecessary steps Apple decided to force me through are broken so I can’t just waste my time to make them happy. No. They have created a failure point where they never should have forced the customer in the first place.

So they not only didn’t mistake-proof the process they mistake-promoted the process by creating a unnecessary step that created an error that could have been avoided if they cared about mistake proofing. But instead they use a mistake-promoting process. As a consumer it is annoying enough to cope with the failures companies force me through due to bad management systems that don’t mistake proof processes.

Companies creating extra opportunities to foist mistakes onto customers is really something we shouldn’t have to put up with. And when they then provide lousy and then even incomprehensible “support” such the “change your name” vision Apple decided to provide me now it is time to move on.

After 5 years of buying every computing device from Apple, they have lost my entire good will in one week of mess ups one after the other. I knew the reason I moved to Apple, the exceptional Macbook Air, was no longer the unmatched hardware it once was; but I was satisfied and was willing to pay a huge iPad premium to avoid the typical junk most companies foist on you. But with Apple choosing to make the process as bad as everyone else there isn’t a decent reason to pay them a huge premium.

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SWAT Raids – Systemic Failures?

I have mentioned Reddit (an online community that is highly skewed toward software engineers who are a bit irreverent) before: Dell, Reddit and Customer Focus. The site highlights stories voted up by the community and so the makeup of the community has a huge impact on what is highlighted. The users are very willing to challenge authority (and in fact anxious to do so I think). So some topics are common: criticizing DRM, science, criticizing the United States’ role in the war in Iraq, programming, iconoclasts, xkcd, criticiszing stupid corporate behavior, Paul Graham, criticizing Fox.

Lately there have been a large number of stories on people being killed in raids by police on the wrong house: police in full swat gear storming the wrong house by accident and then killing occupants. The media in general sees these as “special causes” – isolated incidents. So while tragic the strategy is then to examine what mistake in this unique situation lead to tragedy. I believe that the readers of Reddit sense this is a systemic problem and therefore see the proper examination to undertake is to look at the whole system. That is, to use the common cause improvement strategy – when the tragedy is seen not as an isolated incident but the result of a system.

It seems to me the Reddit readers are right – I think the users natural tendencies (a willingness to question authority and a trained sense of what is a special cause and what is a common cause, even if they don’t use those terms) result in the stories gaining traction within Reddit. To limit future tragedy the system as a whole needs to be examined. Do not seek to find the special cause that led to the problem in one instance. Look to the system and see why this trend has increased. I don’t actually have good data – I am making a guess that this trend has increased in the last 20 years (getting some decent data on what is really going on is obviously one of the first things to do in looking at this issue).
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European Blackout: Human Error-Not

German utility E.On says major European blackout was caused by human error [the broken link was removed]

Germany utility E.On AG said Wednesday that a European-wide blackout earlier this month that left millions without power was the result of human error and not any technical glitches.

The Duesseldorf-based company said the power outage, which led to blackouts in parts of Germany, France, Belgium, Italy, Portugal and Spain on Nov. 4, was not caused by a lack of proper maintenance or enough investment in transmission grids and facilities.
…
The blackout was caused after a high-voltage transmission line over a German river was turned off in an aborted attempt to allow a newly built Norwegian cruise ship to pass safely under it.

That triggered a blackout that briefly left 10 million people without power, stopping trains in their tracks and trapping people in elevators.

Ok, the focus seems to be that we didn’t do anything wrong, just some “human” made an error, which seems to be implied is out of their control. Why would the organization not be responsible for the people and the system working together? Management needs to create systems that work. That system includes people and equipment and process management and suppliers…

E.ON says human error responsible for Nov 4 power outage [the broken link was removed]:

It said that its control centre shut down part of an ultra-high voltage transmission line without checking whether the outage of a second transmission line might overload the power grid.

About half an hour later there was an outage at a second transmission line, which ultimately created a domino effect that led to the temporary disconnection of the European interconnected power grid.

The German utility said that all systems reacted in accordance with standard procedures, effectively preventing a complete blackout across Europe.

It seems obvious the process was not well designed if they believe a mistake was made that led to the tens of millions of people being without power. Failing to admit that the process was designed poorly and needs to be improved is troubling. Blaming “human error” does not help or help improve in the future (and is not a way to develop a culture that respects people). And it reinforces the notion that this event is due to one special cause (or 2…). It seems to me, even with this very little evidence at hand, that this is a system problem.

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Designing In Errors

TiVo’s “self-destruct button” destructs [the broken link was removed]

In so doing, they’ve created a bunch of potential failures in which the user is locked out of her own equipment.

It’s like those movies where an accident or a bad guy triggers the “self-destruct button” on a spaceship. Often the self-destruct button is locked away behind plexiglas and padlocks for safety, but wouldn’t it be safer not to include a single command that blows up the whole space-ship?

You know that is a pretty good explanation of the reasoning behind mistake proofing: eliminate as many possibilities for errors as possible. When you design products that create more possibilities for more errors you create products that will in fact fail more often.