Using Poka-Yoke and Jidoka to Reduce Medical Errors

Session
Lean Six Sigma

Author
John Grout, Ph.D.
Berry College

Description
First, do no harm. When in doubt, is the best action no action at all? Lean techniques, Poka-Yoke (mistake-proofing) and Jidoka (stopping the line), suggest that the answer is yes. Learn how these techniques are done and see how they impacted error rates and financial performance of health care systems.

Abstract
Two significant concerns in health care are spiraling costs and medical errors. These two concerns are correlated. Eliminating medical errors leads to significant cost reductions. Examples are provided where both metrics are improved by creating mechanisms that stop healthcare processes. While businesses often view having their processes stop as a negative result, increasing the stoppages (creating process failures) is often a precursor to improved performance. The rule of thumb is "if in doubt, stop." This concept of creating or engineering stoppages in the processes is linked to two "lean" concepts that come from the Toyota Production System: Jidoka and Poka-yoke. A spectrum of methods for stopping processes will be discussed using existing examples from helathcare. These range from warnings in the work environment, to mechanical devices designed to stop processes, to empowering humans to stop the process. Results from several healthcare systems will demonstrate the financial and medical improvements that may be obtainable by utilizing these methods.