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The Poka-yoke for Safety


The Japanese have a term for fail-safing or mistake-proofing called “poka-yoke.”   While this sounds like a character from a videogame, a poka-yoke is any mechanism in a process that helps an operator avoid (yokeru) mistakes (poka), and has been around for 4o years

This month our blog theme was safety.  Safety has many meanings, but generally it means protection from harm.  What is the poka-yoke  for safety revealed in our blog posts?

 Tom described emerging trends in a relatively new field called “safety across high consequence industries.”   The highest levels of safety require a shift in mind-set from avoiding risk to anticipating, responding and learning from risk.  Safety also needs to be linked to quality efforts for greatest impact.  This shift is required in order to achieve higher levels of safety performance under greater degrees of stress, turbulence, and dynamic uncertainty.   Tom illustrated these principles with a case study of a surgeon who initiated changes in a surgical team of a large teaching hospital. 

Surgical teams can be composed of as many as 150 people of diverse specialties and perspectives, only a small sub-set of whom cross paths on a particular surgery.  Traditionally surgical teams are also very hierarchical.  This made creating a process for involving the members of the team in collaborative problem discovery and problem solving process very challenging.  The surgeon discovered that, as the team worked together over time to share their perspectives on how the team functioned and worked together to discover and test solutions, the team members began to develop a collective perspective and mind-set that was key to improvements in safety, productivity and team satisfaction.

Rick contributed an example of his work improving safety, quality, and productivity in chemical manufacturing.  After gathering information from people across different levels of the organization using interviews and focus groups, Rick combines carefully designed large group meetings with smaller teams that implement improvements.  This approach brings out the expertise of people familiar with the areas targeted for improvement in new, action-enabling ways, and provides the organizational system ways to reflect on and learn from its experience.  This approach requires consultants to facilitate learning instead of acting as “experts” who diagnose the problems and prescribe solutions for others to adopt.  In Rick’s example, clear gains in safety, quality, productivity, and finances were achieved over a year. 

David explained how to grow the economic safety of the US through a smaller number of basic framework laws and rules.  Since the most important source of stability depends on having broad-based income distribution, he said.  Unfortunately, since the late 1970s the inflation-adjusted “real” wages for most US workers has flatlined, except for top earners.  The top 1 percent of households captures over 20 percent of all US pre-tax household income, and the income of this group grew 10 times faster than the bottom 90 percent of households during 2002-2007. 

David recommended breaking up the power of financial and energy oligarchies though a number of strategies, such as by increasing taxes on household incomes over $250,000 while continuing the 2001 and 2003 tax cuts for incomes below that point to help offset highly regressive state sales and property taxes.

Joseph highlighted the power that many diverse minds bring to problem solving in order to reduce unintended consequences.  When enough people of diverse backgrounds are brought together, the amount of collective wisdom goes up exponentially and the fewer unintended consequences result, he said.  This is proven mathematically as an outcome of the many-minds problem in social systems.  Bringing many minds to problem solving works, because, as Joseph put it, “The overlapping Known’s cover the overlapping Know-You-Don’t-Knows, unintended consequences are in the Know-You-Don’t-Knows and the Unknowable, hence all mutually recognized unintended consequences are negated.”

Towards A Fail Safe World

Our blog posts this month on safety have a common theme– spread involvement, information, wealth and power, rather than concentrating it in the hands (or minds) of a few.  Spread expands capacity, rather than diminishing it.  This requires a belief that there is enough for everyone, and that everyone is equally worthy.  But spreading things out exactly the same way to each individual or node in the system in lock-step fashion can lead to another problem, the lowest common denominator.  We need ways to spread the highest common denominator across the many, while also recognizing the need for local customization.

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