How to reduce work errors and work mistakes by 90% with a workflow system (Part 2)

Hi there,
I’m sorry!
My plans have changed.

In the previous blog (part 1) I touched on the causes of mistakes and individual solutions and this time I was planning to explain the causes of mistakes to the solution in the workflow system (the part that has not been explained yet), but it but it turned out to be too voluminous so this time I will explain the following contents.

Fourth and fifth causes of mistakes

Cause Type Solution
 Lack of knowledge Mistakes that can be prevented by training

Require or encourage the creation and updating of work procedures.

Assign a mentor who can be easily consulted and asked questions when the work procedure is not clear

 Lack of skills

Start with simple tasks that do not require advanced use of tools, and gradually move to more complex tasks through on-the-job training

Share working know-how about the tools in the form of workshops and materials

 Lack of morale

Periodically review the validity of procedures
Eliminate unreasonableness and waste from the procedures from the perspective of whether there is any significance to follow the procedures or whether following the procedures is overloading the company.
It prevents the development of a climate of disregard for rules and incentives to violate them

Regularly conduct internal audits to ensure that procedures are being followed
Create a sense of deterrence by periodically checking evidence that work is being done according to procedures to prevent rule violations from becoming a regular occurrence

 Inadequate planning/environment This is a mistake that can be prevented by improving the work environment and procedures, in other words it cannot be prevented by training the workers.

It is important to analyze the causes and consider measures to prevent recurrence based on the premise that humans will always make mistakes.

Occurrence prevention perspective
Respond with the three principles of simplification / substitution / and elimination

Anti-spillover perspective
Use two principles of anomaly detection and mitigation.

  Inadequate procedure

The above data is a summary of elements found in the following paper by Professor Takeshi Nakajo, Management Systems Engineering, Chuo University.
Error Classification and Solution from 1999 the Effects of Work Management System on Human Error Occurence
https://ci.nii.ac.jp/naid/110003154353
The classification of solutions is taken from Human Reliability Engineering: An Engineering Approach to Error Prevention
http://www.indsys.chuo-u.ac.jp/~nakajo/open-data/Healthcare_Errorproofing2.pdf

In my last blog I touched on the causes and solutions for the mistakes that can be prevented by training (lack of knowledge, lack of skills, lack of morale) in the table above (see my previous post here).

I will now explain the remaining causes of mistakes that cannot be prevented by training are Inadequate planning/environment (the fourth cause) and Inadequate procedures (the fifth cause).

Measures to address Inadequate planning/environment and Inadequate procedures

Solution inadequate planning/environment and Inadequate procedures

Occurrence prevention
 Elimination
 ・ Elimination of work
 ・ Elimination of risks

 Substitution
 ・ Automation
 ・ Support systems

 Simplification
 ・ Standardization and centralization
 ・ Specialization and individualization
 ・ Adaptability

Spillover prevention
 Anomaly detection
 ・ A system that calls for immediate attention
 ・ Organize entrances and exits
 ・ Specialization (physical limits)
  ・ Record and verify operation
  ・ Limitations of operation
  ・ Confirmation of results

 Impact mitigation
 ・ Redundancy
 ・ Fail-safe
 ・ Protection

The fourth cause of mistakes is Inadequate planning and environment.

If you think about it very strictly, the concepts and scope of planning and environment are different, but here I will just consider planning (including the environment in which the plan was created).

In this case most of the mistakes are caused by difficulties in the planning itself, such as
An unreasonable work schedule (unreasonable, omission of consideration of factors)
A lack of workers (inadequate dispatching, unforeseen circumstances)


However, I believe that these causes are the way things are supposed to happen.

This is because some of these causes have backgrounds that may be difficult to remedy immediately.

Example of issue) Unreasonable work schedule

・Dependent on the ability of the planner (assumed to be due to impossibility or failure to consider factors)
 →
Proposed Countermeasures
   - Reskilling → (Challenge: It takes time)
   - Change people → (Issue: Unclear whether we can procure suitable personnel)

   As a result of the above issues
   ・ There is a background of wanting to solve the problem but not being able to move forward
   ・ Because the plan is approved by the team including the plan maker, it is impossible to make an objective judgment
   (I think I have to do something, but since it is approved by the team, I just go ahead with it.)

The above background is easy to imagine.

Let’s also show an example of the following issue.

Example of problem: Lack of workers

・Not allocating costs / Not preparing for dynamic staffing (contingency, inadequate planning)
  Proposed Countermeasures
   - Budget supplement → (We’re running on a shoestring to begin with, and we’re not in a financial situation to set up an additional budget)
   - Multifunctional technology → (If you don’t train them in a systematic way, they will become stubborn. It also leads to turnover.)
   ↓
   Due to the above issues,
   ・In the first place, the situation is unsolvable (as an environment)

As mentioned above, environmental issues can also be assumed as a background.

Professor Nakajo has proposed a solution to the problem of inadequate procedures as well as error proofing.


Countermeasures by Error Proofing

To put it simply, it is to improve the work methods of the elements other than people that make up the work system, i.e. system texts and procedures.

The concept of error proofing divides errors that cannot be prevented by training into two categories: prevention of occurrence and prevention of spillover.

Occurrence prevention

Now let’s talk about occurrence prevention.

In order to prevent this from happening, three types of measures have been proposed.

  • Elimination
  • Substitution
  • Simplification

Elimination

Preventing the occurrence of such errors starts with checking whether there is anything unreasonable in the purpose of the work itself (inadequate planning and environment), and then eliminating procedures and operations that be a risk of error occurrence in the first place.

The concern is that it will have a significant impact on business processes with the possibility of a drastic revision of procedures.

In addition, the person in charge of the work may find it difficult to speak up and say, « Let’s not do this. » Therefore, it is recommended to create a place to encourage remarks and objective evaluation by the entire team and organizational layers.

Substitution

This is a method of letting machines and systems take care of tasks where human error may occur. It is costly to implement, but it can reduce inadvertent errors as much as possible. The risk is the possibility of problems occurring, such as bugs in the system. In light of this, it is considered to be less effective in preventing problems than eliminating them.

Furthermore, substitution can be divided into two categories: automation and support systems.

  • Automation: Replace human tasks with mechanical systems
  • Support systems: Provide support tools to ensure that humans can perform the relevant functions (checklists, guides, samples, input forms, etc.)

Simplification

It is about making work itself easier so that people can reliably perform functions such as memory, perception, judgment, and movement while working.

Simplification, like substitution, can be further divided into three categories.

  • Standardization and centralization: Reduce changes and differences in work
  • Specialization and individualization: Identify changes and differences in work
  • Adaptation: Making the objective and environment suitable for human abilities.

Examples of standardization and centralization: Make sure to take certain actions at certain times (timers, alerts, calendar entries, etc.)

Examples of specialization and individualization: The tools used in the process should be labeled with red tape for process 1 and green tape for process 2 to help identify them easily.

Adaptation: Only qualified personnel can perform certain tasks. We are conscious of matching the target and environment, such as not allowing people with weak eyesight to perform tasks that require extreme visual checks.


Prevent the occurrence of mistakes.

From this point of view, it is not a solution that depends on people, but rather a systematic process that includes the environment and planning to prevent the problem.

Prevention of Spillover

As the name implies, the idea behind spillover prevention is to minimize the impact of a mistake, should it occur.

In addition to the idea of preventing errors from occurring, the idea is to have a system in place to comprehensively reduce errors by taking measures to prevent them from occurring in the first place.

Two categories of spillover prevention

Anomaly detection

Anomaly detection means that measures should be taken so that an abnormality can be immediately recognized.

For example, the shape of the end of the hose used to connect the city gas is made and prepared according to a certain standard, so that equipment other than that standard cannot be connected (so that it can be identified as abnormal at that time).

Furthermore, anomaly detection can be divided into three types

  • Record and verify operation
  • Limitations of operation
  • Confirmation of results

Record and verify operation: Record actions and check for errors at specific points in the process

Limitations of operation: Limit error-based behavior so that workers are aware of abnormalities.

Confirmation of results: Review the resulting equipment logs, reporting text, and notifications at specific points in time of work.


Now, let’s cite a surgical procedure as an example.

In the case of surgery, a series of steps are considered, from surgical planning to the use of various instruments and postoperative medication care. Let’s take a look at a few examples.

In this case, it is important to count the number of surgical instruments before and after the surgery to record and confirm the operation (did you leave any equipment inside the body?).

In addition, making sure that the tank of the anesthesia machine is connected to a specific shape is a restriction of movement to prevent connection errors. Checking that the medication has been administered at the prescribed dosage and time after the surgery is a way to confirm the results.

Impact mitigation

Mitigation is the process of lessening or absorbing the impact of an error by adding redundancy, limitations, or protections.

Mitigation can be further divided into three categories.

  • Redundancy
  • Fail-safe
  • Protection

Redundancy: Try to perform tasks with the same function in parallel so that correct results can be obtained even if an error occurs.
Fail-safe: Incorporate mechanisms and conditions into equipment and operations that prevent the transition to dangerous conditions caused by errors.
Protection: Provide protection against loss in the event that an error causes a dangerous situation

Redundancy, for example, is the practice of having two people work on the same task and not moving on to the next step unless the output is a perfect match, preventing disastrous results unless both people make the same mistake.

Fail-safe is defined as, in the case of physical machines, limiting the capability of the equipment to a less hazardous range. In the case of a system, it means that the scope of the relevant process or treatment should be cut out to an appropriate extent so that it can be implemented. (Also, make sure that there is no automatic transfer to the next process.)

The last point, protection, is to prepare the environment in the first place so that even if an error occurs, the impact will be minimal. In the case of physical measures such as protective mask helmets, and in the case of systems such as appropriate access privileges, and a configuration in which data processed in the relevant work process is separated from the master data so that the processed values are stored and used in a way that does not affect the master data.

Now that we’ve covered all the mistakes and the solutions to them, let’s get down to the nitty-gritty.


Proposing Solutions From Different Perspectives

Now that we have discussed the causes of mistakes and solutions, some of you may have felt something strange after reading this far.

In fact, the causes and countermeasures so far have only been organized from an engineering perspective.
Systematization and automation are slogans that are used in actual workplaces, and you may think that your company is already working on them.

So why don’t mistakes disappear?

In fact, I believe that this is where the problems of technical and adaptive issues in corporate organizations lie.

A technical problem is a problem that can be solved with known technology and methods.

For example, if you feel thirsty the best way to solve this problem is to drink water.
This is a knowledge-dependent way of solving problems, and the more knowledge you have, the wider the scope of the problems you can deal with.

In addition, you may want to collect all the files created in your company in one place, or you may want to restrict access to them with appropriate permissions. In such cases, cloud storage or SaaS services can be the solution.

This is something that we can handle because of our knowledge.

On the other hand, what are adaptation issues?

Here is a passage from the book « Working with Others » by Associate Professor Motokazu Udagawa of the Graduate School of Management, Faculty of Economics, Saitama University.

”On the other hand, adaptive issues are problems for which no specific solution can be found, such as when you ask for cooperation from other departments but they do not cooperate. For example, when you propose the introduction of a cloud service at a meeting, they are opposed to it because of the risks involved. And even if you explain logically that the risk can be avoided, you will be opposed again for some other reason, and you will know that this is an adaptive problem. The reason for this is that there is something special behind the words that are said on the surface that is not being said. For example, if the person you’ve shared information with can’t work on their own, it’s too much of a hassle to deal with, or if you’ve shared your own data, you’ll lose your advantage.

This cannot be solved by simply arguing that it is more reasonable to do this. You have to enable the other person to overcome the fear that the change will bring, otherwise things will not move forward.

We live in a world that is so full of knowledge and technology that most of the technical problems can be managed with some resources. In other words, many of the problems that our society is still struggling with are adaptive issues.”

Working with Others: A Theory of Organization that Starts from the Inability to Understand 

When I first came across this article, there were many things that came to mind.

These are the cases that were not accepted no matter how logical the explanation was.
Of course, the people involved may feel that they made the right decision at the time, but when you go back and think about it, whether the problem was solved or not will be hidden in your memory.

So, is there a solution to the adaptation challenge?

The answer is dialogue.

Dialogue does not mean simply talking in a circle or having a drinking session to find out what people really think. Dialogue is about building new relationships.

I would like to borrow again a passage about dialogue from Associate Professor Udagawa’s book.

”A new relationship does not mean suddenly trying to understand each other.
If you look at the example of the proposal to introduce cloud computing services, when you were upset because your proposal was rejected, you were trying to make the other person accept your proposal. However, when you realize that the other party has their own merits and that the proposal will be meaningful in their situation, the relationship has begun to change.”

”This is because an organization is a relationship in the first place. We think of an organization as existing as a thing. But think about the company you are working for. There are people there, there are buildings, but the organization does not exist as a thing, and in fact, no one has ever seen it. But we go to work and have meetings every day for that organization.
In other words, the substance of the organization is actually the relationship itself that drives us.”

Working with Others: A Theory of Organization that Starts from the Inability to Understand

When I take in the text in this way, I feel like I have a new understanding of it.

It is true that there are a myriad of difficult problems that arise in any environment, not just technical problems, but problems that arise in relationships.

Well, the goal of this blog is to explain how workflow can reduce mistakes, so for more details on technical issues and adaptation challenges, please buy the book from the source or run to the library (lol).


Why did we focus on technical issues and adaptation issues this time?

The reason for this was that I thought it could compensate for the blind spots of the earlier engineering approach.

For example, mistakes that are made due to lack of morale.

Let’s assume that this is simply a problem of lack of morale or lack of motivation and a sense of belonging (lack of loyalty) to the company, and attempt to correct it through training and education.

Superficially, there will be a good deal of change and progress.
For example, it could be a remorseful comment from the person who made the mistake, or an apparent change in behavior such as brightening up and asking more questions.

However, it is easy to imagine that this party is actually trying to make it look like they are remorseful and loyal on the surface.

In addition, the person who made the mistake may have suggested some kind of improvement.

Some people may see this as sophistry by the party who made the mistake and not reflect on the proposal.

In the background, are there any unspoken defenses such as « I’m sure we’re prepared » (the system is designed to handle it. I’ve been doing this longer than you, so it’s not a big deal).

In fact, I believe that such concerns are always present in the real world, not just in stories.

This is because a flat view of things is not possible in the structure of human consciousness.(We all have cognitive biases.)

What happens when we try to solve problems with only systems (mechanisms, past processes), leaving aside the understanding of people (person to person) without taking such assumptions into account? What happens when we try to solve problems with only systems (mechanisms, past processes)?

A world where the dialogue (building new relationships) described earlier is not done. A world in which dialogue is viewed as IN and OUT, with API communication as the preferred method of communication (a world in which you answer what you hear).

It is a world where decisions are based on logic rather than building something based on relationships with people.
A world judged by need and necessity

In fact, this is an issue that has a lot to do with the fundamentals of business.

Most businesses need new customers, but whether you see it as building new relationships or conversions from a technical or systemic point of view, I think the future will be very different.

When we think seriously about the causes of mistakes and their solutions, we are entering a phase where we are not only taking an engineering approach, but we are also trying to solve the problem in a relational sense, in order to face its depths.


Well, it’s a long story so I’ll summarize.

Borrowing from past knowledge, I believe that an engineering approach to organizing and categorizing problem concepts and solutions according to the categorization will be effective in its own right.

In order to further improve and sublimate this effect to a satisfactory one, we need to be aware of the adaptation issues and try to build new relationships in parallel with the engineering approach.

That’s it for this time.
In the next blog, I will finally summarize the results and introduce a workflow system that reduces mistakes by 90%.

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