Poke-No-More: Leveraging Poka-Yoke for Quality Healthcare

This week, the US Preventive Services Task Force (USPSTF) introduced new guidelines suggesting that women start regular mammograms every two years at age 40 —a significant change from previous recommendations which suggested age 50. This update has been prompted by increased breast cancer diagnoses among younger women and a concerning number of deaths among Black women, who already face a 40% higher risk.

I’m not a physician, nor am I a health care expert, but several aspects of this announcement are interesting from an operational point of view. 

First, I love the idea of preventive medicine, but will everyone (and in particular those at risk) have access to these services? Well… maybe not.

A recent study found that:

“21 percent of U.S. adults without access to a vehicle or public transit went without needed medical care last year. 

Individuals who lacked access to a vehicle but reported neighborhood access to public transportation services were less likely to skip needed care (9%). 

5 percent of all U.S. adults reported forgoing healthcare due to transportation barriers. 

Black adults (8%), adults with low family incomes (14%), and adults with public health insurance (12%) were all more likely to forgo needed care due to difficulty finding transportation. 

Adults with a disability (17%) were more than three times as likely to report skipping care due to transportation concerns.”

The following graph summarizes the results:

The fact that there’s not enough transportation reminded me of an earlier article by The Atlantic, discussing the impact of failing to show up for appointments:

“As Charles Holzner, one of Zinberg’s initial partners at CareMore and now a senior physician with the company, explains, ‘About one in three of the elderly people we were taking care of were home by themselves. They’d outlived their family resources, they couldn’t drive, and their kids lived out of town. So when they got sick, they ended up calling 911. And when it came to routine doctor visits, they sometimes just couldn’t make it at all.’”

The solution:

“CareMore’s unconventional solution to the problem was to provide transportation, at no charge, to get patients to their medical appointments. Local car-service companies were happy to have the business, and while the transportation cost money, it ultimately saved a lot more. Increased regularity and consistency of medical care meant that many simple problems were recognized and treated in their early stages: complications were avoided, and rates of hospitalization and nursing-home admittance began to fall.”

I’m a huge fan of lean operations and how they can be applied to everything, and one simple example of a core principle is “Quality at the Source” —more specifically, Poka-Yoke: Mistake proofing. 

It sounds so simple. So why we don’t see more of it? This is what I’m exploring today. 

Quality at the Source

Last week, I attended a conference focused on supply chain and resilience at the Mack Institute, a Wharton research center. The conference was great and I had the chance to speak about supply chain nearshoring, a topic very interesting to me. However, the most memorable moment was the dinner preceding the conference and my conversation with James Bonini, president of Toyota’s Production System Support Center. The center supports organizations, including firms, nonprofits, and hospitals, in learning and utilizing the production system.

He explained how Toyota’s Production System (he didn’t use the word lean even once, if I remember correctly) is widely misunderstood. Most people view it as a Just-in-Time method: decrease inventory levels and hope for the best. But in reality, it’s more profound, and constitutes a broader philosophy. It’s an organizational culture of highly engaged people working to solve problems and drive performance. The philosophy focuses relentlessly on customers, and the belief that people are a company’s best asset and the ones who drive continuous improvement (Kaizen) by actually doing the work. 

Those of you who follow my newsletter know that this philosophy is consistent with my own view of lean. And implementing it requires the use of various tools, the first of which is the well-known Just-in-Time. The second is Jidoka:

“Jidoka (English: Autonomation — automation with human intelligence): The principle of designing equipment to stop automatically and to detect and call attention to problems immediately whenever they occur (mechanical jidoka). In the Toyota Production System, operators are equipped with the means to stop the production flow whenever they note anything suspicious (human jidoka), thereby preventing the waste that would result from producing a series of defective items.”

And part of it is the notion of Poka-Yoke:

“Poka-Yoke (English: mistake-proofing): Fail safe devices in the production process that automatically stop the line in case of an error. A Poka-Yoke is any part of a manufacturing process that helps a Toyota member avoid (yokeru) mistakes (poka).”

These are both part of the “Quality at the Source,” idea which refers to the belief that quality should be built into a product or process from the very beginning rather than relying on inspections and quality checks at the end.

The principle of quality at the source involves creating a culture of continuous improvement, where everyone involved (from the workers at the production line to the managers and engineers who design the processes and the equipment) takes responsibility in ensuring quality. Implementing quality at the source involves training and empowering workers to address quality issues promptly and standardizing processes to enhance consistency. By prioritizing quality at the source, organizations can minimize waste, enhance efficiency, and boost customer satisfaction.

You may say: Well it’s clear how it’s used in manufacturing, but does it help me in my daily life? Poka-yoke aims to prevent errors from happening in the first place, or to catch them when they occur. Here’s how it is applied in real-life situations:

Online Credit Card Use: Online systems often use a form of poka-yoke to prevent errors when inputting credit card information. For example, the system may automatically format the credit card number to include spaces every four digits, making it easier to read and verify. It can also validate the card type based on the first digit (4 for Visa, 5 for MasterCard, etc.), or use the Luhn Algorithm to check the card number for typos.

Filling out Website Forms: Required fields on a form are another example of a poka-yoke. Unless these fields are filled in, the user cannot submit the form. Other examples include drop-down menus, which limit input options, and automatic email verification systems, which send a link to ensure the provided email address was entered correctly.

Lavatories on Flights: Airplane lavatory doors are often designed with poka-yoke. Many have a two-step locking process: slide the lock, then pull down the occupied sign. This design prevents accidental lock-ins or outs. Smoke detectors and automatic faucet sensors also serve as a poka-yoke, preventing users from leaving the water running or smoking in the lavatory. 

Another poka-yoke measure is the light that only turns on when the lavatory door is locked. This design has a dual purpose: First, it ensures privacy (the light indicates the door is properly locked saving the user from a potential embarassing situation), and second, it indicates that the lavatory is occupied, signaling to anyone outside that they should wait.

This is a perfect example of a poka-yoke or mistake-proofing design as it prevents users from failing to secure their privacy and from others mistakenly trying to enter an occupied lavatory.

Software Development: In software development, there are various poka-yoke measures that prevent or catch errors: Linting tools that automatically check for syntax errors or formatting inconsistencies, unit tests that check if individual parts of the code work as expected, and version control systems that prevent conflicts when multiple developers work on the same codebase. Integrated development environments (IDEs) often highlight syntax errors as you type, and compilers refuse to build the code if there are outstanding errors, both of which are poka-yoke measures.

Don’t you just wish your entire life was Poka-Yoked (a word I just made up)? 

Yes...

Yes, you do. 

So why Isn’t it?

There are various reasons why firms don’t utilize error-proofing:

Lack of Awareness: Some organizations may be unaware of the benefits and the effectiveness of mistake-proofing techniques. They may not be familiar with the concept or its potential impact on reducing errors and improving overall quality.

Cost Considerations: Implementing mistake-proofing measures may require an upfront investment in equipment, technology, or process redesign. Some firms may be reluctant to allocate resources for these upfront costs, especially if they involve significant amounts or if the firms is facing financial constraints. 

Resistance to Change: Introducing mistake-proofing often requires changes in existing processes, workflows, or employee roles and responsibilities. This can be met with resistance from employees who are either comfortable with the current situation or fear for their job security.

Lack of Expertise: Implementing effective error-proofing techniques requires expertise in identifying potential mistakes, designing foolproof systems, and monitoring their effectiveness. If organizations lack the necessary knowledge or experience, they may hesitate to adopt error-proofing strategies.

Finally,

Short-Term Focus: Some firms prioritize short-term goals and immediate outcomes over long-term improvement. This mindset can hinder the adoption of mistake-proofing, which often entails upfront investments and may not yield immediate returns. This last point was clear in the discussions held at the Mack Institute conference. Organizations prefer short-term tactical solutions, and prioritize them over long-term solutions, especially when there’s low visibility of the long-term benefits. 

Overcoming the aforementioned barriers requires shifting a company’s mindset, raising awareness on mistake-proofing benefits, providing training and supporting employees, and demonstrating the long-term value and return on investment achievable through error prevention. 

Changing a company’s cultural is much harder than just implementing tools. 

Quality at the Source in Health Care

But when it happens, the results are great. 

Back to health care. The book The Checklist Manifesto: How to Get Things Right focuses on the use of checklists in relation to several elements of daily and professional life, particularly in medicine, advocating their use to improve outcomes.

Atul Gawande explores the nature of complexity in our modern world and proposes a simple tool, the checklist, to manage the myriad of tasks we are required to perform. He asserts that today’s volume and complexity of knowledge exceeds our individual ability to deliver its benefits correctly, safely, and reliably without the aid of systems and protocols.

Drawing from diverse fields like aviation and construction, Gawande illustrates how checklists have been instrumental in reducing errors, increasing safety, and improving efficiency. He contrasts this with the field of medicine, where mistakes are common and often accepted as inevitable due to the human body’s complexity.

A key piece of evidence that Gawande uses for proving the effectiveness of checklists is a study conducted by the World Health Organization (WHO), where a surgical checklist was implemented in eight hospitals around the world, from rural Tanzania to bustling Seattle. This “Safe Surgery Saves Lives” checklist covered basic safety checks for surgical procedures, such as confirming the patient’s identity, the type of procedure being done, ensuring the availability of the required tools and supplies, and checking for potential allergies, among others. The results were significant: the rate of major complications fell by 36%, and the number of deaths fell by 47%.

This striking example serves as a centerpiece for Gawande’s argument regarding the power of checklists to reduce errors and improve safety, not just in medicine but in any complex process. A checklist is a form of Poka-Yoke. 

The book The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary discusses the notion of preventive medicine, which takes the idea of ‘quality at the source’… well… to the source. 

Michael P. Pignone from the University of North Carolina-Chapel Hill emphasizes the significance and cost-effectiveness of preventive care, stating that “individuals with one or more chronic conditions account for approximately $1.5 trillion in healthcare spending per year.” Pignone contends that prioritizing high-risk patients with chronic conditions can yield high savings and cost-effectiveness margins, given that “the likelihood of needing high-cost treatments are far greater than the costs incurred by provision of preventive services.” He estimates that “widespread use of effective interventions, such as disease management, postdischarge care, and case management for key chronic conditions could produce substantial savings, perhaps as much as $45 billion per year.” 

But this is where things get a little complicated as it’s not always the case.

Thomas J. Flottemesch of HealthPartners Research Foundation argues that the financial outcomes from preventive services are mixed. He found that “although primary preventive services, such as daily aspirin use and alcohol and tobacco use screenings, could have yielded net savings of nearly $1.5 billion... the use of secondary preventive services, such as mammograms and depression screenings, actually results in net costs of almost $2 billion.” 

He concludes that “while different types of evidence-based clinical preventive services have the potential for differential impacts depending upon current delivery rates and target populations, evidence-based preventive services should be embraced, and their use encouraged, because of their positive health impact.” 

In essence, Flottemesch advocates for an expanded view of prevention that considers the value and benefits beyond just cost savings. But that’s hard in our world, which is so short-term and cost-oriented. 

The main point is that, in many ways, lean is a philosophy. It’s a culture.

Again, one can adopt systems. But changing culture is difficult. 

But quality at the source has other hurdles. What happens if the test for early detection is unreliable? Like for prostate cancer:

“The U.S. Preventive Services Task Force (USPSTF) recommends that men ages 55 to 69 years discuss the possible benefits and harms of prostate-specific antigen (PSA) screening with their health care provider and make an individualized decision about whether to get screened. USPSTF found evidence that PSA screening may slightly lower the chance of death from prostate cancer in some men. But USPSTF also found that many men are at risk of harms from screening, like false-positive test results that lead to more testing, as well as diagnosis of problems that wouldn’t have caused symptoms or death. In addition, USPSTF recommends against PSA-based screening for men age 70 years or older.”

And this brings me to another lean principle: Yesterday’s solutions are tomorrow’s problems, so we have to iterate. We need to implement “quality at the source,” and if the conclusion is that the current (testing) technology is not accurate, we should revert back and try again. And after a few years, try again, and again and again, establishing a culture of continuous improvement. 

So let’s ensure that every woman aged 40 can get a ride to her mammogram exam. I’m sure we can get the autonomous car firms on board. 

And as for you: what’s your poka-yoke?