Going to the Next Level of Preventing Errors

Quality systems, customer feedback, and even maintenance programs end up being mostly reactionary in the prevention of errors. We are trained to use problem solving systems like DMAIC, PDCA, A3, and 8 Step to resolve issues after some hidden chain of events have occurred. This is the troublesome problem solving paradigm most organizations have. Negative customer feedback like missing a delivery date is not corrected until it happens too many times, and maintenance programs continue with a vicious cycle of; Machine Fails > Troubleshoot > Repair > Return to Service > Machine Fails…

There are preventative programs like Failure Mode and Effective Analysis (FMEA) to determine how and where to correct the errors within these three programs. Nevertheless, lower FMEA Risk Priority Number (RPN) overlooks immediate use of improvement resources on potential failures. But I do agree it is one of the better preventative programs if there is a disciplined continuous improvement program that will finally reach the lower RPN failures. Finally, these lower RPN failures can sometimes be misinterpreted when, in reality, they can be more significant than what the RPN indicates.

The prevention of safety incidents has long been successful through the identification of Near Misses. A Near Miss can be defined as an unplanned event that did not result in a process failure but did have the possibility to do so.

The power of the application of Near Miss identification is in the breaking of a chain of events that would have caused a failure(s).

Near Miss identification can also be applied to the three systems I have already mentioned and it is the next level in the prevention of errors.

Reactionary events, as mentioned, have been addressed but a Near Miss prevention program requires a shift in pattern. This of course starts with the acceptance of the organization’s leaders. It has to become part of the continuous improvement strategy.

There are three support programs the leaders can use to successfully implement the shift from reaction to prevention, Standard Work for Managers, Visual Management, and daily Gemba Walks.

Shifting from reaction to prevention with value stream workers will require these four steps: 
1. Train workers on the identification, measure, and recording of Near Misses 
2. Establish the required visual management to measure number and types of Near Misses 
3. Fast problem solving process to address Near Misses 
4. Leaders Standard Work designed to Support, Teach, and Promote the Near Miss program

Near misses must also be categorized. For example, the first late delivery is a Near Miss and must be resolved immediately to prevent any deterioration of world class service to customers. A preventative maintenance Near Miss is related to predictive maintenance where workers measure and record abnormal sounds, feel, and even smells as a Near Miss. Learning to use the human senses and intuition can also be applied to Near Misses for quality.

Going to the next level of preventing errors takes leadership, discipline, and something we should know something about, continuous improvement.

We should always be looking for something to bring us to a new level, this is how world class is achieved. I think this Albert Einstein quote about insanity is applicable:

“Doing the same thing over and over again and expecting different results.”

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