1. Module 11 – Jidoka – 0 defects
LeanSigma® Facilitator Training
Module 11 – Jidoka – 0 defects

2. Topics Jidoka Built in Quality – DFSS, DFLS, 3P……………………………………..6 - 7
Root cause analysis – Ishikawa diagram, 5 Whys, Pareto……8 - 17
Mistake proofing……………………………………………………………

3. Lean Sigma has six steps to optimize processes.
Lean has a methodology (similar to DMAIC for Six Sigma). You’ll will use this methodology each time you run a kaizen or lean project.

4. Without all the elements, the house falls!
This module will focus on Jidoka aspects of the Toyota Production System.
Jidoka
“Built in” Quality
Root Cause Analysis
Mistake Proofing
Principles
of LeanSigma®
Just in
Time
Jidoka
Process Smoothing
Without all the elements, the house falls!
4 - 4

5. Jidoka is a mindset that doesn’t allow errors to pass to customers.
Allows processes to automatically detect abnormalities and prevent reoccurrence until corrected.
Improves productivity by eliminating the need for people to supervise.
Empowers employees at all levels to:
Help solve problems
To make decisions that affect them
Be accountable for their work
Improve productivity and quality
Zero defects!
KBE Module 3 - LeanSigma® Overview
4 - 5

6. Lean and Six Sigma have approaches to design new processes.
Jidoka
“Built in” Quality
Root Cause Analysis
Mistake Proofing
Lean and Six Sigma have approaches to design new processes.
Design for Six Sigma (DFSS), Design for Lean Sigma (DFLS) and the Production Preparation Process (3P) are approaches to build new processes that are efficient from the start rather than fixing existing ones.
Because kaizens focus on fixing existing processes, new process design sessions have a different agenda and objectives than kaizens.
If you can’t say that a process is followed 80% of the time, it’s best to approach it as a new process design.

7. DFLS sessions focus on customer needs.
Steps in DFLS
Map the high-level process in a SIPOC
Discuss & prioritize the customer needs (VOC and Kano model)
Prioritize the process requirements and characteristics
Construct the new process
Click for IMS notes on DFLS
Contact your Lean leader if you think a new process design session is needed.

8. Root cause analysis – understanding problems helps us to solve them.
Jidoka
“Built in” Quality
Root Cause Analysis
Mistake Proofing
Root cause analysis – understanding problems helps us to solve them.
People
Machine
Method
The Y
Problem or
Condition
The X’s
(Causes)
Categories
Material
Measurement
Environment
Because of it’s shape, this is often called a fishbone or an Ishikawa diagram.

9. The “head” of the fish is a problem or condition.
The X’s
(Causes)
People
Machine
Method
The Y
Problem or
Condition
Material
Measurement
Environment
Categories
Material
Products
The “Y” is a problem or condition:
Late delivery
Query responsiveness late
Customer cancellations
Supplier data is late

10. Y = f(X1…Xn) The “bones” of the fish are causes.
Problem
The X’s
(Causes)
People
Machine
Method
The Y
Problem or
Condition
Material
Measurement
Environment
Categories
“X’s” are those factors that may cause the problem or condition “Y”.
Y = f(X1…Xn)
Material
Products
The “Xs” or potential causes are organized into these categories:
People Material
Machine Measurement
Method Environment

11. Examples What are some common root causes at IMS under each category?
Measurement:
The client’s definition of DAP differs from IMS’ definition.
Key project is not included in PMPs.
People:
People don’t have the skills. Training doesn’t exist. The people responsible for the work don’t have the authority to make changes.
Process:
No documented process exist. There are too many manual steps. There are steps that don’t add any value.

12. Examples What are some common root causes at IMS under each category?
Materials (Supplies):
The supplier’s data was late. The supplier blocked access to some of their data.
Equipment:
The servers went down. A processing error occurred.
Environment:
Unions went on strike. A hurricane caused pharmacies to close. The government enforced new data privacy laws.

13. Fishbone diagrams are excellent kaizen tools.
When process mapping, you will often see a decision point that has a “good” path and an exception path.
If the percent of exceptions is higher than you would like, use the fishbone diagram to determine the causes.
Correcting these causes will become part of your action plan.
Why is the coding incorrect?
No – 44%
Code doctor data
Coding correct?
Fix coding errors
Bridge data
Yes 56%

14. The Five Whys tool can help you understanding underlying causes.
Sometimes symptoms of the problem disguise themselves as root causes.
A way to separate them is the Five Why’s approach.
It is what it sounds like…keep asking why until the answers are “I don’t care.
The root cause is the most basic explanation of a problem origin. If eliminated, it would prevent recurrence.
Why, why, why, why, why?

15. Pareto tool can help you understand the vital few causes that cause 80% of issues.
The theory says that 80% of the impact comes from 20% of the causes.
If you can identify the 20% correctly, you’ll be well on your way to fixing 80% of the problems.
80 / 20 15

16. The 80:20 Rule Examples
• 20% of the time expended produced 80% of the results
• 80% of your phone calls go to 20% of the names on your list
• 20% of the streets handle 80% of the traffic
• 80% of the meals in a restaurant come from 20% of the menu
• 20% of the paper has 80% of the news
• 80% of the news is in the first 20% of the article
• 20% of the people cause 80% of the problems
• 20% of the features of an application are used 80% of the time 16

17. Pareto charts show root causes as bar graphs.
The most frequent occurrences are always shown on the left. The line above the bar chart shows the cumulative percent of occurrences.
80% of the issues originate here 17

18. Mistake-Proofing goes one step further than root cause analysis.
Jidoka
“Built in” Quality
Root Cause Analysis
Mistake Proofing
Mistake-Proofing goes one step further than root cause analysis.
Prevent Defects
Determine
Causes
Rank/Sort
Defects
Identify
Mistake
Proofing
C & E
Quality Tools
Hypothesis Testing
Data Collection
Pareto
Check Sheet
The goal of Poka-Yoke is to achieve “Zero Defects”
Poka-Yoke involves both careful observation and data collection as well as ingenuity and creativity.
Poka-Yoke prevents mistakes using simple, inexpensive solutions.
We already know and have used the tools associated with the bottom 3 steps:
First we identify the defects,
Then we can quantify, rank and determine the “greatest offender” that needs to be fixed
Next, we determine the root causes of the greatest offender
Finally, we implement solutions to prevent the defect
We will look further at this model later in the lesson.

19. Mistake-proofing (Poka Yoke) Examples
Parking garages have low clearance. To insure that cars entering the garage will fit, garages are fitted with a go/no-go gauge at the entrance. Hitting the swinging sign or pipe will not damage the vehicle as much as driving into a concrete beam.
This iron turns off automatically when it is left unattended or when it is returned to its holder.
Need Guidon Examples, These are from the internet and require permission to use
Written permission to use these examples can be obtained by writing a short request with your name and company affiliation. Generally, I am willing to extended permission free of charge, if you will include a reference to in your document or presentation.
Fueling area of car has three mistake-proofing devices:
filling pipe insert keeps larger, leaded-fuel nozzle from being inserted
gas cap tether does not allow the motorist to drive off without the cap
gas cap is fitted with ratchet to signal proper tightness and prevent over-tightening.
Even bathroom sinks have a mistake-proofing device. It is the little hole near the top of the sink that helps prevent overflows.
Hand washing and Safety Saw videos

20. Mistake-proofing is especially important in processes with people because we are prone to errors.
Forgetfulness
Misunderstanding/miscommunication
Wrong identification, misread
Lack of experience/knowledge
Inattention
Acting too slowly
Absence of/poor standards
Not following standards
Poor judgment in unusual/emergency situations
Willful commission
Discuss the errors on the list
Ask participants: “Are there other kinds of errors you have experienced?”
Discuss additions to the list from their own work area

21. Error Proofing Techniques
Eliminate Possibility of Error
Reusable code libraries
Child locks on car doors
Cash register calculates change
Programmed phone numbers
Configuration management of code libraries
Delegate Necessary Decisions
Prevent Errors
Match Tasks to Abilities
Implementation checklists/scripts
Color code cables
Error Proofing
Facilitate Tasks
Distinguish Tasks
Do nothing is not an option…
Spell checking in a word processor
Thresholds on disk usage / monitoring
Peer reviews & checks
Detect Errors
Mitigate Errors
Auto-correct feature in word processor
UPS
Resilience X
Mitigate Errors
Nothing
Customer calls you

22. Not all checks are equally effective.
Successive Checks
Self Checks
Mistake Proofing
Associates check work of previous Associate
Associates check own work before passing to next Associate
Automatic check & prevention of defect
Plus:
Generally effective in catching defects
Problem:
Corrective action can only occur after defect is made
Instant correction possible
More palatable than supervisor or peer check
Associate may compromise quality or forget to perform check
100% inspection usually with no extra time expense
Instant correction
Definition
Plusses / Problems

23. Mistake Proofing has different levels of intervention.
Shut Down
Process stop:
Cannot proceed until issue is addressed
Control
Pull-down box:
Only “X” choices available – must select from choices
There are 3 main categories of Poka-Yoke devices:
Shut Down – an example is a line stop where the machine shuts down when an error is detected
Control – and example is a locator pin that is positioned so that a part cannot be inserted into a jig incorrectly
Signal – an example is a light or buzzer that signals when an error is detected
Signal
Error message:
Notification of incorrect data entry by pop-up text box

24. Mistake Proofing examples are common in our lives.
Auto-shut-off on gas pumps
Double-sided car keys
Auto-flush in public facilities
What are your examples?
Ask what failures these error proofing techniques prevent
Examples of controls that we might employ in cheque clearing Process?
In Transport phase (where cheque is scanned through machine), if there is a problem with a cheque (not quite smooth, dog eared) that causes a jam, the machine will shutdown and not process any more until the jam is resolved
After the bundles of cheques have been taken out of the bags (that the courier delivers), the bags are turned inside out so that the person looking after this activity can be sure that they have removed and processed all the cheques that arrived in the bag.
Here are some examples from IT:
Examples of controls that we might employ:
A software installation wizard
Regular housekeeping activities
Configuration Mgmt tool to avoid multiple access to code modules
Read only access to folders
Programming languages with automated syntax checking
Code Libraries with re-useable, proven code modules; routines which always initialise variables/memory
Further Examples
Optional:
Have participants think of Poka-Yokes they would LIKE to see – Examples:
Bank card readers that can read from any direction
Parking spaces/garages that signal when you are in far enough
Floor alarms that sound when dirty socks land on them

25. Characteristics of Mistake Proofing
Reason for mistake proofing device is clear
Never fails
Defective items never passed on
Low or no cost
Made with wisdom & ingenuity
Simple, durable and easy to maintain
Device idea is transferable to other areas
Does not interfere with work
Associate trained in proper use of device

26. Mistake Proofing Methodology
Identify Defects
Tools: Check Sheet
Describe the defects
Determine the defect rates
Rank/Sort Defects
Tools: Data Collection, Pareto
Collect/organize defect rate data
Create Pareto chart
Identify “Main Culprit” on which to focus
Determine Causes
Tools: C & E, Quality Tools/Hypothesis Testing, Red Flag
Identify probable causes
Use C & E and 5 Why’s
Prevent Defects
Tools: Mistake Proofing device
Use associate ingenuity
Use creativity
List alternative ideas to eliminate/detect the error
Create device & test 4 3 2
Cover 4th step of methodology
The next slide gives some examples of Poka-Yoke devices 1

27. Back to EZ Money…. Finalize your plans for EZ Money with your teams.
Consider:
Work station layout (5S)
Standard work (every employee should understand their role.)
Piloting with a stop watch