J. Alex Sherrer 1 www.alexsherrer.

com
Poka-Yoke:
A technique for quality assurance, continual improvement, and enhancing the
customer's experience
Copyright 2010, J. Alex Sherrer
Poka-yoke (pronounced poh-kay yoh-kay) is Japanese for avoiding errors. It is a concept first promoted in
the early 1960s by Shigeo Shingo
1
and later popularized by his 1986 book Zero Quality Control: Source
Inspection and the Poka-Yoke System. Poka-yokes are inexpensive, simple methods built into processes
that prevent defects by eliminating errors or alerting us when errors are made. The key trait of poka-yokes
is that they make it impossible for the error to occur in the first place. For example, electric outlets and
plugs are designed so that its impossible to insert them together in the wrong way. Though poka-yokes
may appear to be most applicable to manufacturing, they're used in all sorts of processes, products, and
services.
Poka-Yoke Failure, Defect, or Error
Prevented
Products Automatic shut-off mechanisms for irons and
portable heaters
Hazards from being left on or
tipping over
Car lights that automatically turn off the ignition
is switched off
Dead battery from lights being left
on
Sink faucets with sensors that automatically turn
the water on and off
Faucet not being shut off
Automatic garage doors with sensors that stop
the door from closing when they encounter an
obstruction
Damage to the car and personal
injury from the door closing on
someone
Processes Color-coded file folders Filing errors
Electronic forms that validate city names to
postal codes
Shipping errors due to city/postal
code mismatches
User accounts that aren't activated until a
confirmation email is responded to
Bad email addresses and bogus
account registrations
Services In-room self-checkout at hotels Guests leaving without checking out
Fast-busy when an analog telephone is left off the
hook
Missed calls because line remains
open
Most of us think of quality tools only as a way of enhancing the customer experience through the
elimination of defects. But if we creatively applying the poka-yoke technique, we can not only make
inexpensive improvements to our products and processes by preventing errors, we can add value by
making them friendlier for the consumer to use.
The Poka-Yoke Technique
1. Understand why people make mistakes.
2. Look for error-prone elements.
3. Look for poka-yoke fixes.
J. Alex Sherrer 2 www.alexsherrer.com
1. Understand why people make mistakes
If we dont understand the human factors that can lead to mistakes, we wont be able to develop effective
poka-yokes. There are four factors that contribute to people making mistakes
2
:
Attention: We can focus well only on a single activity at a time. Multi-tasking and interruptions
will result in a greater likelihood for errors. And over time, with most experts suggesting in as
little as 20 minutes, repetitive processes become automatic responses and we no longer pay
conscious attention to what were doing.
Perception: People analyze a situation by interpreting sensual elements and synthesizing them
into a rational response. This can lead us to misjudge a situation if all of the sensual elements
don't agree. For example, advertisements grab our attention with large text, pictures, and bright
colors, but it's often the extremely small, innocuous print at the bottom of the ad that's most
important for us to read, yet because of its comparative obscurity, our minds gloss over it as
unimportant.
Memory: Short-term memory is good for small chunks of information for very brief periods of
time, but it has to be moved to long-term memory to remain effective. So unfamiliar or new
procedures are error-prone. There are also many factors, including stress, fatigue, boredom, and
noise, that limit how well we can retrieve long-term information, which means regardless of how
thorough our training might have been, it can be forgotten, and we make mistakes.
Logical reasoning: Panic, stress, and pressure can cause even an experienced worker to jump to
the wrong conclusion. For example, many infamous industrial accidents escalated because the
operators thought the gauges were at fault, giving them inaccurate information, rather than
deducing that there was indeed a critical flaw in the process.
2. Look for error-prone elements
At its most basic level, poka-yoke requires only a questioning approach as we look at a product or
process. We can start by looking for the tell-tale signs that a process is a candidate for poka-yokes that
are easy wins:
It has repetitive elements and repeatable outcomes.
It requires specialized skills or training to perform.
It requires attention to detail.
The people performing the task are apt to get frequently interrupted.
The process has frequent delays, such as when one of the process participants is waiting on
somebody else for further action.
People in the process are multi-tasking.
Another method of analyzing a process is to ask ourselves the 5W's about it. We can then review our
answers to identify weaknesses in the processes:
J. Alex Sherrer 3 www.alexsherrer.com
Who: Who are the participants? What roles participate in the process? What are the skills of roles
involved? How familiar are the people with the process?
What: What kinds of errors or defects are likely to be introduced during the process? What kinds
of steps are repetitive in the process? What errors can be introduced by another process?
When: In what stages are errors likely to be introduced? In what stages are errors that were
introduced earlier in the process likely to become apparent?
Where: Where or through what mechanisms are errors or defects introduced (such as tools,
machinery, applications, or devices)? Where do interruptions occur in the process? Where are
there long delays in the process? Where are there hand-offs from one person to another?
Why: Why would errors or defects occur? What conditions can lead to errors being made? What
process components can lead to errors? What human elements can introduce errors or overlook a
defect condition?
If we're analyzing a service-based process, we also have to consider the failures that might be introduced
by the customers
3
:
Failure to understand their roles in the
process;
Failure to engage the correct service;
Failure to set expectations;
Failure to follow the process in the correct
order;
Failure to follow instructions;
Failure to alert us of service failures;
Failure to adjust expectations;
Failure to perform their necessary post-
process actions.
3. Look for Poka-Yoke Fixes
With potential failures identified, we can now look for solutions. Poka-yoke fixes dont rely on training to
prevent errors or detailed human inspection to identify defects because those methods require the
participants to think about what they are doing 100% of the time, and that is itself a point of failure.
As we consider solutions, its easy to get carried away with complexities. If our solution is overly
convoluted, costly, or requires a form of inspection afterwards to identify the defect, it probably isn't a
poka-yoke. The key characteristics of successful poka-yokes are that they:
Are simple approaches;
Are inexpensive (which is why they're best incorporated during design phases);
Are built into the processes;
Provide immediate feedback to the people in the processes;
Take no thought from the participants to invoke.
A poka-yoke is the answer to Murphy's Law,
which states, "If it can go wrong, it will."
Make a poka-yoke so that it can't go wrong --
or will be spotted immediately if it does!"
4
Sheila Julien, Productivity Poka-Yokes, Conway
Management News
J. Alex Sherrer 4 www.alexsherrer.com
There are two primary types of poka-yokes. The first is a shut-out type of approach where we make it
impossible for the error to happen, and the second is an attention-type of approach that provides a
distinctive warning when an error condition exists. As an example, let's consider an online shopping cart
application that asks the consumer for his or her desired delivery date and shipper preference from one of
two shippers.
The first shipper doesn't deliver on a Saturday or Sunday, so if the consumer chooses that shipper
and a Saturday delivery date, the order is not submitted and a warning is displayed, asking the
consumer to choose a non-weekend date or change his or her shipping preference. This is a shut-
out mechanism because the process halts and isnt allowed to continue when the error occurs.
The second shipper will deliver on Saturdays for an additional charge, so in this situation a
prompt is shown that explains what the extra delivery charge will be and gives the consumer the
choice of accepting the charge or going back and changing the order's shipper. This is an
attention-type or warning mechanism because it doesn't definitively prevent all errors (the
consumer may not read the prompt and still later dispute the additional shipping charge).
Using Poka-Yoke Concepts for Innovative Improvements
Many people would not consider poka-yokes as innovative. Poka-yokes are usually part of quality and
continual improvement efforts, such as Kaizen, and there is a lot of controversy as to whether incremental
or small-scale improvements are innovation or not. But limiting what we think of as innovation
immediately puts a collar around creativity and constrains our viewpoint before weve even started.
Innovation can start from the smallest effort and idea, and if we approach poka-yokes with a broader
viewpoint and in combination with solid process design, analysis, and improvement techniques, they can
have innovative consequences. The product or project team can use the poka-yoke technique not only to
make defective-free products, deliverables, and services, but also to add low-cost but high-value attributes
that improve the customer's experience.
To find poka-yokes of this type, we have to get beyond our intimate knowledge about the product or
process were analyzing and look at it from the customers perspective. Because of our familiarity with it,
well have a tendency to keep our focus narrow. For example, if were in the human resources
department and were analyzing our new hire process, were likely only focusing on HR-centric
processes, and we may not think to look for poka-yoke opportunities in related processes owned or
controlled by other departments. But from the perspective of the newly hired employee, its all one
experience, and a failure is a defect regardless of whose ultimate responsibility it was for preventing the
error.
When we look at a product or process from the customers viewpoint, we can better anticipate failures in
a much wider context, and preventing those defects directly enhance the customer's experience.
When the customer comes in contact with the product or process, what are his or her expectations
about it? Which of those expectations might not be met? Which defects are in our direct control
to fix and which could be caused by other processes? What negative customer experiences might
occur but which are only indirectly involve our product?
In ways beyond the intended use, how might the customer use the process or product? Is there
market value in those uses, and if so, how can we incorporate low-cost mechanisms that promote
rather than impede that multi-functionality?
J. Alex Sherrer 5 www.alexsherrer.com
What types of failures can occur when used as intended or in the case of a process, followed per
instructions? What types of failures can occur when the product or process isn't used as intended?
Last, without introducing unnecessary quality and costs, what poka-yoke mechanisms can we
introduce that improve the customer's experience?
Example Failure Contributing Causes Possible Poka-Yokes
Supermarket self-checkout Delays and long lines Produce is one cause of
delays because the
consumer has to find and
enter produce code and not
all produce has labels.
Put barcodes on produce
that will accept labels and
provide barcoded bags for
produce that won't accept
labels.
Ice cream Poor texture when it
reaches the consumer
Thawing/refreezing
during transit.
Put temperature-sensitive
labels on the product that
change colors if it's
exposed to temperatures
above freezing.
Dry cleaner Lost tickets Customer loses claim
ticket.
Rather than issuing new
tickets with each visit,
regular/repeat customers
are assigned a permanent
ticket number.
Fast-food drive through Order fulfillment errors
and delays
Poor speaker quality/noise;
multi-tasking.
Touch-screen device at
drive-through that allows
customers to enter their
own orders.
New commercial accounts Delays in credit approval
(customer can't place its
first order until approved)
Multiple sequential
approvals with information
coming from different
sources.
Credit and business
references gathered from
commercial databases,
compiled into a single
report, and distributed
electronically to all
approvers in a shared
workspace rather than
sequentially.
Standard operating
procedures for technicians
Equipment is not serviced
correctly
Traditional online
procedures don't render
well on portable devices
(making them hard to read
and follow).
Create procedural
documents in alternative
formats for mobile
devices, like ebook
formats for the BlackBerry
and iPhone.
Conclusion
Poka-yokes are simple but effective quality assurance methods that prevent errors. To apply the poka-
yoke concept, we need to understand why people make errors and we have to analyze the process to know
where errors are likely to occur and what root causes contribute to them. But by taking a broader
viewpoint of failures, we can use poka-yoke techniques during the design phases of products and services
to find where we can incorporate low-cost features that improve the customer's experience.
J. Alex Sherrer 6 www.alexsherrer.com
References
1. Wikipedia. (n.d.). Poka-Yoke. Retrieved from http://en.wikipedia.org/wiki/Poka-yoke
2. Parliamentary Office of Science and Technology, United Kingdom. (June, 2001). Managing Human
Error. POSTnote, June 2001, (number 156). Retrieved from http://www.parliament.uk/post/pn156.pdf
3: Chase, R. B. and Stewart, D. M. Make Your Service Fail-safe. Sloan Management Review, Spring
1994 (Volume 35, Number 3), 35.
4. Julien, Sheila. (n.d.). Productivity Poka-Yokes. Conway Management News (17), 4. Retrieved from
http://www.conwaymgmt.com/pdfs/NL17-4-ProductivityPoka-Yokes.pdf