Chapter 6 – Page 4 – The OM Blog by Heizer, Render, & Munson

OM in the News: A New View of TQM in Hospitals

The atrium of the Henry Ford West Bloomfield Hospital

At the Henry Ford West Bloomfield Hospital outside Detroit, patients arrive to uniformed valets and professional greeters. Wi-Fi is free and patient meals are served on demand 24 hours a day. Members of the spa staff give in-room massages and other treatments.

While clinical care is the focus of any medical center, hospitals have many incentives to move toward hotel-inspired features, services and staff training. And competing on the amenities is all the more important because there is so little reliable comparative data on hospitals’ medical outcomes. “In the absence of hard data on cancer treatment or surgery success, patients may look to the quality of the hospital’s environment,” writes The New York Times (Aug.2, 2016).

In 2009, a 24-hour room service at Henry Ford West Bloomfield was introduced instead of set meal schedules. Similarly, patients at the more than 50 Henry Ford Medical outpatient centers in the region can choose the time and location of many tests, procedures and appointments using an online system modeled on airline reservation portals. When it was introduced in 2014, cancellation and no-show rates dropped immediately.

At Henry Ford West Bloomfield, scores from federally mandated surveys show that the evolving features at the hospital have helped to improve its customer satisfaction ratings and make patients more likely to recommend the hospital to others. Length of stay and readmission rates have also decreased, which allows more beds to open up and the hospital to treat more patients. Indeed, a study by Deloitte found that hospitals with higher patient experience ratings were generally more profitable than those with lower scores. “Hospitals want to create a loyal customer base,” says an industry expert.

Classroom discussion questions:

Referring to the Global Company Profile featuring Arnold Palmer Hospital (see Ch. 6), what techniques does Arnold Palmer use that are not noted in the Henry Ford article?
Why is it hard to measure hospital quality?

OM in the News: Chipotle’s Battle for Quality Control

At lunchtime, people peered into a Chipotle in Washington, one of the stores that closed on Monday. — At lunchtime Monday, people peered into a closed Chipotle

Chipotle Mexican Grill closed its more than 2,000 restaurants for 4 hours this past Monday to hold a “virtual” town hall meeting with its employees about steps it said it was taking to improve food safety and regain consumers’ trust. The firm also announced a $10 million program to help small farmers who are Chipotle suppliers shoulder the costs of putting in place the company’s new food safety system, which will require them to do more rigorous testing.

Chipotle has experienced 6 food safety failures involving norovirus, salmonella and E. coli since July, with more than 500 customers reporting that they fell ill afterward, reports The New York Times (Feb. 9, 2016). But “it’s going to take significant meaningful action that goes beyond telling employees to be more careful and, unfortunately, some time before consumers start to believe it,” says an industry expert. The best example of a company regaining consumer trust was of Tylenol in 1982 when 7 people died after taking medicine that had been tampered with. Johnson & Johnson moved quickly to recall the product and establish ties with the police and the FDA. Tylenol’s market share crashed, but J&J introduced new tamper-proof packaging and heavily promoted the brand. Today, Tylenol is a best-selling over-the-counter analgesic.

The norovirus contaminations that caused the greatest number of illnesses were introduced to the restaurants by sick employees. Since the outbreaks, the company has instituted paid sick leave for employees in an effort to encourage them to stay home. A salmonella outbreak that sickened more than 60 people was linked to chopped tomatoes. The company now washes, dices and tests tomatoes in its central kitchens and then ships them in sealed bags to restaurants. As for the most serious contamination, 2 different types of E. coli that sickened 60 people after they ate in Chipotle restaurants in 14 states, neither Chipotle nor the C.D.C. had been able to determine the exact cause.

Classroom discussion questions:

Why is Chipotle’s supply chain a major issue here?
What other firms faced similar problems and what did they do to win back market share?

OM in the News: Takata Lacks Processes for Tackling Air-Bag Defects

The panel’s report found Takata lacked its own program for spotting defects in air bags once they’re installed in vehicles

Takata Corp., the supplier behind defective air bags in millions of recalled vehicles, lacks clear processes for tackling potential safety defects and needs improved manufacturing methods, an independent panel found. Takata employees tasked with raising safety concerns also don’t have well-defined roles and rely on reports from auto makers about quality problems instead of ferreting out problems themselves. In addition, Takata often has employees load air-bag-inflater propellants by hand and lacks enough automated manufacturing processes that can better ensure consistent products, the report found.

Takata’s CEO said the company planned to implement all of the panel’s recommendations. “Takata’s products play a critical role in protecting the driving public, and we understand that the quality of our operations needs to be beyond question,” he said. Car companies are recalling more than 24 million vehicles in the U.S. equipped with the air bags, which can explode and spray shrapnel.

Regulators also cited Takata for misleading and inaccurate testing reports. “I don’t think they lived it and breathed it the way other people do,” noted the report’s author in The Wall Street Journal (Feb. 2, 2016). The report outlined a series of recommendations to improve Takata’s approach to quality, and suggested employees working on quality be able to not only intervene in manufacturing, but stop product designs when raising concerns.

The report concluded: (1) Testing data must be recorded and reported accurately; (2) Takata should develop its own standards for air-bag-inflater testing as opposed to relying on specifications from auto makers, regulators and others; (3) employees should be paid based on how the address quality issues to incentivize reporting concerns; and (4) Takata should create a dedicated quality team to implement the recommendations.

Classroom discussion questions:

What were the weaknesses in Takata’s quality program?
What tools in Chapter 6 could the firm employ?

OM in the News: Measures of Airline Quality

As airlines shrink personal space in cabins, they are also finding other ways to aggravate travelers: Flight delays, cancellations, lost baggage and complaints all increased last year. U.S. airlines canceled nearly 66,000 more flights and the percentage of canceled flights jumped to 2.7% from 1.9% the previous year. The number of complaints filed with the DOT shot up 26% last year. Although airlines have been investing in new technology to help boost reliability, the U.S. air transportation is still fragile. A few disruptions triggered airline meltdowns, and old equipment is failing more often under increased passenger loads: Southwest says its baggage belts suffered a lot of breakdowns that left luggage in huge piles. Airlines lost or delayed more than 2.1 million bags, a 17% increase over the same period a year earlier.

In The Wall Street Journal’s annual scorecard of airline service (Jan. 14, 2016), which tracks 7 different key measures of airline performance, Alaska Airlines and Virgin America, perennial good performers, placed at the top of rankings. Alaska has invested in satellite based technology that helps it keep flying in fog and other bad weather. Its customer surveys onboard planes helped reduce complaints, and a 20-minute delivery time guarantee on getting bags to carousels has forced improved baggage handling. (We feature Alaska in our upcoming video case series that is available this spring).

Virgin America credits a generous employee incentive program that offers a 3% bonus for high scores in customer satisfaction surveys, aircraft operations and safety, and on-time performance. United and American occupied the bottom two rungs of the scorecard for the 4th straight year. This month, though, United will be rolling out new software for gate agents to better set the time to close the door to a departing flight. Flight attendants will also get hand-held computers that let them report broken parts inside cabins easily.

Classroom discussion questions:

1. What tools in Chapter 6 can the airlines use to measure and improve quality?

2. Why do you think Alaska and Virgin America rank high so often?

OM in the News: Molecular Sensors Revolutionize Quality Control

A chocolate bar undergoing testing with SCiO technology to detect fake or mislabeled ingredients

The recent food outbreaks of norovirus at Chipotle Mexican Grill are a reminder that one in six people in the U.S. experience food poisoning every year, and 128,000 are hospitalized for it. Add to that all the other hazards in our food—carcinogens, pesticides, mislabeling of everything from seafood to meatballs—and you realize that in the U.S., the price of cheap and bountiful food is an array of unsavory compromises. “But w hat if you could know exactly what you’re putting in your mouth, down to the last bite? What if we all had the ability to inspect our food in a way previously accessible only to chemists with costly laboratories”, asks The Wall Street Journal (Dec. 14, 2015)?

The $250 Nima from 6SensorLabs is an organic-chemistry lab small enough to carry in your pocket, and able detecting gluten in foods at minuscule concentrations, as little as 20 parts per million. In the near future, Nima will recognize all manner of proteins—including ones that would allow it to recognize bacterial contaminants such as E. coli and salmonella. Nima is typical of a new breed of sensors that are cheap and fast enough to add more layers of inspection to our food system, for suppliers, restaurants and even individual consumers.

Another such technology, by Safe Catch, offers the world’s lowest mercury-contaminated canned tuna fish. This process allows Safe Catch to inspect every single fish as soon as it comes off the boat, rather than sampling just a small percentage of them. Then there is SCiO from Consumer Physics of Israel, which can identify substances by measuring the spectrum of light they reflect. Its sensor has the advantage of being so small—it is basically a camera technology—that it could be incorporated directly into cellphones. These and similar electronic products will almost certainly create whole new applications, markets and billion-dollar businesses.

Classroom discussion questions:

Why are these new sensors so important to operations managers?
What other applications can you envisage for such products?

OM in the News: The Dangers in Measuring Hospital Quality

One of our definitions of quality in Chapter 6 is user based: “quality lies in the eyes of the beholder.” The Atlantic’s article (April 17, 2015), titled “The Problem With Satisfied Patients,” states though, that a misguided attempt to improve healthcare has led some hospitals to focus on making people happy, rather than making them well. When healthcare is at its best, hospitals are 4-star hotels, and nurses, personal butlers at the ready—at least, that’s how many hospitals seem to interpret the government mandate by the Department of Health and Human Services. DHHS announced that 30% of hospitals’ Medicare reimbursement would be based on patient satisfaction survey scores. The goal: transparency and accountability, which would improve healthcare.

But a recent study revealed that patients who reported being most satisfied with their doctors actually had higher healthcare and prescription costs and were more likely to be hospitalized than patients who were not as satisfied. Worse, the most satisfied patients were significantly more likely to die in the next 4 years. As one MD said: “Patients can be very satisfied and dead an hour later.”

The concept of “patient experience” has characterized patients as customers and nurses as automatons. Some hospital job postings advertise that they are looking for nurses with “good customer-service skills” as their first qualification. By treating patients like customers, hospitals accept the cultural notion that the customer is always right. But hospitals, too, can offer poor care and still get high patient-satisfaction ratings. A study of poor performing hospitals found that 2/3 of them scored higher than the national average on the key patient question; “YES, they would definitely recommend the hospital.”

Research has shown that hiring more nurses is the true key to patient satisfaction. Higher staffing of nurses has been linked to fewer patient deaths and improved quality of health. Failure-to-rescue rates drop. Patients are less likely to die or to get readmitted to the hospital. Their hospital stay is shorter and their likelihood of being the victim of a fatigue-related error is lower.

Classroom discussion questions:
1. What are the definitions of quality (see Chapter 6) and how do they relate to hospitals?

2. What are the flaws, if any, in surveying patients to measure hospital quality?

OM in the News: Measuring Health Care Quality

“The goal of tying more Medicare payments to the quality—not the quantity—of health care by 2018 has intensified the debate over how ‘quality’ is defined and measured,” writes The Wall Street Journal (Jan. 31-Feb.1, 2015). Many doctors, hospitals, insurers and cost experts want to move away from the myriad quality metrics that largely measure process–toward broader measures that assess patient outcomes. This week, the National Quality Forum submitted recommendations on 199 performance measures to the U.S. Dept. of Health and Human Services. The goal is to better align measures among various programs and replace narrow process-oriented metrics with “measures that matter.”

Some doctors question whether the measures that exist can adequately measure quality. And there is little agreement on what measures matter most or are more likely to produce good value. “Measurement fatigue is a real problem in hospitals,” said a Dartmouth medical prof. “But, to me, the only metric that matters is, did you get better?”

As of last year, 33 federal programs asked providers to submit data on 1,675 quality measures. State, local and private health plans use hundreds more. Hospitals and doctors stand to lose millions in Medicare payments for missing filing deadlines or improvement benchmarks in programs that track hospital-acquired infections, readmissions and electronic-record use. The Centers for Medicare and Medicaid Services wants to move toward more quality measures “that matter most to patients and clinicians,” and note that some already had an impact on outcomes. Central-line bloodstream infections have dropped by 50% since hospitals were required to report them, and 150,000 fewer Medicare patients were readmitted to hospitals within 30 days of discharge in 2012-2013 under a federal program holding them accountable. More than 2,600 hospitals will see their Medicare payments cut 1- 3% this year—a total of $428 million— for not reducing 30-day readmissions sufficiently.

Classroom discussion questions:

1. What are the advantages and disadvantages of setting quality metrics?

2. Why do doctors oppose some of the quality measures?

OM in the News: Checklists as a TQM Tool in Hospitals

How can we use the TQM tools in Chapter 6 to reduce deaths in surgery? One tool is a kind of poka-yoke called a checklist (see p. 223). The Wall Street Journal (Dec. 13-14, 2014) quotes Dr. Atul Gawande describing how he worked with a team from the airline industry to design what emerged as just a checklist. Surgical blunders, says Gawande, are “most often basically failures of communications. The checklist had some dumb things—do you have the right patient ? But the most powerful components are: Does everybody on the team know each other’s name and role? Has the anesthesia team described the medical issues the patient has? Has the surgeon briefed the team on the goals of the operation, how long the case will take, how much blood they should be prepared to give? Has the nurse been able to outline what equipment is prepared? Are all questions answered? And only then do you begin.”

The result, after he tested in 8 cities around the world, was that in every hospital that used the checklist, complication rates fell. The average reduction in complications was 35%. The average reduction in deaths was 47%. The system has since been replicated in multiple places. Scotland has implemented it and taught it at the frontlines –and has now demonstrated that 9,000 people’s lives have been saved over the last 4 years.

“The hardest part,” says Gawande, “is to bring the culture that has the humility to recognize that even the most experienced people, even the most expert fail.” Doctors fear these kinds of checklist systems. When he surveyed surgeons 3 months after they adopted it and asked, “What do you think about this approach?” he found that about 20% really dislike it—“It’s paperwork, it’s a pain in the butt, I don’t want to do this.” But when he asked, “If you’re having an operation, would you want the team to use the checklist?” 94% did.

Classroom discussion questions:

1. How else can checklists be used in hospitals?

2. What other TQM tools can be employed in a surgery process?

OM in the News: Nurses, Ebola, and the Subject of Quality

With Ebola leading the news every day, I am reminded of the words of Dr. Edwards Deming: management needs to accept responsibility for quality in building systems. Deming believed an employee could not, on average, exceed the quality of a process’ capability. (His famous 14 points are summarized in Table 6.2 on page 212). Now with some nurses being blamed for the lax Ebola virus procedures in Texas, we are seeing a response from the leading nursing association.

Following news that the first U.S. nurse has now tested positive for the Ebola virus, National Nurses United (NNU, Oct.12, 2014) called for all hospitals to have in place the highest standard of optimal protections, including Hazmat suits, and hands-on training to protect all RNs, other hospital personnel to confront Ebola . NNU’s new survey of 2,000 nurses shows:

76% still say their hospital has not communicated to them any policy regarding potential admission of patients infected by Ebola
85% say their hospital has not provided education on Ebola with the ability for the nurses to interact and ask questions
37% say their hospital has insufficient current supplies of eye protection for daily use on their unit; 36% say there are insufficient supplies of fluid resistant/impermeable gowns in their hospital
39% say their hospital does not have plans to equip isolation rooms with plastic covered mattresses and pillows and discard all linens after use; only 8% said they were aware their hospital does have such a plan in place

Not having supplies; not having equipment; not educating employees; not having a plan. All of these are systems problems, not employee problems, Deming would say.

Classroom discussion questions:

1. Who is responsible for setting quality standards and processes for Ebola treatment and prevention?

2. Which of Dr. Deming’s 14 points particularly apply in this situation?

OM in the News: How Operations Management Improves Hospital Procedures

Swamped with tasks such as hunting for supplies, tracking down medications, filling out paperwork at the nursing station and looking for missing test results, nurses may spend less than two hours of a 12-hour shift in direct patient care, says The Wall Street Journal (July 22, 2014). But research has also found that the more time nurses spend at the bedside, the less likely patients are to suffer falls, infections and medication errors, and the more likely they will be satisfied with their care.

Now hospitals are changing traditional work practices, shifting more routine tasks to certified nurse assistants and other less highly skilled staffers. They are eliminating inefficient processes that make nurses walk as many as 5 miles around the hospital in a single shift. Some hospitals are aiming to triple the amount of time nurses spend with patients. That means locating supplies inside patient rooms and having pharmacists deliver medications to patient floors. As more hospitals adopt electronic medical records and place computers in patient rooms, they are enabling nurses to access information quickly and fill out medical charts while keeping close to patients.

Presbyterian Medical Center, in Winston-Salem, N.C., found in a 2010 internal audit that nurses were involved in direct patient care at the bedside for only 2.5 hours every 12-hour shift. “Not only was that eye-opening, it was also completely unacceptable,” says its chief clinical officer. With a shift to a team-based model, the hospital hit 6.5 hours per shift at the end of 2013, with a goal to hit 8.5 hours by the end of 2015. Process changes helped save $20 million last year at Presbyterian, and the transfer to electronic records also reduced by 42 minutes the amount of time spent paging doctors, copying and faxing, and tracking down tests.

This is a good article to link to the video case studies on Arnold Palmer Hospital in Chapters 6 (Quality), 7 (Process Analysis), and 9 (Layout).

Classroom discussion questions:

1. What tools of TQM could be used to help improve hospital processes (see pages 218-222)?

2. Why is it important for nurses to spend more time with patients, and less time at their stations?

OM in the News: Best Practices at the Sanford Health System

In 2012, waste in the national health care system was measured at $750 billion annually. Driven by tightening margins and increased pressure for positive outcomes, health systems nationwide are looking for ways to maximize resources and trim costs, writes Argus Leader (May 7, 2014).

“It’s not just about cutting costs,” said the CEO of Sanford Clinic in South Dakota. “We do have to cut per-unit costs, but we have to look at standardization, best practices. We have a very fragmented health care system, and that’s where integration and coordination of care is so critical. It’s not just for efficiencies. It’s for best outcomes and eliminating errors and waste.” The clinic’s approach to becoming more efficient involves the approaches of Kaizen and Six Sigma, tools used in business for process improvement, but the greater goal is to integrate continuous performance improvement into the culture.

The Sanford Health System, of which the clinic is a part, set a goal of finding $100 million in efficiencies this year, with much of the savings coming through better supply chain management. “We looked at cost transformation opportunities, which is tying it back to product standardization; maybe some miscellaneous contracts we have from one region to another that we could consolidate,” added the President of Sanford USD Medical Center. As the system has grown, it has commanded better pricing options from vendors. Various Sanford locations have worked together to identify best practices and streamline products and pharmaceuticals to achieve more savings through buying in bigger quantities.

Agreeing to use a common spine hardware, for example, saved $2.5 million annually. Working with cardiologists to determine the pacemaker of choice across the system saved another $2.4 million. Further, a new asset management system is designed to further optimize staffing and supplies. It will monitor where patients and care providers are to manage patient flow and track equipment.

Classroom discussion questions:

1. Why is OM so important in hospitals?

2. What tools in Chapter 6 can be used to improve hospital quality?

Teaching Tip: Pareto Charts and Pork Processing

When Upton Sinclair published The Jungle in 1906, he hoped to shock readers about the mistreatment of immigrant workers in Chicago’s slaughterhouses. Instead, his book created outrage over the unsanitary conditions it described—how poisoned rats got swept into the sausage grinders; how tripe and cartilage were dyed and flavored with spices and sold as canned ham; how men in the cook room occasionally fell into open vats and sometimes went undiscovered for days, their flesh sold to consumers as lard. Sinclair groused that the book became a bestseller “not because the public cared anything about the workers, but simply because the public did not want to eat tubercular beef.”

Now 100+ years later, if you read the latest edition of BusinessWeek (Dec. 9-15, 2013), you will likely eat a lot less pork in 2014. The lengthy article, titled “The Truth About Pork,” documents how the US Dept. of Agriculture cut the number of inspectors on the pork processing line with the agreement that plants would hire their own quality assurance officers. Line speeds that are now “dangerously fast” and there are vastly increased violations of food safety requirements. A recent USDA Inspector’s General report states: “As a result, there is reduced assurance of inspectors effectively identifying pork that should not enter the food supply.”

The good news is that the data provided makes for a nice example which can be used to construct a Pareto chart when you are teaching Chapter 6. Using the 223 violations in 2012 at a sample plant (Quality Pork Processors, in Minnesota), students can construct an interesting chart. Here are the safety violations: Food contact preoperational sanitation–69 violations: Contamination such as fecal matter–60: Sanitation lacking–46: Nonfood contact surfaces unclean–20: Record keeping errors–10: Condemned carcasses–8: Inhumane hog handling, mislabeling, misc. violations–10.

Sinclair predicted that the industry would make sure inspection addressed only the barest concerns about the deadliness of a product. Repeatedly he warned against letting meatpackers carry out their own inspections. His warnings still resonate.

OM in the News: Kaizen at San Francisco General Hospital

Kaizen team leader at SF General Hospital

At San Francisco General Hospital, clinicians, executives and staff are peppering their conversations with Japanese words like kaizen and muda. This “Toyota Way”, writes the San Francisco Chronicle (Oct. 14, 2013), is an effort to infuse the Japanese automaker’s management philosophy and practices into the way the hospital delivers medicine to its patients.

To make the system work, a team of employees is assigned to analyze a particular area targeted for improvement. The group immerses itself in a weeklong, hands-on session, and emerges with a plan to make specific changes designed to have a big impact on costs or the patient’s experience. One recent kaizen focused on the number of minutes it takes from the moment a patient is wheeled into the operating room to when the first incision is made. A team spent a week trying to come up with ways to whittle 10 minutes off the hospital’s average “wheels in” to incision time of 40 minutes. Another targeted the Urgent Care Center and dropped the average wait from 5 hours down to 2.5 by adding an on-site X-ray machine–instead of forcing patients to endure a 15 min. walk to the main radiology department.

Toyota’s production system has been increasingly adopted by hospitals trying to improve medical quality and increase patient satisfaction. Here are some of its Japanese terms, many of which do not have a direct English translation: Gemba: the place where work is performed. Hansei: a period of critical self reflection. Heijunka: a level production schedule that provides balance and smooths day-to-day variation. Jidoka: using both human intelligence and technology to stop a process at the first sign of a potential problem. Kaizen: continuous improvement. Kanban: a visual card or signal used to trigger the fulfillment of need, such as restocking supplies. Muda: anything that consumes resources but provides no value. Poke-yoke: a mistake-proofing device that prevents errors.

(Ironically, the day before this flattering article about quality appeared, NBC News reported that SF General lost a 57-year old female patient for 2 weeks–she was just found dead in a hospital stairway.)

Classroom discussion questions:

1. Why are hospitals adopting the “Toyota Way”?

2. Which of the many Japanese terms above could have prevented the lost patient?

OM in the News: Air Berlin’s Service Implosion

How could a passenger plane take off without a single piece of luggage? That’s the question from 200 Air Berlin passengers on flight AB 8109, whose bags were left sitting at the airport when their flight took off, and then apparently vanished. Nearly a month later the airline still doesn’t know where all the bags are, reports Slate.com (Sept.4, 2013).

Passengers’ inquiries were met with endless redirects. One email to Air Berlin reads: “ NONE of the checked luggage was loaded on the airplane—almost 200 missing pieces missing among the passengers. We filled out forms and were given baggage service numbers to call, but the phone line has no answer. Days later, still no information whatsoever, nobody to call, not sure what to do. Baggage company says to contact airline; airline says to contact baggage company. Why did the captain decide to take off before any pieces of luggage were loaded? We need support from Air Berlin. This isn’t one lost bag, it’s a whole plane of lost bags!”

And, in a separate event, here is twitter bot over a 2-day period earlier this month between a frustrated passenger and the airline:

@5Foot1: “Arrived in Dusseldorf without my bag. @airberlin are useless. No apology, no idea. What happened to German efficiency?”

@airberlin: “We’re sorry for the inconvenience caused. Did you contact the Lost & Found?”

@5Foot1: “Of course. Bag left in LDN. No assurance it will be on the next flight. I’m here for business meetings with no clothes.”

@airberlin: “We understand how annoying this is and apologise! Unfortunately we can’t help you right now. Lost & Found will contact you.”

@5Foot1: “Do you have a number I can call and speak to a human being. The tracking number is giving me no information.”

@airberlin: “Unfortunately there is no number I can give you. Lost & Found will get in touch as soon as they found your bag.”

Concludes Slate: “Air Berlin’s total inability to transport a suitcase from point A to point B can’t be a good sign”.

Classroom discussion questions:

1. In Chapter 6, Managing Quality, we list the 10 Determinants of Service Quality (see Table 6.5). On which of the 10 service determinants did Air Berlin fail?

2. Why did the pilot of AB 8109 leave without any baggage?

OM in the News: Need a Poka Yoke at San Francisco’s Baseball Stadium?

$99 batter's box template — $99 batter’s box template

Though it doesn’t take long for them to get destroyed and disappear, the batter’s boxes originally drawn in for this week’s Reds-Giants baseball game at San Francisco’s AT&T Park “may be the most crooked and awkward looking we’ve ever seen,” reports Yahoo Sports (July 25, 2013).

Of course that also means they were not up to Major League Baseball standards — or sandlot ball standards, for that matter — but no one on the field seemed to notice or care — most notably home plate umpire Chris Guccione — as the game started and carried on without the lines being corrected. The umpires collectively missed it or ignored it.

Most hitters, like Miguel Cabrera, can sense when a line is an inch too long or too close to the pitcher’s mound. A lot of that is based on routine. A lot of that is based on instincts. But, in this case the errors weren’t even marginal. Both sides were angled so noticeably. The cure is a poka yoke like the one shown here, available for less than $100 on-line. (For more on poka yoke, see Chapter 6, Managing Quality).

Discussion questions:

1. Why does the crooked batter’s box make a difference?

2. Name some other popular poka yokes.