Changing how work is done.
WHY MOST IMPROVEMENTS FAIL
They depend on people remembering to behave differently.
WHAT WORKS BETTER
Changing the process so the old way is difficult or impossible.
WHAT EXAMPLES LOOK LIKE
A form that will not submit without the required field A checklist that must be completed Equipment that only fits one way Defaults that produce the right outcome
WHY DEFAULTS MATTER
Most people accept them, so the default determines the outcome.
WHAT TO AVOID
Improvement that relies on being more careful Training as the sole response to error Exhortation
WHY BEING MORE CAREFUL FAILS
Attention varies, and the failure returns under pressure.
WHAT TO DO INSTEAD
Make the error harder to make.
HOW TO IMPLEMENT A CHANGE
Involve the people doing the work Try it small first Measure before and after Adjust Then standardise
WHY SMALL FIRST
Failed changes rolled out widely are expensive and damage appetite for improvement.
WHAT TO MEASURE
Something specific that should improve.
WHAT TO DO IF IT DID NOT
Establish why, and revert if necessary.
WHY REVERTING IS ACCEPTABLE
Not every idea works, and pretending otherwise prevents the next one.
WHAT TO DO WHEN IT DOES WORK
Document it, and make it the standard way.
WHAT TO REVIEW
Whether the change held, months later.
