Int J Adv Manuf Technol
DOI 10.1007/s00170-015-7217-9
ORIGINAL ARTICLE
Six Sigma through Poka-Yoke: a navigation through literature
arena
M. Vinod 1 & S. R. Devadasan 1 & D. T. Sunil 1 & V. M. M. Thilak 1
Received: 21 August 2014 / Accepted: 26 April 2015
# Springer-Verlag London 2015
Abstract From the middle of 1980s, Six Sigma concept
emerged in Motorola. Because Six Sigma implementation fa-
cilitated the companies to achieve profitability, it was imple-
mented subsequently in many parts of the world. Six Sigma is
implemented by majority of the companies situated in the
world by applying DMAIC (stands for define, measure, ana-
lyse, improve and control) phases. Meanwhile, there have been
reports of the failures of implementing Six Sigma programmes
presumably due to the failure to consider and apply the appro-
priate tools and techniques. In this regard, it is to be noticed that
Poka-Yoke, which is a tool that can be used to achieve zero-
defect manufacturing, has the potential to support the imple-
mentation of DMAIC phases of Six Sigma. On deriving this
observation, the literature navigation reported in this paper was
carried out to understand the essence of Six Sigma and Poka-
Yoke as well as the trend of applying Poka-Yoke in DMAIC
phases. In the literature survey conducted to carry out this lit-
erature navigation, the researches on applying Poka-Yoke con-
cept in DMAIC phases were studied by referring to the relevant
research papers. It has been pointed out that the Poka-Yoke
solutions suggested in these research papers were not actually
implemented in real-time scenario. Hence, this article ends with
a suggestion that future researchers can make efforts to actually
implement Poka-Yoke technique in DMAIC phases for achiev-
ing the goals of Six Sigma.
Keywords Six Sigma . Poka-Yoke . Total quality
management . DMAIC . Radio-frequency identification .
Zero-defect manufacturing
* M. Vinod
vinodmwarrier@yahoo.co.in
1
PSG College of Technology, Coimbatore, Tamil Nadu, India
1 Introduction
As soon as the intensification of competition was experienced
in several markets, the world began to witness the appearance
of the principles of Total Quality Management (TQM) [1, 2].
A historical study indicates that the theoretical development of
TQM principles took place during 1950s when quality gurus
like Deming, Ishikawa and Juran brought out their principles
on achieving continuous quality improvement [3]. After this
development, the TQM principles were first intensively im-
plemented in Japanese companies. As a result of applying
TQM principles, products with high quality but priced low
could be produced by Japanese companies. On seeing this
progressive development, TQM principles were largely ap-
plied from 1980s in companies situated in most parts of the
world. Although several benefits were reported in the begin-
ning, from the middle part of 1980s, it was reported that the
profitability of the companies which implemented TQM was
in peril. In this background, the Six Sigma model emerged in
Motorola [3, 4].
A unique feature of Six Sigma is that its implementation
facilitates the achievement of continuous quality improvement
without losing profitability [5]. By exploiting this unique fea-
ture, companies like General Electric, Motorola and Allied
Signal implemented Six Sigma and gained significant finan-
cial benefits [6–12]. This development was even termed by
some authors as ‘Big Dollar Impact’. The objective of Six
Sigma is to ensure that the companies implementing it should
produce less than 3.4 defects per million opportunities
(DPMO) [3, 13, 14]. This value is very nearer to zero-defect
manufacturing level. In order to achieve 3.4 DPMO of quality
level, the Six Sigma programme progresses through several
stages by adopting several tools, techniques and approaches
[15]. For example, in the first stage, on implementing Six
Sigma in a company, the sigma level will increase from 2 to

3. After making more efforts to implement Six Sigma, the
sigma level will improve gradually to reach the value of 6.
In order to reach this level, several projects of Six Sigma [16]
need to be implemented in companies by consuming several
days or weeks or even years. In order to constrict the duration
of implementing projects, a suitable technique is required to
be integrated with Six Sigma to make it a powerful model. In
this regard, the capabilities of Poka-Yoke are noted with
interest.
Poka-Yoke has got the capability of preventing failure to
occur. This will result in achieving zero-defect manufacturing.
Quite interestingly, this capability coincides with that of Six
Sigma. Hence, it is high time that the integration of Poka-Yoke
in Six Sigma is required to be studied. An outlook in literature
arena would indicate that very little efforts on integrating
Poka-Yoke and Six Sigma have so far been made by both
researchers and practitioners [17]. In this background, the au-
thors of this paper developed curiosity to navigate thoroughly
the literature arena to survey the research projects in which
efforts were made to achieve zero-defect manufacturing by
integrating Poka-Yoke with Six Sigma principles. The details
of the literature survey conducted in this regard are presented
in this paper.
During the conduct of the literature survey reported in this
paper, the activities were carried out in two phases. In the first
phase, the research papers that have appeared in databases like
‘Science Direct’, ‘Emeraldinsight’, ‘Springer Link’ and ‘Tay-
lor and Francis’ and dealt with ‘Six Sigma research’ were
gathered. Subsequently, the research details reported in these
papers were studied. During the second phase, the papers
reporting research on Poka-Yoke were gathered from the
above-mentioned databases. The research details reported in
these papers were also studied. At the end of conducting the
second phase of the literature survey, papers reporting the
research on integrating Poka-Yoke with Six Sigma principles
and applying them in real-time situations were gathered. The
research details reported in these papers were also studied.
The highlights of information and knowledge that were gath-
ered by conducting these two phases of the literature survey
are presented in the following sections of this paper.
2 History and growth of Six Sigma
While conducting the literature survey being reported here, as
many as 12 papers reporting the history of Six Sigma could be
identified. Majority of the authors of these papers have men-
tioned that Six Sigma emerged in Motorola during the middle
part of 1980s [18]. Most precisely, Karthi et al. [19] have
mentioned that Six Sigma emerged on January 15, 1987 at
Motorola. Slightly in a different context, Iwarden et al. [9]
have mentioned that the foundational concepts of Six Sigma
emerged in the world in the year 1920 itself. The rationale
Int J Adv Manuf Technol
behind making this claim is that during this period itself, con-
cepts like ‘statistical quality control’ and ‘variation control’
emerged in the world. The emergence of these concepts trig-
gered the human community to move towards achieving
defect-free production and servicing. This progression further
led to the emanation of TQM. Although TQM triggered the
human community to apply numerous tools and techniques to
achieve continuous quality improvement, their impact on
achieving business results was not very impressive [20]. In
order to tune the TQM to meet the needs of achieving business
results, Six Sigma was developed by Bill Smith in Motorola in
the year 1987 [14]. As mentioned in the previous section, the
companies which implemented Six Sigma gained significant
financial benefit [21]. Hence, after the year 1986, the pace of
adopting Six Sigma in the world has been significant [22, 23].
This trend continues even today not only in practical scenario
but also in the research arena [24]; besides, the scope of ap-
plying Six Sigma has enlarged from the manufacturing arena
to other service areas like hospital and banking sectors [25].
Thus, the momentum of implementing Six Sigma continues
today without showing any sign of slackness [12, 24]. This is
due to the reason that Six Sigma is applied by employing
scientifically proven TQM tools and techniques [26], and its
outcomes are realised in the form of business results.
3 DMAIC Framework of Six Sigma
While conducting the literature survey being reported here, it
was found that the project-driven methods dominated the re-
search on Six Sigma [12, 26, 27]. In order to execute a Six
Sigma project, activities under the five phases, namely, define,
measure, analyse, improve and control, are required to be
carried out. These phases are shortly denoted as DMAIC
[18, 28]. The propagandists of Six Sigma emphasised that
while carrying out DMAIC, the members of the Six Sigma
team need to undergo relevant and result-oriented training to
execute the projects effectively. In order to enhance the effec-
tiveness of such training programme, the trainees are
recognised by assigning designations, namely, Champion,
Master Black Belt, Black Belt, Green Belt and White Belt.
This kind of imparting formal and result-oriented training is
regarded as belt-based training infrastructure in the Six Sigma
field. In essence, DMAIC framework and belt-based training
infrastructure are regarded as the cornerstones of the Six Sig-
ma programme by its propagandists [29, 30]. As its expansion
implies, while carrying out the Six Sigma project by
employing DMAIC, during the define phase, the problem
considered in the project is defined. During the measure
phase, the current sigma level quality is measured. During
the analyse phase, the causes that lead to the occurrence of
the problem and performance with less than Six Sigma level
quality are to be determined. During improve phase, the
Int J Adv Manuf Technol

solutions to overcome the occurrence of the problem and per- As shown in Table 1, besides finding wide application in
formance less than Six Sigma level quality are proposed and manufacturing area, Six Sigma programme involving only the
implemented. After experiencing the improvement, the con- DMAIC phases have also found applications in non-
trol phase is implemented to ensure the continued and manufacturing areas like hospital management, knowledge
sustained implementation of the solutions so as to enable the management, energy management, financial services and hu-
company to perform at Six Sigma level quality [31]. man resource management.
Although several approaches and principles have been While spreading its applications to areas other than
suggested and critical success factors of implementation manufacturing, certain variations in the way of applying
have been identified by the researchers [23] to enhance DMAIC were observed upon studying the research presented
the performance of Six Sigma projects in companies, in the papers enumerated in Table 1. For example, in
majority of these efforts have been made by keeping manufacturing companies, under the define phase, develop-
DMAIC as the framework [23, 28, 29]. Although the ment of a project charter has been given highest importance.
belt-based training system is prescribed as yet another However, when DMAIC is applied in the hospital industry,
cornerstone of Six Sigma framework, many case studies under the define phase, project charter has been developed
reporting only the implementation of DMAIC to achieve only under very rare circumstances. Likewise, under different
the goals of Six Sigma (without the implementation of DMAIC phases, in order to tune with the specific circum-
belt-based training infrastructure) have been reported in stances, different tools and techniques have been applied.
the literature arena [8, 15, 30, 32–34]. In fact, during the The usage of different tools and techniques has formed the
conduct of the literature survey being reported here, as hallmark of Six Sigma projects which are implemented by
many as 21 papers dealing only with the DMAIC frame- employing DMAIC phases. This observation reveals that a
work of Six Sigma could be encountered. The areas of common technique has to be identified which will strongly
application of DMAIC phases reported in those papers aid the achievement of Six Sigma quality while implementing
are indicated in Table 1. DMAIC in different application areas. In the context of this
observation, numerous tools and techniques applied in Six
Sigma projects were studied in the literature arena. The details
Table 1 Application areas of Six Sigma programme involving only the of the facts observed by carrying out this study are presented
DMAIC phases
in the next section.
Paper Paper Application area of Six Sigma
number programme involving only the
DMAIC phases 4 Tools and Techniques used in Six Sigma
1 Kumar and Sosnoski [35] Manufacturing
2 Kaushik et al. [36] Manufacturing Six Sigma is an advanced version of TQM [51], and hence
3 Gijo and Scaria [37] Manufacturing
numerous tools and techniques that aid towards achieving
4 Nepal et al. [38] Manufacturing
continuous quality improvement are adopted in Six Sigma
5 Hwang [39] Manufacturing
projects as well. Hence, many authors have mentioned about
the usage of numerous tools and techniques while executing
6 Bunce et al. [40] Manufacturing
Six Sigma projects. For example, Bilgen and Sen [26] have
7 Bilgen and Sen [26] Manufacturing
listed 22 tools which have been applied in different DMAIC
8 Kumar and Steinbach [41] Hospital management
phases of Six Sigma projects. Although numerous tools and
9 Lin et al. [42] Knowledge management
techniques have been applied while implementing Six Sigma
10 Shahin and Jaberi [43] Manufacturing
projects by employing DMAIC phases, the frequency of case
11 Ghosh and Maiti [44] Manufacturing
studies reporting their application has been varied in the liter-
12 Chuang [45] Manufacturing
ature arena. While carrying out the literature survey being
13 Lee et al. [46] Energy management
reported here, the frequency of applying Six Sigma tools and
14 Prasad et al. [4] Manufacturing
techniques was found to vary from 1 to 10. For example, Six
15 He et al. [47] Human resource Management
Sigma tools and techniques, namely, cause and effect diagram,
16 Kumaravadivel and Natarajan Manufacturing
design of experiments, gauge repeatability and reproducibility
[31]
17 Banawi and Bilec [7] Construction process (gauge R&R) study, Pareto chart, process capability analysis
18 Jirasukprasert et al. [21] Manufacturing and suppliers inputs process outputs and customers (SIPOC)
19 Kumar et al. [48] Online retailing business have appeared in more than six papers. Many other tools like
20 Kumar et al. [49] Financial services F test, Enterprises Resource Planning, CTQ tree and histo-
21 Southard et al. [50] Hospital management gram have appeared in only one paper reporting the applica-
tion of DMAIC phases while executing Six Sigma projects.

Amidst the usage of these techniques and tools, it is interesting
to note the gradual increase of the frequency of appearance of
Poka-Yoke in the Six Sigma literature arena. As mentioned
earlier, Poka-Yoke system has the power to prevent the occur-
rence of failures [52] and enable organisations to produce
products and offer services within Six Sigma limit of 3.4
DPMO [42]. The appearance of little growing number of pa-
pers on the application of Poka-Yoke in Six Sigma favoured to
navigate the literature arena to study the history and charac-
teristics of Poka-Yoke. The results of such study are presented
in the next section.
5 History and characteristics of Poka-Yoke system
While navigating the literature arena, only two papers describ-
ing the history and characteristics of Poka-Yoke could be en-
countered. However, as many as seven papers describing the
characteristics of Poka-Yoke from the point of view of adopting
it to implement lean manufacturing paradigm in organisations
were encountered in the literature arena. In the beginning of this
section, the contents extracted from the first two papers are
highlighted. Then, in “Poka-Yoke from the viewpoint of lean
manufacturing”, the characteristics of Poka-Yoke mentioned in
the remaining seven papers are described.
Fisher [53] has described the history of development and
different characteristics of Poka-Yoke technique. A Poka-Yoke
technique is a device which prevents the occurrence of any
defect. This author has mentioned that Shigeo Shingo is
regarded as the creator of zero defect concept and Poka-Yoke
technique. Shigeo Shingo introduced the concept of this tech-
nique by devising simple mechanisms which would prevent
any defect to occur. Even though mistake is unavoidable, de-
fect is not. This is because a mistake becomes a defect only
when it reaches the customers. In the year 1961, Shigeo Shingo
visited Yamada plant in Japan. The executives of this plant
informed him about a defect in one of their products which
they could not control. The product was a switch which
contained two springs. The operators would pick up the
springs from a big box and attach them to the switch. The
defect occurred when the operators failed to attach these
springs with the switch. Even after the executives informed
the operators about the mistakes committed by them, the op-
erators committed this mistake inadvertently. In order to over-
come this mistake and in turn to prevent the occurrence of
defects, Shigeo Shingo put forward the idea of placing a small
tray in front of each operator assembling the switch. While
assembling the switch, the operators were asked to pick up
two springs and put in the tray. By executing this step, each
operator assembling the switch could ascertain himself that
both the springs were mounted on the switch before it was
moved for carrying out further processing. Such kind of simple
mechanisms were proposed as Poka-Yoke solutions. It is also
Int J Adv Manuf Technol
stated that some Poka-Yoke devices are implicitly used while
using jigs and fixtures to prevent the occurrence of defects.
Further, in the year 1977, Shigeo Shingo visited the
Shizuoko plant of Matsushita’s washing machine division.
During this visit, he observed that Poka-Yoke devices were
used in this plant. Due to the usage of these Poka-Yoke de-
vices, the drain pipe assembly line of that division was run-
ning continuously without experiencing the occurrence of de-
fects for a duration of 1 month. Shigeo Shingo classified in-
spection into three categories under the titles ‘judgement in-
spection’, ‘informative inspection’ and ‘source inspection.’
Poka-Yoke devices fall under source inspection category un-
der which mistakes would be prevented at the source itself,
while under other two categories inspection is carried out after
the defect occurs. Therefore, source inspection could be con-
sidered cost effective when compared to other two categories
of inspection. This type of quality control which involves
source inspection and incorporation of Poka-Yoke devices
was termed as Zero Quality Control by Shigeo Shingo. Ac-
cording to this author, Shigeo Shingo’s quality control initia-
tives involve engineering and design modifications after
conducting thorough process analysis.
Saurin et al. [52] have presented a framework for assessing
the use of Poka-Yoke devices. These authors have defined
Poka-Yoke as a device which could prevent the occurrence
of abnormality during the execution of the process and also
a device which would protect the health and safety of the
workers. These authors have also classified Poka-Yoke de-
vices as (a) physical, (b) functional and (c) symbolic. These
authors have also classified Poka-Yoke devices as proactive
and reactive types. Proactive Poka-Yoke devices would pre-
vent the occurrence of defects, while reactive Poka-Yoke de-
vices would detect the defects or abnormalities. The frame-
work presented by these authors facilitates to assess the use of
Poka-Yoke in three stages. These stages are (a) definition of
attributes of Poka-Yoke device, (b) throwing light on evidence
of existence of each attribute and (c) development of a scoring
system to explain the outcome of assessment. As the title
implies, during the initial stage, the attributes of Poka-Yoke
are defined. The definition of attributes should be governed by
the following stipulations:
1. The attributes should encompass both safety and quality
aspects of Poka-Yoke devices.
2. The attributes should be related to the manufacturing of
the product.
3. The attributes should show consistency as far as preven-
tion of defects is concerned.
4. The attributes should be having theoretical basis on hu-
man factors and lean production.
Based on the above stipulations as well as the information
drawn from the literature arena, these authors have identified
Int J Adv Manuf Technol

15 attributes of Poka-Yoke concept. These authors have
grouped these Poka-Yoke attributes under two categories. Un-
der one category, eight attributes would be used to assess the
Poka-Yoke when fail safe characteristics exist. Under another
category, seven attributes are grouped which would be used to
assess the best practices concerning design, implementation
and maintenance of Poka-Yoke devices. These authors have
mentioned that under each attribute, there should be at least
two sources of evidence. Assessment of the use of Poka-Yoke
devices has to be carried out by assigning scores. The scores
could be made on a scale ranging from 0 to 4. A score of 0
means that the corresponding attribute of Poka-Yoke devices
is not met, and a score of 4 means that the corresponding
attribute of Poka-Yoke device is fully met.
5.1 Poka-Yoke from the viewpoint of lean manufacturing
revealed that Poka-Yoke technology is flexible enough to ac-
commodate any kind of devices for preventing the mistakes and
achieving the goals of approaches like lean manufacturing.
On the whole, the information and knowledge derived by
reviewing the papers presented in this section have affirmed
clearly that Poka-Yoke technique is very powerful in
preventing the occurrence of defects not only on manufactur-
ing products but also during the offering of services. Preven-
tion of defects accelerates a company to achieve zero-defect
manufacturing. The implementation of Six Sigma also leads to
the achievement of zero-defect manufacturing by allowing the
defects to occur in companies only to a maximum of 3.4
DPMO [15]. The coherence of the objectives of Poka-Yoke
and Six Sigma favours to study the case studies on
implementing the former in companies.

While searching the literature arena, it was found that some
authors have mentioned the need of adopting Poka-Yoke while
implementing lean manufacturing paradigm in organisations.
These authors have described the characteristics of Poka-Yoke
from the point of view of implementing the same in lean
manufacturing paradigm. The characteristics of Poka-Yoke that
have been mentioned by these authors are presented in Table 2.
As indicated in this table, Poka-Yoke is a mistake proofing
technique. In order to implement Poka-Yoke, manual and auto-
matic devices are used. Manual methods include the usage of
devices like jigs, fixtures and warning devices. The automated
devices that are used in Poka-Yoke applications are program-
mable logic controllers and robots. Then, these authors have
6 Case studies on Poka-Yoke
Some authors have exclusively and elaborately dealt with the
application of Poka-Yoke in preventing failures. In the first
part of this section, case studies reported by these authors
are described. Some authors have peripherally mentioned
about employing Poka-Yoke devices in certain cases. Those
case studies are briefed in the second part of this section by
tabulating their highlights.
Saurin et al. [52] have mentioned that application of Poka-
Yoke devices leads to the elimination of defects. Elimination of
defect is a cornerstone of lean production. These authors have
presented case studies on assessing the use of Poka-Yoke

Table 2 Characteristics of Poka-Yoke as enumerated from the lean manufacturing point of view

Serial number Paper Characteristics of Poka-Yoke

1 deBucourt et al. [54]
2 Conti et al. [55]
3 Al-Tahat and Jalham [56]
4 Wasim et al. [57]
5 Hedelind and Jackson [58]
6 Amin and Atre [59]
7 Matt [60]
These authors have indicated that the original name of Poka-Yoke was Baka-Yoke. The meaning
of this term is ‘fool-proofing’. Baka-Yoke was later renamed as Poka-Yoke
These authors have cited references to mention that fool-proofing techniques including
Poka-Yoke help to eliminate judgement and discretion in the selection of production
processes and development of product characteristics
These authors have indicated that variability reduction is having an important relationship with
Poka-Yoke devices. Poka-Yoke technique is implemented by employing devices like jigs,
fixtures, paper systems and warning devices
These authors have explained about the implementation of a Poka-Yoke device to avoid mistakes
while carrying out ‘product design and development’ in lean manufacturing scenario. The
proposed Poka-Yoke is rule-based which is used to measure machine availability and geometric
features
These authors have explained about the application of industrial robots in lean manufacturing
system. These authors have mentioned about programmable logic controllers-based Poka-Yoke
used for arresting manual errors in manually operated work stations
These authors have described the efforts made to apply Poka-Yoke technique in an axle hole
processing machine when it was being converted from a large complicated machine to a simple
and lean machine. In the lubrication oil unit of this machine, audio-visual alarm would be
functioning when oil was not sufficient
This author has suggested the employment of Poka-Yoke principles to prevent defects in
template-based production systems

devices in an industrial scenario. These case studies were con-
ducted in three companies. In the first company, two Poka-Yoke
devices, namely, quality Poka-Yoke and safety Poka-Yoke, were
assessed. In the second company, quality Poka-Yoke was
assessed. Both companies were supplying automotive parts to
major car manufacturers. In order to assess the applicability of
Poka-Yoke devices in a non-manufacturing scenario, the assess-
ment was carried out in a construction company. The Poka-Yoke
device used in this company was a safety Poka-Yoke.
In the first company, components of transmission systems
used in medium and heavy vehicles are manufactured. In this
company, Poka-Yoke device for quality was installed in a
polishing operation of a component of automobile axle. In the
polishing operation, an end yoke which was manufactured in
the previous operation had to be screwed into a clamp. Also, the
end yoke was to be positioned into a template using the hole on
its base. If the positioning of the end yoke was not proper, the
polishing operation would not be perfect. For detecting the
presence of holes in the end yoke, a sensor was installed. An-
other safety Poka-Yoke device was installed in a press. If any
body parts of the operator encroached the press operations, the
Poka-Yoke device would stop the operation of the press.
One more quality Poka-Yoke device was installed in the
second company to identify the defective brake pads. It was
installed as the consequence of the receipt of frequent custom-
er complaints regarding the dimensions of brake pads. This
Poka-Yoke device consisted of a machine whose main com-
ponents were a conveyor belt, a video camera and a monitor.
The conveyor belt would be carrying the brake pads to the
location of the camera, and the image would be captured by
this camera. The captured image and standard image would be
displayed by the monitor, and if any deviation was found, an
alert would be made so that the operator would be able to
change that component.
A second safety Poka-Yoke device was applied in the con-
struction company. This Poka-Yoke device was installed on
the access gate of the freight elevator of the construction com-
pany. If any door of the access gate was open, the elevator
would be stopped. The intention of the employment of safety
Poka-Yoke device was to prevent any accident when an indi-
vidual put any of his body parts on the shaft of the elevator.
Zhang [61] has presented a case study in which the moni-
toring of injection moulding flash was carried out using an in-
process Poka-Yoke system comprising an accelerometer and
logistic regression modelling. The material used for carrying
out the injection moulding process was a mixture of pure
polystyrene and a small quantity of low-density polyethylene.
When a mixed material consisting primarily of plastic resin
with certain additives was used for carrying out the injection
moulding process, flash occurred due to change in properties
of additives. For example, in the case study considered, the
fluidity and viscosity of the added materials were considerably
different from that of the parent material. If flash occurred in
Int J Adv Manuf Technol
the injection-moulded tensile testing bars, additional labour
force was required to trim the flashes, and it caused cost bur-
den on the organisation, so it was necessary to develop an in-
process Poka-Yoke device for preventing flashes to occur in
the injection moulding process.
The essential components of the in-process Poka-Yoke de-
vice were an accelerometer sensor and a decision-making al-
gorithm, which worked based on logistic regression principle.
When the injection moulding process was going on, the ac-
celerometer would generate signals, and these signals would
be fed into a signal conditioning device and micro controller-
based data acquisition system. From these devices, feature
signals would be extracted. The feature signals would be fed
into a logistic regression modelling algorithm to predict the
possibility of occurrence of flashes in the injection-moulded
parts. In case a corrective action, if any, is to be taken, the
same is sent as feedback to the machine control unit. A soft-
ware program written using Microsoft Excel Visual Basic Ap-
plication was used to interface with the accelerometer and also
for driving the data acquisition system. Identification of fea-
ture signal from raw data was performed using Microsoft Ex-
cel. Logistic regression model was developed using John’s
Macintosh Program. In order to test the Poka-Yoke system,
ten samples each of pure resin and mixed resin were produced.
While exclusive case studies on applying Poka-Yoke con-
cept have been presented in the above papers, as mentioned in
the beginning paragraph of this section, some authors have
peripherally mentioned about the application of Poka-Yoke
in certain cases. The highlights of these case studies are pre-
sented in Table 3.
The case studies presented in this section have affirmed that
Poka-Yoke concept is powerful enough to trigger the minds of
decision-makers like engineers and managers to prevent the
occurrence of defects which leads to the occurrence of fail-
ures. This capability of Poka-Yoke clearly indicates its poten-
tial in enabling the organisations to achieve the goals of Six
Sigma. In this context, it evokes interest to navigate the liter-
ature arena to study the application of Poka-Yoke systems in
Six Sigma projects.
7 Application of Poka-Yoke in Six Sigma
In the literature arena, some papers reporting research which
deal with the application of Poka-Yoke devices in Six Sigma
projects have appeared. The research activities reported in
these papers are briefly described in this section.
Kumar and Steinbach [41] have reported about the elimina-
tion of medical errors in US hospitals by utilising a close-loop
system in a Six Sigma environment. These authors have
stressed for the need of applying standardisation in hospital
procedures, tools and methods for minimising the errors. Before
implementing the DMAIC phases, a service blue print to depict
Int J Adv Manuf Technol

Table 3 Auxiliary employment of Poka-Yoke solutions in cases

Serial number Paper Application of Poka-Yoke in case studies

1 Gitlow et al. [62]
2 Wadhwa [63]
3 Chase and Apte [64]
4 Kattman [65]
5 Myszewski [66]
6 Veronneau and Roy [67]
7 Fast-Berglund et al. [68]
These authors have described the need of employing Poka-Yoke devices in a hospital environment.
The Poka-Yoke devices suggested by these authors are (1) colour code for all geriatric patients’
wristbands in order to pay more attention to them and (2) injection vials containing white rubber
at the top for insertion of injection needle
A case study has been reported in which efforts were made to sustain the flexibility of automation
through the application of Poka-Yoke devices. In this case study, Poka-Yoke was utilised for
identifying vision system. These authors have indicated that modification of the process would
be required for the implementation of Poka-Yoke devices
These authors have indicated that application of Poka-Yoke devices is successful in service operations,
too. Some of the examples illustrated by these authors are mirrors kept near to telephone to ascertain
that calls were attended with a smile and surgical trays with indented design for keeping back all
of the surgical instruments after surgery was over
This author has mentioned about the application of Poka-Yoke in visual control in work place practices.
This author has mentioned that Poka-Yoke devices are available in detecting, restricting or signalling
device types. The purpose of these Poka-Yoke devices is to prevent defects from occurring or
preventing the defects that have occurred from passing over to succeeding stages
This author has mentioned that irrespective of the cost elements involved, proper safety requirements
should be incorporated for preventing the side effects of errors. In order to prevent the occurrence of
these errors, this author has recommended the employment of Poka-Yoke devices
These authors have described the application of radio-frequency identification for improving the
performance of global service supply chain and have prescribed the usage of loading door portals
as a Poka-Yoke solution
These authors have suggested the employment of Poka-Yoke devices to prevent failures in mixed-model
assembly practice. These authors have suggested pick-by-light systems as Poka-Yoke devices which
would guide the operators to choose the correct parts

the existing procedures was prepared. The service blue print Improve: After finding out potential causes of errors, suit-
depicted information on the flow of processes and activities that able Poka-Yoke solution were suggested to prevent the
were carried out in the hospital. Some of these processes and occurrence of these errors. The causes of errors were
activities were visible to the customers, while others were not identified as failures. The failures thus considered and
visible to the customers. In order to make the blueprint robust, Poka-Yoke solutions suggested are briefly described
DMAIC phases were conducted. The activities carried out un- below:
der these phases are briefly described here:
Failures 1, 2 and 3 The patients’ identities were often
Define: In this case study, patients were considered as mistaken as many patients were
customers. The two main expectations of customers were having the same or closely identical
‘getting the surgery done without any medical errors’ and names.
‘getting it done in a reasonable amount of time and with- Recommended Poka-Yoke solu-
out any pain’. tion to overcome failures 1, 2 and 3:
Measure: In measure phase, current processes and perfor- It was suggested that every patient
mances were measured. In a US hospital scenario, the cur- should be given a wristband con-
rent performance level was four sigma, which correspond to taining the patient number, name
6210 medical errors in a million opportunities. Considering and date of birth. It is pointed out
the seriousness of the impact of the medical errors, the ob- that this practice was already follow-
jective was set to enhance the performance level by limiting ed to avoid confusion in the identity
the occurrence of defects to 3.4 per million opportunities. of newborn babies. It was also sug-
Analyse: In this phase, cause and effect diagrams were gested to develop an electronic data-
developed to analyse the causes of medical errors. The base containing the general and
errors thus studied and analysed were (1) error in giving medical background of the patients.
anaesthesia to the patient, (2) medication error, (3) proce- This information should be accessi-
dural error in performing a surgery and (4) infection and ble on scanning the wristband worn
wrong dosage of medication. by the patients.

Failure 4 There existed an inefficient communication
system between the doctor and nurses.
Recommended Poka-Yoke solution to
overcome failure 4: It was suggested to create
a database which has to be accessed online to
enter and retrieve data about the treatment of-
fered to each patient. For example, a doctor
should access this online database to enter the
medicine and dosage to be offered to a patient.
The nurse should access this database to select
the exact medicine and dosage prescribed by
the doctor and offer the same to the patient.
Failure 5 Patients were given wrong medicines and
dosages.
Recommended Poka-Yoke solution to
overcome failure 5: It was suggested to em-
ploy an online medicine ordering system. The
current practice of prescribing the medicine
and dosage in paper should be dispensed
with. Only the doctor was to be allowed to
order medicines for administering the same
to each patient. Subsequently, the medicines
were to be bought from the pharmacist, who
has to deliver the medicines prescribed by the
doctor through the online medicine system. In
order to avoid delivering wrong medicines,
the pharmacist was required to scan the same.
Failure 6 Doctors and nurses did not possess sufficient
experience. This led to the occurrence of
medical errors.
Recommended Poka-Yoke solution to
overcome failure 6: The doctors and nurses
must undergo on-the-job training.
Failure 7 Medical errors occurred due to the fatige of
doctors and nurses who worked for too many
hours.
Recommended Poka-Yoke solution to
overcome failure 7: The maximum permissi-
ble working hours of doctors and nurses
should be stipulated. Doctors and nurses
should not be allowed to work beyond the
maximum permissible working hours.
Failure 8 During the time when the situation demanded
the doctors and nurses to act hastily, medical
errors occurred. These medical errors occurred
mainly due to the doctors and nurses being
understaffed.
Recommended Poka-Yoke solution to over-
come failure 8: The doctors and nurses were to
be employed in such a way that the number of
those personnel actually employed was to be
made equal to the number of doctors and nurses
required for carrying out medical duties.
Int J Adv Manuf Technol
Failure 9 Negligence in performing the duties resulted in
medical errors.
Recommended Poka-Yoke solution to over-
come failure 9: It was suggested to make use of
checklists which needed to be filled by at least
more than one personnel who performed the
duty.
Failure 10 Patients who were about to undergo surgery
were often required to avoid taking
unprescribed medicines and food prior to a
day before the surgery was to be performed.
Often, unknowingly, this kind of patients
took unprescribed medicines and ate food just
before the conduct of surgery. This made the
patients unsuitable for undergoing surgery.
Recommended Poka-Yoke solution to
overcome failure 10: An online database of
the patient was to be created which should be
supported by e-mail communication system.
This system would entail the sending of e-
mail asking the patients not to eat food or take
unprescribed medicine immediately before
the surgery was to be performed.
Control: In this phase, suggestions for sustaining the re-
sults of the previous stages were made. It was suggested
that all of the improved procedures developed by apply-
ing Poka-Yoke solutions should be documented. A new
service blue print indicating new patient flow process
should be documented and handed over to each hospital
staff member. These actions were necessary to prevent
the hospital staff members from reverting back to adopt
the original practices.
Kumar et al. [48] have reported a research that was carried
out to improve consumer purchases in e-tailing operations. In
this paper, the steps to be taken for enhancing the operational
efficiency of a company named Bellacor are presented.
Bellacor is an online retailer which sells over 5,000,000 prod-
ucts supplied by approximately 700 manufacturers. Majority of
the product mix comprises plumbing and lighting categories. In
the research carried out in this company, DMAIC improvement
methodology was applied to modify the existing service blue
print by incorporating Poka-Yoke devices in the improve phase
of DMAIC cycle. While carrying out this task, employment of
Poka-Yoke solutions for overcoming failures was recommend-
ed. These failures and the Poka-Yoke solutions recommended
to overcome the same are described below:
Failure 1 Due to an excessive number of incoming calls,
customer service personnel are unable to attend
to all of the incoming calls. Due to this
undercapacity problem, many calls remain
Int J Adv Manuf Technol
unattended, resulting in the loss of business to the
company.
Recommended Poka-Yoke solution for over-
coming failure 1: It is recommended to identify
the peak call timings. During these peak call tim-
ings, additional customer service personnel are re-
quired to be deployed. Also, a warning system is
to be implemented which is required to alert the
personnel when the number of incoming calls
exceeded the current capacity of call attending.
On getting alerted by the warning system, the ad-
ditional customer service personnel are required to
minimise the present call duration and attend to
the new incoming call.
Failure 2 Customer orders are dishonoured due to lack of
sufficient goods at warehouses.
Recommended Poka-Yoke solution for over-
coming failure 2: Currently, two of 724 suppliers
of Bellacor are supplying approximately 20 % of
the total goods distributed. If the product is un-
available in the warehouse, the customer order is
dishonoured. In the proposed Poka-Yoke, the em-
ployment of an alternative order fulfilment process
is suggested in which goods are required to be
issued from the warehouse situated nearest to the
customer delivery location. If out-of-stock situa-
tion prevails in that warehouse, customer order is
required to be honoured from the next nearest
warehouse.
Failure 3 Back-order details provided by the vendors are not
accurate.
Recommended Poka-Yoke solution for over-
coming of failure 3: Every week, customer support
personnel is required to contact the manufacturers
to gather back-order information, and they are re-
quired to communicate with customers in this re-
gard. Communication made using Electronic Data
Interchange (EDI) from manufacturers is required
to be closely monitored by the customer support
personnel, and the information is required to be
passed on to the merchandising team. On observ-
ing the patterns and trends, the merchandising
team is required to identify flaws in communica-
tion made using EDI from the manufacturers’ side,
and appropriate corrective actions are required to
be taken. The improvement achieved by taking
these activities is expected to reduce the number
of calls made by the customers to the customer
support section.
Failure 4 EDI technology is not utilised by the vendors,
resulting in failures in order fulfilment.
Recommended Poka-Yoke solution for over-
coming failure 4: Poka-Yoke recommended is to
switch over to Internet-based EDI. On installation
of Internet-based EDI, customers will be served
with real-time information about product move-
ment from warehouse to delivery point. In this
case, customers’ service problems could also be
reduced significantly.
Failure 5 Absence of account order information.
Recommended Poka-Yoke solution for failure
5: All of the manufacturers are required to use
Internet-based EDI system for displaying informa-
tion about stages of order shipment. Bellacor’s
website may be improved so that all of the cus-
tomers could log on to this website and gather
information about order status. Many calls from
customers regarding order fulfilment can be
avoided by incorporating this facility.
In total, these authors have strongly recommended the us-
age of EDI, which will reduce the errors occurring while car-
rying out the order management.
Kumar et al. [49] have reported the application of DMAIC
phases for improving the credit initiation process in a financial
service operation. While carrying out the improve phase of
DMAIC, four Poka-Yoke solutions were suggested to over-
come four failures. Those failures and Poka-Yoke solutions
suggested to overcome the same are described below:
Failure 1 Financial information is not made available to the
analysts.
Recommended Poka-Yoke solutionfor over-
coming failure 1: Currently, the financial data are
sent through mail. As Poka-Yoke solution, it is
recommended to send the financial information
electronically for overcoming this failure.
Failure 2 Certain financial information are required to be
backed by the results of conducting the initial
analysis. Due to the absence of these results, usu-
ally these financial information are not supplied
on time, so the processing is delayed until finan-
cial information is supplied.
Recommended Poka-Yoke solution for over-
coming failure 2: It is recommended to develop
an Excel sheet to clearly indicate the type of finan-
cial data required. One more Poka-Yoke is recom-
mended. According to this Poka-Yoke, proper
training is to be imparted to the sales administra-
tors and sales team with regard to the supply of
appropriate information pertaining to each queried
financial data.
Failure 3 Sales team is not responding to credit teams’
requests.
Recommended Poka-Yoke solution to over-
come failure3: It is recommended that sales

administrators are to be made accountable for re-
trieving and supplying financial information to
the credit analysts.
Failure 4 Delay occurs while carrying out the approval
process.
Recommended Poka-Yoke solution to over-
come failure 4: Currently, analysts drop all of
the approval requests into the credit manager’s
inbox. It is recommended that those approval re-
quests which would have to be processed within
2 days are to be put in a red-coloured folder. Cred-
it managers should be made responsible for the
processing of the approval requests within 3 days.
The credit manager should forward a report to his
superior regarding the number of approval re-
quests processed in a time span of 3 days.
These authors have projected that the implementation of
the above Poka-Yoke solutions will reduce the processing
time from 20 to 18 days. However, these authors have admit-
ted that implementing these proposals in the existing system is
a very difficult task.
Southard et al. [50] have provided Poka-Yoke solutions
using radio-frequency identification (RFID) in a health care
scenario against the failures presented in Kumar and
Steinbach [41]. These authors have claimed that significant
cost and time savings could be made by employing Poka-
Yoke devices developed using RFID technology. RFID en-
compasses a tag, reader and a software program which would
integrate the company database with RFID equipment data-
base. A computer simulation package, Arena, was used to
model two systems, one without RFID and one with RFID.
Overall throughput time was considered as the dependent var-
iable while carrying out this simulation study. While
conducting the analyse phase of this case study, many Poka-
Yoke solutions were recommended. These Poka-Yoke solu-
tions are explained below:
Failures 1, 2 and 3 Failure to link patients and their health
records.
Recommended Poka-Yoke solution to
overcome failures 1, 2 and 3: It is recom-
mended that each patient should wear a
wristband containing RFID tag in which
a patient number is to be impregnated.
On executing this action, mixing up of
patient records can be prevented because
each patient’s RFID tag would be
scanned by the tag readers, and informa-
tion pertaining to the patient would be
collected from them. The RFID chip
would contain the patient’s name, date
of birth and brief health history.
Int J Adv Manuf Technol
Failure 4 Communication gap between doctors and nurses.
Recommended Poka-Yoke solution to over-
come failure 4: The information pertaining to di-
agnosis, prescription, history of allergy and tests to
be conducted for a patient are to be entered in an
online record. Wireless scanners and readers are to
be utilised to scan and read the data incorporated in
the chip using RFID, and hence, at the time of
entry of a patient in the diagnosis room, his or
her personal details including record history would
be automatically shown on the display screen. On
checking these facilities, errors occurring due to
the communication gap prevailing between doc-
tors and nurses would be eliminated.
Failure 5 Mistake of administering wrong medicine or
wrong dosage of medicine.
Recommended Poka-Yoke solution to over-
come failure 5: Online medication ordering sys-
tem is required to be used instead of paper pre-
scription. The doctors are required to log on to an
online medication ordering system and type the
name of the medicine and dosage. This will be
followed by the issuance of an identity code with
RFID tag. These RFID tags are to be produced by
the patient at the pharmacy to purchase the med-
icines ordered online by the doctor. It is also sug-
gested that the government may advice medicine
companies to incorporate RFID in the medicine
containers for ensuring their easy and correct
identification.
Failure 6 Inadequate knowledge leading to wrong diagnosis,
medication and dosage of medicines.
Recommended Poka-Yoke solution to over-
come failure 6: Continuous training is to be pro-
vided to the doctors and nurses for enhancing their
skills. Opportunities for updating new knowledge
and new skills would be made available to them.
The credentials of ‘attending staff members’ would
be displayed on scanning of the RFID tag in the
wristbands of the patients, and if it is found not up
to the mark, an alert is required to be signalled.
Failure 7 Lack of experience of the personnel results in
medical errors.
Recommended Poka-Yoke solution to over-
come failure 7: The RFID system shall facilitate
to indicate the credentials of the medical person-
nel. This facility can be used to decide whether the
medical personnel possess sufficient experience to
carry out the task.
Failure 8 Medical errors, which are caused due to fatigue
experienced by doctors and nurses.
Recommended Poka-Yoke solution to over-
come failure 8: Working limit is to be ensured by
Int J Adv Manuf Technol
specifying the maximum permissible working
hours. This would be recorded in the employee’s
RFID tag. When the working limit is crossed, an
alert signal is required to be generated.
Failure 9 The personnel show negligence while attending to
the patients. This results in errors while attending
to the patients.
Recommended Poka-Yoke solution to over-
come failure 9: It is suggested to employ checklists
to arrest errors that arise due to negligence. If the
equipment used are RFID-tagged, then trays or
shelves kept on them will prompt the equipment
which are in place and those equipment which are
out of place.
Before concluding the article, these authors have projected
that the use of RFID in a health care system is prone to reduce
errors significantly. Further, these authors have compared the
cost of operation in health care systems with or without the
application of RFID. The result of this comparison has sug-
gested that, in total, a saving of $1.93 million can be achieved
by applying RFID-integrated Poka-Yoke solutions in the
health care system.
A careful study of the research presented in the above pa-
pers has indicated that there has been a realisation over the
power of utilising Poka-Yoke principles in the DMAIC frame-
work. However, in all of these research projects, only the
recommendations for implementing Poka-Yoke solutions
have been presented. Hence, in those research projects, the
actual increase of sigma value due to the implementation of
Poka-Yoke solutions could not be ascertained. Moreover, the-
se research activities have largely been conducted in non-
manufacturing companies. Therefore, while this situation re-
veals the feasibility of employing Poka-Yoke solutions in
DMAIC framework, it also indicates the need for conducting
research projects in manufacturing companies to examine this
proposition.
8 Conclusion
Six Sigma has been implemented in many organisations. Dur-
ing the implementation of Six Sigma, numerous tools and
techniques are employed. However, some of the tools and
techniques which are very effective in achieving the goals of
Six Sigma are yet to be employed in Six Sigma projects. One
among those techniques is Poka-Yoke. In order to explore the
implementation of Poka-Yoke in Six Sigma projects, the liter-
ature navigation reported in this paper was carried out. The
collective outcome of this literature navigation has indicated
that in comparison to the research on Six Sigma, the quantum
of research on applying Poka-Yoke in real-time situation has
been dismal. Particularly, the number of papers reporting the
research on applying Poka-Yoke in Six Sigma projects exe-
cuted in the manufacturing arena was so minimal, which
forced the authors of this paper to gather information and
knowledge on applying Poka-Yoke in Six Sigma projects ex-
ecuted in non-manufacturing fields like health care, financial
service operation and online retailing business. Apparently,
inclusion of the research on the application of Poka-Yoke in
Six Sigma projects executed in these non-manufacturing
fields appears like the limitation of the literature navigation
reported in this paper as the scope of this journal is limited to
deliberate the research carried out in a manufacturing arena.
However, the information and knowledge derived by
reviewing these papers were found to be useful for applying
the same in manufacturing fields as well. Out of the four
research projects reported in such papers, in three research
projects, Poka-Yoke solutions have been applied in ‘improve
phase’ of Six Sigma’s DMAIC framework. In one such re-
search, Poka-Yoke solutions have been evolved during ana-
lyse phase. In all of these research activities, the Poka-Yoke
solutions have only been suggested, and hence the im-
provement achieved in sigma level due to their actual
implementation could not be assessed. In this back-
ground, the collective inference drawn through the nav-
igation of the literature arena presented in this paper has
revealed that a model blending Poka-Yoke concept with
the DMAIC phases of Six Sigma programme is the
need of the hour. Such a model encompassing this fea-
ture shall be designed to suit the application of Poka-
Yoke solutions through the implementation of DMAIC
phases in manufacturing companies. Through the imple-
mentation and examination of this model in manufactur-
ing companies, the validity of such model will have to
be established.
Compliance with ethical standards The authors state that this paper
has not been submitted for the consideration of publication to any other
journal other than IJAMT. The authors further state that the contents of
this paper comply with the rules of good scientific practice of the Com-
mittee on Publication Ethics.
Funding The research reported in this paper has been indirectly funded
by the Government of India as the first author has carried out this research
work to obtain Ph.D. degree under Quality Improvement Programme
which is sponsored by Ministry of Human Resource Development, Gov-
ernment of India.
Conflict of interest The authors declare that they have no conflict of
interest.
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