Handoffs = Errors

I saw a perfect illustration this morning of how unnecessary handoffs in a process can lead to errors.

I visited a local coffee shop in Albuquerque and ordered a cup of coffee from the woman working the register. I asked for a muffin, had to describe it as “the one on the end with the almonds on top” since the pastry case wasn’t right there in front of us. She said, “the bran muffin?” and I said, “sure.”

She got my coffee and I paid her.

But the “muffin fulfillment process” (if you will) was handed off to a man working behind the counter. He went and bagged the muffin, I didn’t double check (the waste of inspection, right?).

So I get to my client site and open the bag….. blueberry muffin. Wrong muffin, not even one with almonds on top.

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Fine, not a mistake on par with operating on the wrong limb. I enjoyed the blueberry muffin. I generally like blueberry muffins and this was a good one.

But still, I thought about the handoff between the two employees. If she had just gotten the muffin herself, she would have probably gotten the right one. The communication between them wasn’t “clear and unambiguous” apparently.

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Think about your processes. How many unncecessary handoffs are there? What miscommuncations could or do occur? How does that impact your customers? How does that impact the bottom line? Can you reduce the number of handoffs? Or, are there clear and unambiguous signals you can put in place to prevent miscommunications? A kanban card is a perfect example of a clear and unamibguous communication device.

I’m not saying a kanban card is the right solution for the coffee shop. They just need to simplify their process. Think of how Starbucks communicates your drink order from the register person to the “Barista.” They write the drink details on the side of the cup. Clear and unamiguous. If I drank triple tall skinny soy caramel lattes, I’d much rather they write that down (with my name) on the side of the cup rather than communicating that verbally.

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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an book titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

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2 Comments

  1. Jamie Flinchbaugh says

    Lean matra: every handoff is an opportunity for an error AND a delay.

    Think about the simple process of requisition. Minutes worth of work turn into weeks of lead time. The dominate culprit: handoffs.

    Is stopping at Starbucks and waiting in line the new 8th waste?

  2. How Handoffs Can Kill — Lean Blog

    […] how handoffs in a process create opportunities for errors. I wrote about a trivial situation where I got the wrong muffin and Seth Godin wrote about getting the right breakfast because there were fewer […]

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