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.

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.

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
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. 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?


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