I was at the Delta customer service counter at LAX a couple years ago, dealing with yet another air travel fiasco from my life on the road. As my elbows rested on the countertop waiting for the customer service agent, I looked to my right to see a brochure caddy containing a stack of attractive, laminated bookmarks. “Please accept our sincere apologies” was printed across the top in attractive Delta motif and colors.
I picked up one of these collector items and gazed at it. Thoughts started racing through my mind: How did Delta know that I was coming? What premonition did they have that they wanted to make sure there were enough of these for me and my fellow passengers, how sincere are they really, and finally who at Delta thought this was a good idea?
As every quality professional knows, the worst type of defect is the one that reaches the customer. And the fact that Delta expects so many defects to reach their customers is troubling, especially because Delta is one of the most awarded airlines in the industry. But who proposed that offering bookmarks to customers would come close to retaining goodwill?
From the point of view of the quality world, it would be preferable to take money that is spent on goodwill (or bookmarks) and funnel this into processes that are incapable of producing an error in the first place. The field of error proofing has given way to significant gains in our ability to prevent defects from reaching customers and protecting patients from harm.
Error proofing starts with the recognition that “trying harder” is generally not enough to prevent defects from happening. Furthermore, we must make it easy for employees to do the right thing. If they are doing the same thing often, such as in repetitive work, then the risk of falling into a state of “unconsciously incompetent” is more likely, just like the days we drive up to our garage and wonder how we got there.
Error proofing performs optimally before production is completed, as this also reduces need for inspection while increasing confidence from the perspective of the customer. Once an error-prone process is revealed, a vigilant response is needed:
- Eliminate the error prone part of the process entirely
- Replace the process with an approach that is more reliable
- Prevent the error from occurring in the future
- Improve the ability to detect errors as quickly as possible
- Introduce mitigation strategies to minimize harm
Obviously if we are apologizing for poor service, or passing out the equivalent of bookmarks, we have failed to eliminate, replace, prevent or detect errors, and this is not a happy place to be. Not only do you frustrate your customers, but your employees also deserve a reliable process, and apologizing often will demoralize staff.
The medical industry is one place where error-proofing has been very successfully applied, and may instruct other industries on where to start.
Staff will repeatedly ask the patient to confirm their date of birth to confirm they are in the right place at the right time. Markings on skin are applied to prevent wrong side surgery. Small lot sizes for lab tests prevent the prevalence of batching when errors are more likely to go undetected. Color coding of supplies and medicines help staff find the right product quickly and accurately. “Forcing functions” are used to support tasks that prevent an error from happening in the first place—such as gas lines that use unique connections to the equipment that depends on them.
We in quality don’t believe that staff come to work in the morning thinking “I’ll only make a few mistakes today;” on the contrary, when mistakes are made it is usually the process itself that contributed to the root cause. Besides this, if an employee shows total disregard for the process, or attempts to improve it, then this is a management issue and must be dealt with accordingly.
To be sure, an error-proofing initiative will not solve all quality problems in a business, but it is a good place to start and belongs in your toolkit. Error proofing may not eliminate the need to apologize, but it can save thousands on laminated bookmarks.
