Lessons learned on feedback loops from a coffee pot at a meeting.

I was at an all-day meeting recently of an industry advisory committee related to my day job.

There was a large insulated container of coffee brought in and set on a white table cloth. Under the spigot was a coaster of some kind designed to catch coffee drips to keep from messing up the tablecloth.

I went to get the first cup of coffee from the setup and soon discovered that the setup was fatally flawed. The coffee container spigot sat too low. If you put a cup over the coaster and filled it, you couldn’t pull it out again without tipping it sideways enough to spill coffee. They either needed a shorter coaster, to raise the coffee container a little, or some combination of the two. Less than an inch would have fixed the issue.

I went back later and noted that somebody trying to get coffee had simply shoved the coaster out of the way, perhaps after dumping hot coffee on their hand. There was a brown stain of wet coffee now better than a foot wide under the spigot. It looked terrible.

It was also entirely predictable. However, I am willing to bet that this same issue happened before and will be repeated at the next event. I stress that this happened at a major university and a professionally-run conference center. Something as simple as having coffee at a meeting, an activity that should have been routine, turned into a mess and a potential safety hazard.

Absent a mechanism to test the setup (someone working for the conference center is tasked with getting a cup after setting it up), a feedback loop (hey, the coffee is spilling all over the place and the attendees want you to fix it) or a post-event review process (every tablecloth comes back with massive coffee stains and something is wrong) — it is predictable that this error will be repeated.

However, this isn’t unique. It happens all the time. If you are an analyst, you can see it constantly. The frustrating thing is that you will see the same errors over and over again because there isn’t a built-in mechanism to address them. If you analyze health care (my day gig), repeated error is the norm rather than the exception.

It is sort of like the intersection where there are wrecks all the time. It usually takes a fatality before someone comes in and puts in the stop light.

So, as an exercise, try looking a something as simple as a a coffee stain on a table and do a root cause analysis of it in your head. Ponder how it could have been prevented and, if not prevented, kept from being repeated.

The steps you take to think it through are no different than the ones you would use on a far more complex problem.


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