#IHI Even at a process improvement conference, you encounter failed processes. Have you ever noticed, in a cafeteria or buffet line, that the serving ladle for oatmeal is often too large for the bowl into which it is being put? Such is the case at the Marriott in Orlando here at the IHI Annual Forum.
I captured this problem this morning at breakfast. What's interesting is to see the rapid development of work-arounds. One person abandoned the ladle and used a coffee cup to extract the oatmeal. In so doing, she put her fingers in very close vicinity to the food that would be taken by the following persons. And she then left a goopy, oatmeal covered coffee cup on the table -- in the way of the next person and too dirty to be reused. Other people tried different serving techniques, but they ran into problems because oatmeal just doesn't flow very well!
In the manner of some surgeons who resist acknowledging systemic problems, one person said that he is able to overcome the design problem because he has "a steady hand."