STAR Technique Can Help a Latte

Added on Dec 28, 2015

I was recently at a Starbucks in the afternoon and ordered my typical decaf latte. I happened to be the only one waiting for their order at the time and the barista said to me, “I’m sorry, I have to remake your coffee, I started to make it regular instead of decaf.” When she handed me my decaf (which I confirmed with a clarifying question) she said to me, “I apologize again, my head just didn’t catch up with my hands in time.”

Patient Safety

I immediately thought here’s a student of high reliability organizing at Starbucks! She already recognizes the risk of your hands moving before your head has a chance to think. I once made small talk with another barista and asked her, “Do you make coffee in your sleep?” She replied, “all the time.”

Jens Rasmussen, who developed the Skill-Rule-Knowledge (SRK) system taught that routine, familiar tasks are known as skill-based actions. They often do not require much conscious thought and can be performed on auto-pilot. Our risk of experiencing error while in that mode is 1:1000 acts. One out of a thousand? That doesn’t sound bad, does it? You’re correct; it’s actually our most reliable mode of human performance.

That being said, a skill-based error can have disastrous consequences. We’ve heard examples of these in our work in patient safety: the wrong medication selected from the dispensing cabinet, the IV pump programmed incorrectly, the wrong setting on a piece of equipment, failing to turn on an alarm, or even starting a procedure on the incorrect side. One of these slips or lapses can have major consequence for our patients and the clinicians caring for them.

One way to reduce our likelihood of experiencing a skill-based error is to practice STAR Technique (Stop-Think-Act-Review). It’s a one second pause to give our heads a moment to catch up with our hands. We stop for a moment, think about what it is we are about to do, carry out the act and review to make sure we did it correctly.

While the coffee order error may have only led to a sleepless night, we know that other skill-based errors have much higher stakes. I’m positive STAR technique could help a lot (or in my case a latte) on incorrect coffee orders.

Next improvement opportunity; the spelling of the names on the cups! I’d love to see the face of the barista when I order my next coffee using phonetic clarification and say “that’s for Tiffany: Tango-India-Foxtrot-Foxtrot-Alpha-November-Yankee.”

Questions to consider:

  • 1) Have you identified the skill-based tasks your teams perform on a daily basis? If so, have you been explicit where STAR Technique should be practiced?
  • 2) What are the visual cues or reinforcement methods you can be utilizing to drive the practice of STAR Technique?