Business Systems and Processes.

The Systems Thinker Blog

When a System Failure Can Kill People!

When our business systems are bad, we usually just lose money or customers. However, a front-page news story a few years ago illustrated how poor business systems or processes can sometimes kill people.

Nine individuals died, and hundreds were hospitalized by peanut butter containing a deadly form of salmonella.  The company, King Nut, sold its product to schools, nursing homes, and hospitals in ten states.

Procuct Recall

The consequence of this serious quality control problem was death and injuring to unsuspecting customers. It could also have meant the death of King Nut.

From the customer’s viewpoint, certain things are “critical to quality” (CTQ). You must meet these customer CTQ specifications or expectations precisely or you will lose their business. Healthy food is always going to be critical to quality. Consequently, I predict that many of the schools, nursing homes, and hospitals will not buy from King Nut again.

A spokesperson for the company said, “We just want everyone to know that safety is our highest priority.” It may be. Mistakes happen. However, to the customer, King Nut’s booboo may fall under the category of “unpardonable sin.”

A news analyst said the solution to the problem is to hire more FDA inspectors. As a Systems Thinker, you know that it’s always better to catch quality problems immediately at the source, not at a later inspection of accumulated inventory, or worse, after customers have had a bad experience. Instead of hiring more inspectors, King Nut and others should improve its internal systems to catch food contamination earlier in the process.

(Update: In June of 2015, King Nut received a level 2 certification for Safe Quality Food (SQF) by NSF International, a very high rating that took years to achieve. Congratulations!)

More recently in my backyard, an employee of Dickey’s Barbecue Pit confused oven cleaner (lye) with sugar in making its sweet tea for customers. A retired teacher drank a sip and complained that it tasted like acid. In minutes, she was on her way to the hospital in critical condition and almost died. The woman required surgery to repair deep, ulcerated burns covering the upper esophagus.

Do you have any business systems or processes that need closer attention to quality? Don’t take chances. Save yourself a lot of money and grief by building quality into every business system and process.

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It's time for me to focus on other things. Many hours and dollars have gone into my software and written materials over the last fourteen years. Now it's time to give back. This is not a gimmick. There is nothing to buy. I give it all to you for free. If you use the software and apply the principles, you can create a remarkable company. See Below. Have fun!

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Michael Gerber, "E-Myth"

Michael Gerber

"Organize around business functions, not people. Build systems within each business function. Let systems run the business and people run the systems. People come and go but the systems remain constant."

W. Edwards Deming, Total Quality Management

W. Edwards Deming

"If you can't describe what you are doing as a process, you don't know what you're doing. . . . 94% of all failure is a result of the system, not people."
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