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Tag: Blame

My Thoughts on “10 Ideas That Hospital and Health System CEOs Need to Ditch,” Including Blame

My Thoughts on “10 Ideas That Hospital and Health System CEOs Need to Ditch,” Including Blame

I saw this piece by Bob Herman at Becker’s Hospital Review and ended up writing a blog post here instead of writing a long comment there. The piece is: 10 Ideas That Hospital and Health System CEOs Need to Ditch I was happy to see ThedaCare’s CEO Dr. Dean Gruner quoted – listen to my podcasts […]

Podcast #203 – Chris Jerry, The Emily Jerry Foundation, Part 1

Podcast #203 – Chris Jerry, The Emily Jerry Foundation, Part 1

MP3 File (run time 40:21)  | Listen via YouTube Read the transcript My guest for Episode #203 (and an upcoming Part 2) is Chris Jerry, founder of The Emily Jerry Foundation.  The foundation was created in the aftermath of the tragic death of his daughter, Emily - a preventable medical error caused by a number of factors and […]

The Real #VAscandal is the Long Waiting Times & Bad Management, Not Gaming by Bad Apples

The Real #VAscandal is the Long Waiting Times & Bad Management, Not Gaming by Bad Apples

Look at the System, Not the Individuals I’ve been wanting to blog about the “VA Scandal,” but have avoided it because it is somewhat politicized (as tends to happen), the allegations and story are moving quickly, and the whole thing just makes me sad, so I stop writing. Building on Monday’s post… when the news first […]

Blame: Human Error Occurs Even IF We’re Being Careful

Blame: Human Error Occurs Even IF We’re Being Careful

I’m not sure why “error” was put in quotes since this seems like an actual error, not a quote-unquote error: Staff ‘error’ blamed for chlorine leak at Louth’s Kenwick Park Hotel which led to five being taken to hospital When people talk about human error, they often seem to miss the point. They think calling […]

Learning Not to Blame: Baseball Edition

Learning Not to Blame: Baseball Edition

Following up my post about not blaming a bartender, here’s another look at learning to cast aside our old habit of blaming individuals… this time, baseball related. Modern organizations (in healthcare and business) tend to blame an individual when something goes wrong. It’s commonplace in our societies and it’s, basically, human nature to blame. But, […]

Lean Thinking: We Don’t Blame Individuals for Systemic Errors

Lean Thinking: We Don’t Blame Individuals for Systemic Errors

I saw this video last night on Paul Levy’s blog and it’s important enough that I want to share it here with a few additional thoughts. In the Lean methodology, our mindset is that we respect people as individuals, respecting their human nature, and this means we appreciate that we are fallible and make mistakes. […]

Is it Lean’s Fault or the Old Management System’s?

Is it Lean’s Fault or the Old Management System’s?

It’s easy for an organization to say they are “doing Lean” or they have “started a Lean transformation.” They might hire a consultant or put out a press release… or maybe there’s an optimistic (but premature) news article about how the hospital or health system is going to turn around with Lean. The problem is […]

A Whiteboard Accident Waiting to Happen – How to Error Proof?

A Whiteboard Accident Waiting to Happen – How to Error Proof?

Yesterday, Jim Benson and I were facilitating a “Lean for Knowledge Work” class at Geekdom in San Antonio and had a great time with attendees from healthcare and high tech companies. We facilitated some “Lean Coffee” discussion sessions in a conference room. While the format is facilitated with sticky notes and pens, I noticed the […]

Parallels (and Differences) Between the Book “Traction” and Kaizen

Parallels (and Differences) Between the Book “Traction” and Kaizen

When I recently did a Healthcare Kaizen workshop near Detroit, I invited an old friend of mine to attend as a guest. Marisa Smith, an entrepreneur and business owner in Ann Arbor, saw the connections between my Kaizen work and a book that she uses within her company and with her clients: Traction: Get a Grip […]

By February 4, 2014 0 Comments Read More →
Medical Errors: The Names Change, but the Headlines Are Sadly the Same

Medical Errors: The Names Change, but the Headlines Are Sadly the Same

When I started blogging here in 2005, I was still about six months away from my transition from “lean manufacturing” to “lean healthcare.” It was mind boggling and disturbing to me to learn about the healthcare quality and patient safety crisis (something I had been oblivious to being healthy and not having a family member […]

By January 29, 2014 5 Comments Read More →
Learning Not to Blame: “Jerk Bartender”

Learning Not to Blame: “Jerk Bartender”

In the Lean methodology, building upon the teachings of Dr. W. Edwards Deming, we work hard to shift away from “naming, blaming, and shaming.” Dr. John Toussaint is one of many who provide alternatives to the “blame and shame” approach that’s, sadly, so common in healthcare. When I teach about focusing more on fixing systems […]

By November 21, 2013 4 Comments Read More →
My Medication Error on Myself

My Medication Error on Myself

Thankfully, it was nothing harmful or that dangerous… but I committed a medical mistake on myself last Saturday. I tweaked my lower back last Wednesday – something that, thankfully, isn’t a chronic problem (but I did just turn 40). It got progressively more painful over the next few days, so I went to an urgent […]

By November 15, 2013 5 Comments Read More →
Talking about Lean Healthcare in Winnipeg – #SDEC13 – and Visiting St. Boniface General Hospital

Talking about Lean Healthcare in Winnipeg – #SDEC13 – and Visiting St. Boniface General Hospital

Thanks to the organizing sponsor Protegra and other sponsors, including my friends at LeanKit, for having me give a keynote talk about the Software Development and Evolution Conference (SDEC) 2013 Conference in Winnipeg yesterday (Storify summary here). I always enjoy being around a group of developers (it dredges up memories of my childhood coding on […]

By October 22, 2013 3 Comments Read More →
Some Mature & Wise High School Students on Preventable Medical Errors

Some Mature & Wise High School Students on Preventable Medical Errors

Near home in San Antonio, I had a chance to volunteer last Friday, speaking for an hour to a group of high school juniors and seniors who are part of the health professions  program  within in the Alamo Academies program that prepares students for careers in areas including aerospace and manufacturing (companies like Boeing, Lockheed […]

By October 15, 2013 4 Comments Read More →
SF General Adopts Lean, Faces a Big Test with a “Never Event”

SF General Adopts Lean, Faces a Big Test with a “Never Event”

They just started a year ago (better late than never?), but San Francisco General Hospital had its Lean efforts highlighted in the San Francisco Chronicle last week: “S.F. General following ‘Toyota Way’ to efficiency.” On the very same day, another headline flew past about a patient who had wandered off and gotten lost in the […]

By October 14, 2013 0 Comments Read More →
Management Improvement Carnival #197: Lean & Deming

Management Improvement Carnival #197: Lean & Deming

Again, I’m very happy to host the Carnival for  John Hunter  and his  Curious Cat management improvement blog. My job here is to share some noteworthy and thought provoking posts from the past few weeks from the blogs I try to keep up with regularly. I hope you’ll discover a new blog or two (or […]

Blame the Worker or the System – British Airways Engine Covers

Blame the Worker or the System – British Airways Engine Covers

I flew back safely from Finland on Saturday – or I should say British Airways and American Airlines flew me safety, including in the 747 pictured at left. 15 hours across three flights. It was a long day. But, I wasn’t really worried about my safety because of the great track record that the aviation […]

Negligent People or a Bad System Leading to Surgical Errors?

Negligent People or a Bad System Leading to Surgical Errors?

A woman has the wrong side of her brain operated on. The headline features the hospital’s name and the surgeon’s name. It seems the “name, blame, and shame” process has begun. SSM Health Care St. Louis, Dr. Armond Levy face lawsuit after wrong-side brain surgery In complex systems, like healthcare, is it overly simplistic to […]