Tag: Blame

10 Key Lean Mindsets for Factories, Hospitals, Startups, and More

10 Key Lean Mindsets for Factories, Hospitals, Startups, and More

Here’s my latest post for LinkedIn through their “Influencers” series. It might be old hat to readers of this blog, but I hope what I shared is useful for a wider audience that I have there. 10 Key Lean Mindsets for Factories, Hospitals, Startups, and More Feel free to comment there at LinkedIn or here […]

Throwback Thursday: A Lean Healthcare Conference From 2007

Throwback Thursday: A Lean Healthcare Conference From 2007

Back in 2007, I had my first opportunity to travel to England, a country I really love visiting. I had the chance to attend the “First Global Lean Healthcare Summit” that was produced by Dan Jones and the Lean Enterprise Academy. They actually have posted many of the slide decks from the Summit there on […]

Please Help with Research Topics – Understanding Variation & Reducing Blame

Please Help with Research Topics – Understanding Variation & Reducing Blame

OK, so it’s not the kind of scientific research that involves lab coats and microscopes, but I’m doing some research that I’d like your help with. I’m looking to do some research and some interviews for writing projects related to two different topics. Understanding Variation I’ve been working with Mike Stoecklein from the ThedaCare Center […]

“Accountability” Shouldn’t Mean Blaming People for Things Out of Their Control

“Accountability” Shouldn’t Mean Blaming People for Things Out of Their Control

“Accountability” is a word that’s easy to throw around in an organization. It’s often pretty meaningless (or not well understood). What does it really mean? People say things like: “We need a culture of accountability.” “We need to hold people accountable.” When I hear that phrase, I like to call time out and ask, “What […]

By February 23, 2015 4 Comments Read More →
#Throwback Thursday: Punishing and Jailing People for Patient Harm

#Throwback Thursday: Punishing and Jailing People for Patient Harm

Today is another “Throwback Thursday” post where I revisit posts from the past. Friday and Saturday, I’m going to be attending the “Patient Safety, Science & Technology Summit” in Irvine, California. I won’t be speaking, but I’ll be participating and networking in my role as a board member for the Louise H. Batz Patient Safety Foundation, […]

By January 21, 2015 0 Comments Read More →
A Hotel, Time Quotas, Systemic Problems, and Employees Not Having the Right Tools

A Hotel, Time Quotas, Systemic Problems, and Employees Not Having the Right Tools

I travel a lot and, thanks to my work, I’m pretty well attuned to the idea of not blaming individuals for systemic problems in an organization. Or, at least I try to be good about this. I’m human, so I slip up sometimes… like the time I wrongly blamed a bartender for a bad attitude, […]

By December 9, 2014 7 Comments Read More →
GM CEO Mary Barra Celebrates Employee Kaizen

GM CEO Mary Barra Celebrates Employee Kaizen

Time magazine recently featured GM’s relatively new CEO, Mary Barra, on the cover and in this story: “Mary Barra’s Bumpy Ride at the Wheel of GM“ I can’t find a free version of the story online. Here is a USA Today summary that says “Five things ‘Time’ revealed about GM CEO Mary Barra.” I’ve been critical […]

By October 13, 2014 1 Comments Read More →
Ebola & Systems & Processes: Can We Do Better? Can We Learn?

Ebola & Systems & Processes: Can We Do Better? Can We Learn?

Yesterday, Thomas Eric Duncan, the first person diagnosed with Ebola in the U.S. died in a Dallas hospital. As I’ve been following this story, I keep thinking about bad systems and bad processes. Sometimes, there’s a lack of planning and sometimes it’s a lack of proper execution, it seems. I’m not spending much time asking […]

Managing With Red/Green Charts is Like Driving By Looking at the Rear-View Mirror

Managing With Red/Green Charts is Like Driving By Looking at the Rear-View Mirror

There’s an expression that was used by Dr. W. Edwards Deming, and also by Dr. Don Wheeler, that says managing through metrics (and comparisons to targets) is like driving by looking in the rear-view mirror. Deming said: Taking action on the basis of results without theory of knowledge, without theory of variation, without knowledge about […]

By September 2, 2014 17 Comments Read More →
What I’m Reading: Diner Muda, No Blame at Etsy, Toyota Treats Cancer Faster, etc.

What I’m Reading: Diner Muda, No Blame at Etsy, Toyota Treats Cancer Faster, etc.

In case you missed it, see Saturday’s post: “Why Toyota is Eliminating the Andon Cord from its Factories.” As I occasionally do, today’s post is one where I’m going to close out some open browser tabs and post links to articles that I’ve been reading that are worth sharing (as I often do on Twitter), […]

3 Ways to React to Human Error

3 Ways to React to Human Error

What happens when a mistake is made in your organization? How do you react when an error occurs? A lab specimen gets mislabeled. The wrong product is shipped to the wrong customer. A patient is injected with the wrong medication. These are moments that matter. Does emotion take over or do we stay calm? How […]

The Worst Root Cause Problem Solver in the Animal World Is… Who?

The Worst Root Cause Problem Solver in the Animal World Is… Who?

We all know the beaver is “the engineer of the animal kingdom.” That’s why MIT has a beaver as a mascot… it’s an engineer who likes to build things and is generally nocturnal, an apt description of MIT students. A survey taken by the National Geographic Society has found that the owl, however, is the […]

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 for Part 2 of our discussion in episode #207) 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 […]

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. […]

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