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Tag: Blame

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 5 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 16 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 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 →