Do you "Embrace your Misses?"


Another great thought from David Mann this week was highlighting how a Lean culture will “embrace it's misses” rather than try to cover them up.

His example was in the context of a production line not making it's production goal for a 30-minute time frame. Do you make excuses for why it didn't happen or do you consider the “miss” an opportunity to fix a problem?

We had a similar discussion in the context of using “near misses” to drive process improvement. I posed the example of how a nurse might catch, at the last minute, the error that the wrong drug (or wrong dosage) was nearly administered to a patient. I asked, “Do you hide that error or do you embrace that and figure out how things could have gotten that far? Sure, you caught the error next time, but what if you're not so lucky the next time?” We need to fix the root cause problems that led to the error and the near miss so we can avoid future near misses or future negative outcomes.

An experienced healthcare person in the room pointed out, “Many nurses would look at that scenario and say ‘see, the system worked, we caught the error.”

We have to re-train ourselves to realize that a “process error” is anything that goes wrong and could have been prevented, not just an error that causes harm to somebody.

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Mark Graban is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. His latest book is Measures of Success: React Less, Lead Better, Improve More. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. He also published the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus.

1 Comment
  1. robert says

    A great post highlighting how a lean culture can support the promotion of safe working practices. Safety has a direct impact on people, morale, work ethics, performance and cost. If a business has a good and well practiced safety strategy and culture, workers will operate at a higher level and perform more effectively, efficiently and add greater value through productivity and quality.


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