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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