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


Screen Shot 2014-03-23 at 10.51.42 PMI 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. Therefore, we don't blame and punish individuals for things that are systemic problems. There is a high degree of overlap here with “Just Culture” and the modern patient safety movement.

What happened? One nurse misread a patient's glucometer, thinking it was high, when it was really low.

It would have been really easy for the hospital to “name, blame, and shame” the nurse and punish her. That's the common reaction before Lean thinking (or systems thinking) principles are introduced.

But, then a second nurse made the same error.

The initial reaction was still to want to suspend the nurse, pending an investigation.

The nurse said, “I was talked to like I was a five year old. I wasn't talked to like I'm an adult.”

There's that “respect for people” notion again… or lack thereof. We can do better. We can (and must) treat adults like adults.

A nursing director pushed back on suspension and called in the “human factors” department to look at the process. There was a design issue that contributed to the process, they said.

Not surprisingly, the video references the “Just Culture” approach. “You can't fault any one individual… that's a process problem that needed to be addressed.” They took away the threat of discipline and it helped the nurse regain her confidence (since she felt horribly about the error).

We show respect for future patients… by ensuring their safety… and that means treating nurses and professionals with respect. People are then more likely to come forward about near misses and other safety risks… so we can work together to get things fixed.

We need to make sure this is part of our “Lean transformation efforts.” Medstar is an organization that uses “Lean Six Sigma” as a methodology.  Thanks for their leadership on this front.

This shift in thinking is just one reason why nurses (and their unions) should support and embrace Lean healthcare.

Two of my favorite quotes:

“Human error is inevitable.  We can never eliminate it.”  We can eliminate problems in the system that make it more likely to happen.”

– Sir Liam Donaldson
WHO World Health Alliance for Patient safety


“You respect people, you listen to them, you work together. You don't blame them. Maybe the process was not set up well, so it was easy to make a mistake.”

– Gary Convis, Toyota

It's good thinking and it's the right thinking for nurses, patients, and safety.


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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. Mark Graban says

    Here’s an article I saw over the weekend:

    Errors made by nurse at Yeovil District Hospital were so serious others thought he was ‘not qualified’

    A nurse can be blamed for being poorly qualified.

    But, system issues include:

    – the process for selecting the temporary nurse agency (did they choose the cheapest one?)
    – the process for hiring a temporary nurse
    – the hospital’s process for on-boarding a temporary nurse
    – the hospital’s reaction (or lack thereof) to reports that the nurse might not be very good

    The nurse, in this case, was accused of not completely hourly rounding activities with patients. This is often a systemic issue caused by lack of time (overburden).

  2. Michael Lombard says

    I’m glad that in Annie’s story they did realize that it was a systemic issue at play and avoided the blame game with the nurse. However, it’s a little disturbing that in healthcare we often act as if it’s some sort of amazing revelation that “Oh, maybe it’s not all the nurses’s fault and maybe the system is flawed.” This should be a default mindset. Even if a Just Culture algorithm identifies at-risk or reckless behavior, we should still assume that there are opportunities to improve the system (in addition to addressing improper nurse behavior). Sometimes I get the feeling we’re waiting for a nurse to be “proven innocent” before looking for systemic failures.

    1. Mark Graban says

      The common healthcare mindset is to assume that an individual is fault “until proven otherwise.”

      I think Lean thinking assumes it’s the system unless proven otherwise.

      The Just Culture algorithm almost always ends up with the system being at fault.

      A traditional system says “it’s the worker’s fault, they are a bad worker, so re-train them.”

      Just Culture would say that the need to re-train (if training wasn’t done right the first time) is a system problem.

  3. romicom says

    Lean Healthcare aims at achieving zero defect as much as humanely possible. The costs can be devastating as the end of the process is human. Not only medical costs but losts of lives should be minimised to the minimum. Processes should improve continuously to limit problems occurring. A way to improve systems could be to have an open environment whereby near-misses are addressed promptly by the management. The problem in the public sector is that it is quite monolithic. SOP are defined and taken as biblical by the staff. This gives less initiative to managers. Beside the culture of `naming and shaming` tends to defeat the culture of openness that should prevail. Healthcare workers would try by all means to hide their mistakes by fear of being victimised. How to add flexibility and responsiveness to a system where decisions are centralised as that is the case in my health system?

  4. […] Graban shared a video in a recent post on respect for people that highlights a great example of how an organization shifted during an […]

  5. […] (forrás: Mark Graban, Lean Blog) […]

  6. […] most problems and errors and defects are not caused by “bad apples” or individuals. We don’t blame individuals for systemic problems. As Dr. W. Edwards Deming taught, most problems are caused by bad systems and processes. Improving […]

  7. […] In healthcare, most problems, errors, mistakes, and harm are caused by systemic factors, such as overburden, poor training, or other process problems. It’s not just Lean that believes and teaches this, but also see “Just Culture” as a methodology. It’s not fair to expect people to “be careful” in a bad system or when they are overburdened. Lean helps us move away from the traditional “name, blame, and shame” healthcare environment. This culture shift is not just the “nice” or “right” thing to do — stopping the blame game is the best way to protect patients and improve quality. Read more about this. […]

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