tl;dr: Shingo renamed “foolproofing” to poka-yoke (mistake-proofing) after the old term made a worker cry. The lesson holds: blame doesn’t prevent defects, and respecting people is what makes zero defects possible. I’m currently working on a Mistake Proofing class for…
Thanks as always to Ryan McCormack for this… there’s always so much good reading, listening, and viewing shared here by him! Get these directly from Ryan via email. Insights about improvement, innovation, and leadership… Operational Excellence, Improvement, and Innovation What’s…
TL;DR: Medication and vaccine errors don’t happen because people are careless–they happen when systems make mistakes possible. This post looks at COVID vaccination examples to show why mistake-proofing, good process design, and psychological safety are essential to preventing harm in…
In this Lean Blog Podcast episode, Tom Peters reflects on leading through the chaos of COVID-19. He shares why people-first leadership, training, kindness, and trust become non-negotiable during crisis. I’m really excited to be speaking to my guest for Episode…
Thanks as always to Ryan McCormack for this… Healthcare – Creating Value for Patients Customer Experience practices are being more widely adopted in healthcare. Patient satisfaction surveys are no longer enough to put the patient experience at the centre of care.…
Healthcare – Creating Value for Patients It’s been more than 10 years since Atul Gawande wrote The Checklist Manifesto, showing the world that a simple 2-minute checklist prior to surgery resulted in fewer deaths. Adoption is “pretty spotty”, and in…
Joining me today for Episode #329 of the podcast is Mike Eisenberg, the director, editor, and producer of the film “To Err is Human,” a documentary about the incredibly important issue of patient safety. The film shares a title with the…
Healthcare – Creating Value for Patients The benefits of Electronic healthcare records are a polarizing topic with healthcare providers. Standardization and electronic workflows have their upsides, but many are developed to optimize billing and payments, and are not designed with…
I bet the company that services my pool was surprised that I had a checklist-related process improvement suggestion for them after a mistake was made instead of being angry and wanting somebody punished or talked to...
Last week, I received a few questions from somebody at a hospital system and I thought I'd address one of them here: "Can you suggest any "quick wins" to get staff engaged in a Lean culture?"
Aviation lessons for patient safety anchor this conversation with Steve Montague, a retired Navy fighter pilot and commercial airline pilot who consults with hospitals on high-reliability practices. We get into checklists done well and done badly, why most hospital mistakes…
Alternate title: “Lean is an Integrated System. Of Course Just Implementing Pieces Leads to Failure.” Throughout the 10 years that I’ve been involved with Lean healthcare efforts, I’ve heard multiple stories of organizations that ended their formal Lean initiatives. They do so, as I’ve been told, because they need to cut costs...
