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Relying on Memory Leads to Rework

Biden Takes Shot at Roberts for Flubbing Presidential Oath – First 100 Days of Presidency – Politics FOXNews.com On Tuesday, Chief Justice John Roberts appeared to flub his giving of the presidential oath of office, leaving out the word “faithfully”…

Yes, We Can… but by What Method?

TRANSCRIPT: Obama’s Inaugural Address: I guess this is a “mashup” of sorts… between Dr. W. Edwards Deming and President Obama… The President said yesterday, in his inauguration speech: “We will … wield technology’s wonders to raise health care’s quality and…

Naida Grunden and Lean Healthcare

The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods Below is a guest post from fellow author and Lean Healthcare practitioner, Naida Grunden. Her book (linked above) is an outstanding collection of principles and case examples…

Using Lean Simulations to Spur Emergency Room Improvement

Institute for Healthcare Improvement: Getting Lean in the ED Here is a story that includes examples of Lean improvements at Rockford Health System in Rockford, Illinois. “The simulation embodied the difference between a classroom lecture and a psycho-motor experience,” explains…

Management Improvement Carnival #29

It’s once again my pleasure to host the Carnival for John Hunter and his Curious Cat blog. Please submit your favorite management posts to the carnival. Read the previous management carnivals. Coconuts, Bamboo, and Pedal Power (Mike Wroblewski, Got Boondoggle?)…

This Story Gets It Right On Healthcare Errors

‘It’s never just one thing’ that leads to serious error – Los Angeles Times This is a stunning headline, it’s pretty amazing (in a good way) to find an article that doesn’t focus on blaming individuals. “It’s never just one…

Yes, Standardized Work Saves Lives

‘Bundling’ hospital processes may help prevent infections – USATODAY.com “Bundling hospital processes” = Standardized Work Why isn’t every hospital doing this? Why isn’t every hospital administrator making sure this is happening? The IHI [Institute for Healthcare Improvement] defines bundling as…

A Defect in My Morning Coffee Routine

I could have also titled this post “I screwed up!” or “Who Screwed Up? Me!” but we try not to point the finger of blame in the Lean mindset…. it’s especially uncomfortable when you have to point it in the…

Lack of CT Scan Error Proofing Leads to Death

WOAI: San Antonio News – Woman Dies after Medical Mistake at CTRC An 81 year-old woman died tragically after she was injected with 100cc of air instead of contrast die before a CT scan. The documents also state, “Found to…