My guest for Episode #409 of the Lean Blog Interviews podcast is Ritsuo Shingo. I first met Mr. Shingo at the Shingo Institute Annual Conference in 2009 when my book Lean Hospitals received the publication prize that’s named after his father, Shigeo…
Before I get into this post, I want to also point you to another post that I wrote for the Value Capture blog: Salem Health Presentation on Their Covid Vaccination Process and Lean Now, on to the injection mistakes discussion.…
TL;DR: Blaming “human error” is where root cause analysis goes to die. Keep asking why — the system made the error possible, and the system is what leaders can fix. When Covid vaccines first rolled out, the pressure to avoid…
TL;DR: When the wrong house gets demolished–again–it’s not a rogue worker problem. It’s a system and verification failure. Blame doesn’t prevent recurrence; better process design does. I can’t believe I’m writing about this again. But, I saw in the news…
Here is a story that was sent to me by a blog reader, who needs to remain anonymous. I know the blog reader fairly well and believe what’s written here to be true. The blog reader is a career-long Lean…
Joining me for episode #354 of the podcast is Kim Hollon, the CEO and President of Signature Healthcare, based in Brockton, Massachusetts. I first met Kim about a decade ago and, as we discover during the podcast discussion, one of…
Many of you have asked if I’m at the AME Conference this week in Chicago. I am not, as I had a previous invitation to speak at the Swiss Lean Conference today. My theme was Kaizen — engaging everybody, everywhere,…
t;dr: A visit to Toyota’s North American headquarters offered more than a virtual plant tour. It revealed how Toyota blends the Toyota Production System, Lean leadership, and learning from crisis to build trust, improve communication, and continuously improve–inside and outside…
tl;dr: I recently returned from my first visit to Brazil, where I spoke at a Lean Six Sigma conference, led a workshop on Process Behavior Charts, and visited two organizations applying Lean principles. From churrascarias to Gemba walks, this trip…
This past weekend, an old friend came down from Michigan to spend two days in the Dallas area. Amongst the activities and catching up, we went bowling — something I did a lot of as a kid and something my…
tl;dr: High-profile “never events” aren’t caused by careless clinicians–and they aren’t prevented by warning signs. Signs that tell people to “be careful” substitute reminders for real system design, error-proofing, and a culture that makes it easy to do the right…
TL;DR: A non-standard calendar layout caused me to book the wrong tour date. When the same mistake happens repeatedly to different people, it’s not a personal failure–it’s a system design problem. Standardizing calendars and using mistake-proofing (poka-yoke) reduces errors far…
