Blame is often mistaken for accountability—but in practice, it creates fear, silence, and surface-level compliance. These posts examine blame through a Lean and systems-thinking lens, showing how punishment-based responses undermine learning, psychological safety, and continuous improvement.
Across healthcare, manufacturing, aviation, and leadership culture, this archive focuses less on who to fault—and more on how leaders design systems that either encourage learning or drive mistakes underground.
Following up on the LEI survey that was released and discussed here, I’ve been talking with a few folks offline about what the “root causes” really are for Lean struggles. Instead of pointing at “who?” what would we find if…
Explosions rock downtown Dallas | Latest News | WFAA.com Working from home with this news on in the background, the massive gas cylinder explosions at a business near downtown Dallas, about 30 miles from my home. What jumped out at…
Woman dies in ER lobby as 911 refuses to help Click here for a more positive ER story posted on the same day… a UK hospital that used Lean to reduce ER waiting time dramatically… read this and think about…
How H-P Reclaimed Its PC Lead Over Dell – WSJ.com Today’s WSJ article doesn’t focus on the Dell layoffs (although it does mention them, as did the Evolving Excellence blog post on the layoffs), but rather the competitive dynamics between…
Chinese say U.S. shares blame in food scandal – USATODAY.com I’ve been tempted a few times to post about the pet deaths from contaminated pet food — the contaminated ingredients came from China. This article caught my eye last week:…
NPR : Reasons for GM Slide Go Beyond Work Force Honestly, I’d expect more from liberal NPR and their headline. You’d expect NPR to be the friend of the UAW “working man” (or woman), but I don’t appreciate how their…
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…
Toyota fears U.S. backlash over gains (Detroit Free Press article) I tend to fall on the side of those who think the “Detroit Three” are indeed scapegoating Toyota and that Detroit’s past and present horrible management mistakes are to blame,…
In the news: Charges against nurse igniting a debate This case — involving Wisconsin nurse Julie Thao — is still referenced in debates about whether medical professionals should face criminal charges for unintentional errors. A Fatal Medication Error — and…
… and the system sucks!” That was the final line of a recent episode of ER that we just watched last night (thanks to the DVR). The major focus of the episode was a patient in court with a claim…
This is an incredibly sad, and completely preventable, situation. Three babies are dead, and three more injured, because the wrong drug was administered to them at an Indianapolis hospital. Let’s keep in mind, first, this quote from the World Health…
State’s long disciplinary process doesn’t protect patients, critics say Here is a story about complaints with Florida’s disciplinary system for physicians. The system seems to be based very much on individual blame and punishment for things gone wrong. If an…