Tag: Blame

[Updated] Somebody *Did* Get Unjustly Fired in Hawaii, But System Problems...

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The official report is out in Hawaii after the traumatic accidental missile warning that was sent last month. An employee was fired. The leader accepted responsibility and resigned. Why are others being punished?

Podcast #297 – JJ Villarreal, Ed.D. on #Lean in Public Education

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My guest for Episode #297 is John (JJ) Villareal, Ed.D., the superintendent of the Rockwall I.S.D. here in the Dallas area. In this podcast, we talk about the applications of Lean in education, how to move beyond what JJ calls "the behavior waste of judgment and blame," and how visiting a factory was inspiring and helpful, among other topics. Even if you don't work in education, I hope you'll be inspired by this podcast.

The Response to the Hawaii False Alarm Can’t End With Firing...

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Saturday, you might have seen the news about a "false alarm" push alert that was sent to many iPhones and other smart phones in Hawaii. An alert was also sent out over many TV channels through the Emergency Response System. Is the response one that focuses on blame and punishment? Or is it focused on understanding how systems fail and how to improve them to prevent future recurrence? How does this all apply to your organization?

“Our Hospitals Are Killing Us” – From a 1966 Magazine

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Three or four months ago, in the midst of a discussion on LinkedIn about patient safety, somebody made reference to a 1966 cover story...

A Lesson From Toyota: Thanking Employees for Pointing Out Problems

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Thanks to Lean Frontiers for sharing a story from Mike Hoseus on LinkedIn. Mike is, of course, co-author of the excellent book Toyota Culture: The Heart and Soul of the Toyota Way (written with Jeff Liker, who I just learned is retiring from the University of Michigan... more on that soon).

My LinkedIn Article: Supply Chain Matters – at the Oscars® and...

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The mistakes at The Oscars were trivial and unimportant in the grand scheme of things. What are some lessons learned that apply to improving healthcare supply chains?

The United Flight 3411 Mess, Holding Individuals Accountable vs. Fixing the...

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I posted this on LinkedIn earlier today and am re-posting as a blog post to get your thoughts... and then, as I writing this, the news about the man being forcibly removed from a United Airlines flight went viral.

Learning Not to Blame: Spring Training Baseball Edition

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Lean thinkers do their best to avoid blaming individuals for systemic problems. This lesson comes also from W. Edwards Deming who was deeply influential...

#TBT: Don’t Blame the Kicker, Don’t Blame the Oscar Presenter, and...

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Today's Post in <50 words: Lean thinkers don't blame individuals who are in a bad system, whether that's a presenter at Oscars, a kicker in a football game, or a healthcare professional in a hospital.

Without Kaizen, There Can Be No Accountability

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During the class, there was a case study discussion about a hospital that was trying to solve the problem of nurses not always scanning patient bar codes and medications 100% of the time. In the discussion, I was disappointed that an attendee fell back on saying...

The Oscars, An Embarrassing Preventable Error, #Lean, and Process Improvement

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Alternative headline: “Poorly Designed Card Trips Up Beatty and Dunaway at The Oscars.” Or “A Bad Process Beats Warren Beatty Every Time.” What are the Lean lessons from this mistake?

Exposé About Detroit Medical Center, Dirty Surgical Instruments, Dysfunction, and… Lean?

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A number of you emailed me about this report in the Detroit News. I grew up in Detroit and my first job was as...