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.
I did manage to buy a book that was published by NUMMI to celebrate their 10th anniversary. "10 Years of Quality & Teamwork" is the title.
Here is the cover and I'll share a few things that caught my attention inside. It's interesting to think through this book in the context of :
Tesla (the current owners of the building - see my past blog post)
Healthcare organizations
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?
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.
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?
TL;DR: A 1966 magazine exposé documented widespread, preventable patient harm caused by system failures in American hospitals. While some areas have improved, many of the same problems–errors, infections, lack of transparency, and blame instead of learning–still persist today. Three or…
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).
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?
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.
Lean thinkers do their best to avoid blaming individuals for systemic problems. This lesson comes also from W. Edwards Deming who was deeply influential on Toyota. It’s easier said than done. Old habits die hard. We all sometimes find ourselves…
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.
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...
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?