What Makes a Hospital Great? Culture
This has been sitting in my “to blog about” queue since March, but I wanted to catch up and post this article: “What Makes a Hospital Great” by Dr. Pauline Chen. Maybe it’s not very “lean” of me to have…
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.
This has been sitting in my “to blog about” queue since March, but I wanted to catch up and post this article: “What Makes a Hospital Great” by Dr. Pauline Chen. Maybe it’s not very “lean” of me to have…
This one got stuck in the “stuff to blog about” pile for a few months, but HBR published a gem of an article called “How To Stop the Blame Game.” Dr. Deming always talked about how destructive blame could be,…
In the news yesterday, a General Motors recall over what could be just one isolated steering wheel problem in an Ohio-built Chevrolet (don’t call it Chevy) Cruze. Most news stories, like this one, about the recall just mention that one…
Today, I’m sharing a brilliant Slate.com interview: “Risky Business: James Bagian “NASA astronaut turned patient safety expert” on Being Wrong.” He’s actually also an engineer and an anesthesiologist. An impressive background and impressive thinking. I will share a few highlights…

So Monday’s blog post was about preventable medical errors – namely errors involving pharmacies giving the wrong meds or wrong doses to patients. That’s not rocket science – it’s a clearly preventable error. But it’s also something to not blame…
A few weeks ago, I saw a horrific story about a retail pharmacy error in the article “Pharmacy Mistakenly Gives Pregnant Woman Abortion Pill.” Mareena Silva was mistakenly given the wrong drug by her Safeway pharmacy, which means she might…

Episode #113 is a discussion with Aubrey Daniels, PhD, the founder and chairman of his firm Aubrey Daniels International. Today, we are talking about his most recent book titled Safe By Accident?, a book I really enjoyed. So I was…

I really enjoyed having the chance to be in Cincinnati yesterday to participate in a Lean Healthcare workshop put on by TechSolve, a non-profit consultancy that teaches process improvement methodologies, including Lean, across multiple industries. We had well over 100…

Jeffrey Liker explains why Toyota’s recalls were not a failure of the Toyota Way, but a breakdown in listening, speed, and customer understanding. The episode explores how Toyota used rigorous problem-solving to learn from crisis and emerge stronger. Episode #111…

I got a question via Twitter yesterday from somebody who asked how to help production operators make the case to supervisors that their kaizen ideas should be implemented. My response was that the supervisors are the ones you need to…
I received a question from a reader, a retiree from a manufacturing company who is now a volunteer for a healthcare organization. We have exchanged messages before about opportunities to apply Lean thinking in a faith-based mission-driven organization like this,…
Short post today, but a simple message, I think. One of the best lessons I’ve learned about Lean management is about the need to ask “why?” Don’t assume, don’t blame – ask why. It’s a very common situation in a…