Tag: Blame

Blame, Accountability, and Leadership in Lean

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.

3 Reasons the General Public Doesn’t Think Healthcare Can Improve

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Lean thinkers see the waste in healthcare when they are at the hospital "gemba". I think this is true whether you are a Lean...

Reader Question: Rapid Response Teams (Oops, We Don’t Have the Items)

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I received an email from a reader that I'm sharing and commenting on with permission. "Dear Mark: I am a lean coordinator for a manufacturing...

A First-Person Lean Leadership Story from John Toussaint, MD

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I've had the pleasure to work with Dr. John Toussaint, CEO of the ThedaCare Center for Healthcare Value, over the past year.  John's...

Guest Post: What It Means

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Mark's Note: Here's part 4 of a series by our guest blogger, Andy Wagner. Start reading with Part 1 here. "What lies behind us...

Guest Post: Lean Lessons from the Non Profit World

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Mark's note: I consider myself very fortunate to have met Patrick Anderson during my journeys in the Lean world. Patrick is the executive director...

Everyday Lean (or Not): Whole Foods and an Herbal Near Miss

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Saturday morning, as part of my preparation to cook for a brunch gathering (I really enjoy cooking as a hobby, for those who don't...

Exceptional Efforts in Imperfect Circumstances – Celebrated or Lamented?

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Here's a thought starter for a Monday morning - I'm looking forward to hearing your perspectives. A few weeks ago, I heard a leader...

Is Ford’s Resurgence Due to a Less Blame-y Culture Under Alan...

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Mark's note: It's great to welcome Andy Wagner back to the blog. Read his older posts here. General Motors, Chrysler, and Toyota have been dominating...

Of 777s and Heart Rate Monitors

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In recent years, healthcare has been learning a lot of lessons from aviation -- including checklists and "Crew Resource Management," as written about in...

How the Olympic Gold Medal Puck Was Almost Lost — A...

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TL;DR: The Olympic gold-medal puck was almost lost not because of bad intent, but because the system relied on people remembering under chaotic conditions....

Detroit Firefighter Not Thinking, Parks on Train Tracks

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We had a lot of spirited debate last week around the case of the pharmacist who was jailed after the tragic medical-mistake death of...

A Pharmacist’s Jail Cell Interview – What Good Does Blame Do?

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Here's one to ponder and comment on - does putting a pharmacist in jail for six months and ruining his career and life do...
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