Tag: Just Culture
No, You Can’t Have Too Much Psychological Safety
Thanks to Timothy R. Clark and Junior Clark for this excellent episode of their "Culture by Design" podcast from LeaderFactor:
In the episode, they debunk...
What Didn’t Happen After This Preventable (and Potentially-Fatal) Medication Error
Here is a story that was sent to me by a blog reader, who needs to remain anonymous. I know the blog reader fairly...
From Silence to Safety: How Japanese Hospitals Learn from Toyota to...
tl;dr summary: Two Japanese hospitals have improved patient safety by combining Toyota's problem-solving methods with a culture of psychological safety. By making it safe...
What This Hospital President Said About Lean, Respecting Staff, and Just...
This article made me smile the other day -- especially the comments about Lean, front-line staff, and systems:
Q & A with Art Gianelli, president...
Are Hospitals Not Getting Any Closer to Having “Just Cultures?”
For a long time, I've been an advocate for the parallels between Lean and an approach called "Just Culture." See previous blog posts on this topic. Here's a good overview of Just Culture, which says, in part:
"A just culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control. A just culture also recognizes that many individual or active errors represent predictable interactions between human operators and the system in which they work.
However, in contrast to a culture that touts no blame as its governing principle, a just culture does not tolerate conscious disregard of clear risks to patients or gross misconduct, such as falsifying a record, performing professional duties while intoxicated, etc."
Did Bad Systems & Training, Weak Problem Solving, and Poor Supervision...
The cancelation of a meaningless NFL exhibition pre-season game is probably one of the least important problems in the world. But, it happened recently...
Steve Montague on Patient Safety, Checklists, and Lean Lessons from Aviation
Listen:
Episode #246 is my second episode in recognition of Patient Safety Awareness Week.
My guest is Steve Montague, who talked about Lean and Crew Resource Management...
Rethinking the Five Whys: Introducing the ‘Many Whys’ Approach in Lean...
There’s no magic about the number five. I’ve seen some people write that five is somehow a “magic number.” No, that’s not really the case. Ask why more than once, probably more than twice…
What I’m Reading: Diner Muda, No Blame at Etsy, Toyota Treats...
In case you missed it, see Saturday's post: "Why Toyota is Eliminating the Andon Cord from its Factories."
As I occasionally do, today's post is...
Blame: Human Error Occurs Even IF We’re Being Careful
I'm not sure why "error" was put in quotes since this seems like an actual error, not a quote-unquote error:
Staff 'error' blamed for chlorine...