Tag: Just Culture
No, You Can’t Have Too Much Psychological Safety at Work
TL;DR: Claims that workplaces can have "too much" psychological safety are based on a flawed definition. Psychological safety doesn't eliminate accountability--it enables speaking up,...
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...
How Japanese Hospitals Use Toyota Thinking to Improve Patient Safety
TL;DR: Two Japanese hospitals improved patient safety by combining Toyota-style problem-solving with psychological safety. By making it safe for staff to report problems and...
What a Hospital President Says About Lean, Respect for People, and...
TL;DR: A hospital president explains how Lean healthcare leadership, Respect for People, and Just Culture help engage frontline staff, reduce blame, and improve patient...
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...
