Patient safety doesn’t improve through punishment, vigilance posters, or telling people to “be more careful.” It improves when leaders design safer systems, support speaking up, and focus on learning instead of blame. This archive brings together blog posts, podcasts, and reflections on patient safety through a Lean lens—exploring medical errors, near misses, psychological safety, leadership behaviors, and how healthcare organizations can reduce harm by fixing systems rather than blaming individuals.
It's tempting to visit a place like ThedaCare and then mandate "everybody must have huddle boards." Then, a bunch of huddle boards get purchased and installed... and maybe not used. It's another thing for executives to realize that they have to change the way they manage. There's a great quote that ThedaCare folks readily share, including Kim Barnas in her book Beyond Heroes:
In healthcare, it’s a well-known problem that people often don’t speak up to point out risks or to report near misses. It’s an organizational culture problem… people are afraid of being blamed, punished, or retaliated against for speaking up. A…
tl;dr: A sushi company’s safety and quality policy illustrates what hospital operational excellence really requires: visible leadership commitment, daily practice, and systems that make safety the default–not a slogan. I love the Texas-based grocery store chain “Central Market.” It’s basically…
As I wrote about last month, I love newspapers, so I felt like I fit into the culture last week when I spent five days of my vacation in London, a city I really love. People in England seem to…
Wednesday was the first day of the 6th annual Lean Healthcare Transformation Summit, being held this year in Addison (Dallas), Texas. I’m here and this year my colleagues Dr. Greg Jacobson and Jeff Roussel from KaiNexus are attending, so please say hi…
There’s been a back-and-forth of views about the state of pediatric emergency medicine recently in the Wall Street Journal. Let me start first, actually, with the more recent statement, a rebuttal from Michael Gerardi M.D., FACEP, President of the American College of Emergency…
Following up on yesterday’s post on seemingly successful experiments with ACOs, here’s another article, from HBR, on “safety huddles” in healthcare: “How Every Hospital Should Start the Day“ I’ve seen some hospitals using daily safety huddles. It sends a powerful message…
You might be considered “wonky” for enjoying the topics discussed here at LeanBlog.org… but that’s fine. This is a safe environment for being wonky about Lean and improvement. From Vox.com, Sarah Kliff normally does a great job covering healthcare topics,…
As I sometimes do, I’m going to close out a bunch of browser tabs (which makes my Mac run faster) and I’ll do that by sharing some articles that caught my eye but maybe don’t merit full blog posts of…
Organizations put up slogans because they want to inspire better performance. The intent usually isn’t the problem. The problem is that slogans assume the issue is with workers’ effort or attitude rather than with the system they’re forced to work…
Mark’s Note: I met today’s guest blogger, Gus Lusack, when I was working with a hospital pathology department in the British NHS. Gus was the microbiology manager at the time and, while most of my engagement was in the core…
Every time I am in a hospital or clinic setting, one of the first things I do is get a pump or squirt of gel or foam from a wall-mounted dispenser to clean my hands. Or, I should say *try*…
