Below is some material that I wrote, but didn’t use, in my book The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. Maybe it was a mistake to cut it. But the material wasn’t really related to…
As is often the case, I have too many open browser tabs full of articles that I was going to potentially blog about. This slows down my Mac (thanks, Chrome!). So, it’s time for me to clear out my backlog and…
Recent lessons from NICU innovation, primary care access, fan safety in baseball, and ongoing VA wait-time gaming This post is a collection of recent updates and follow-ups to topics I’ve written about before–spanning healthcare improvement, patient access, safety in sports,…
This article caught my attention the other day: “Philly VA employees ask for golf shirts in suggestion box for improving veteran care.“ I hesitate to throw stones, but there are some very predictable dynamics involved here… and I will provide…
=Following up on posts from Monday and Wednesday, we see this headline today: “Shinseki resigns after VA scandal.” As I wrote about on LinkedIn, instead of blaming “bad managers” or a “lack of integrity” at local VA sites, like Phoenix,…
TL;DR: Long VA wait times weren’t the result of “bad apples.” They were the predictable outcome of bad management systems that used unrealistic targets, bonuses, and fear-based accountability–creating incentives to game the numbers instead of improving care. Look at the…
When I started blogging here in 2005, I was still about six months away from my transition from “lean manufacturing” to “lean healthcare.” It was mind boggling and disturbing to me to learn about the healthcare quality and patient safety…
Today is Veterans Day in the U.S. and it’s also Remembrance Day in Canada, the UK, and the Commonwealth countries. The poppy pin is worn as a symbol of Remembrance Day (as I wore, at left, last week while in…
In honor of Veterans’ Day (in the U.S.) and Remembrance Day (in Canada, where I spent most of the last two weeks, often wearing a poppy pin), let’s pause to honor those who have served their country. Let’s also maybe…
You might have read my blog post from last week about an unsafe taxi driver and medical errors – Said the Unsafe Taxi Driver, “Well, Did I Hit Anybody?” In a colossal coincidence, the New York Times columnist Maureen Dowd…
Obama Awards Budget-Minded Federal Employee I saw this in the news yesterday about a federal employee from the VA, Nancy Fichtner, a clerk at the Grand Junction Veterans Medical Center. President Obama awarded her the “SAVE award,” which stands for…
VA Pittsburgh Healthcare System, Toyota Production System –> Dead Link Here is a nice succinct definition of the Veteran’s Affairs hospital production system in Pittsburgh. It draws on the work of Spear and Bowen and their “Decoding the DNA” definition…
