Tag: Blame
Accountability in Leadership: A GM Flashback on Blame, Fear, and Culture
TL;DR: A GM flashback shows how blame-based, command-and-control leadership destroys accountability instead of creating it. Real accountability starts at the top--when leaders model learning,...
Just-in-Time vs. Short-Term Thinking: What Really Caused Supply Chain Failures?
True Just-in-Time (JIT) is about short, stable supply chains, production leveling, built-in quality, and long-term thinking--not zero inventory. What many companies practiced instead was...
Wrong-Side Surgery and the Pressure to Cover It Up: A Patient...
TL;DR: Wrong-side surgery is a system failure, not just human error. Fear, silence, and lack of psychological safety allow mistakes to be hidden--making repeat...
Stop Blaming Workers: How Psychological Safety Prevents Harm and Improves Safety
TL;DR:Blaming workers after mistakes makes organizations less safe. Psychological safety shifts the focus from "who failed" to "what in the system allowed this to...
Being Logical and Kind When a Mistake is Made
In this post, I'm going to share some reflections from one of my workplaces, some things that occurred last week. I'm going to be...
When Hospitals Punish Necessary Workarounds Instead of Fixing Broken Systems
TL;DR: When staff invent workarounds to cope with shortages or failures, the real problem isn't their behavior--it's the system leaders allowed to fail.
This blog...
Third Time’s the Charm for the Iced Tea — On Errors,...
This past weekend, an old friend came down from Michigan to spend two days in the Dallas area.
Amongst the activities and catching up, we...
The Academy Awards Add an Inspector, Practice “Andon Cord Pulls,” Avoid...
Tomorrow, my post will be about headlines that scream about ratings for The Oscars being "down from last year" or "the lowest in X years." As I've blogged about before, I'm always skeptical of such simplistic comparisons that might mask the real underlying trend.
But first, could the Academy avoid last year's embarrassing mixup?
Lessons from NUMMI’s 10th Anniversary Book: Respect, Teamwork, and Lean Leadership
I did manage to buy a book that was published by NUMMI to celebrate their 10th anniversary. "10 Years of Quality & Teamwork" is the title.
Here is the cover and I'll share a few things that caught my attention inside. It's interesting to think through this book in the context of :
Tesla (the current owners of the building - see my past blog post)
Healthcare organizations
Somebody *Did* Get Unjustly Fired in Hawaii, But System Problems Should...
The official report is out in Hawaii after the traumatic accidental missile warning that was sent last month. An employee was fired. The leader accepted responsibility and resigned. Why are others being punished?
Podcast #297 – JJ Villarreal, Ed.D. on #Lean in Public Education
My guest for Episode #297 is John (JJ) Villareal, Ed.D., the superintendent of the Rockwall I.S.D. here in the Dallas area.
In this podcast, we talk about the applications of Lean in education, how to move beyond what JJ calls "the behavior waste of judgment and blame," and how visiting a factory was inspiring and helpful, among other topics.
Even if you don't work in education, I hope you'll be inspired by this podcast.
The Response to the Hawaii False Alarm Can’t End With Firing...
Saturday, you might have seen the news about a "false alarm" push alert that was sent to many iPhones and other smart phones in Hawaii. An alert was also sent out over many TV channels through the Emergency Response System.
Is the response one that focuses on blame and punishment? Or is it focused on understanding how systems fail and how to improve them to prevent future recurrence?
How does this all apply to your organization?
