Tag: Blame

The Worst Root Cause Problem Solver in the Animal World Is…...

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We all know the beaver is "the engineer of the animal kingdom." That's why MIT has a beaver as a mascot... it's an engineer...

My Thoughts on “10 Ideas That Hospital and Health System CEOs...

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I saw this piece by Bob Herman at Becker's Hospital Review and ended up writing a blog post here instead of writing a long...

Podcast #203 – Chris Jerry, Part 1, on the Death of...

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Listen My guest for Episode #203 (and for Part 2 of our discussion in episode #207) is Chris Jerry, founder of The Emily Jerry Foundation.  The...

The Real #VAscandal is the Long Waiting Times & Bad Management,...

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Look at the System, Not the Individuals I've been wanting to blog about the "VA Scandal," but have avoided it because it is somewhat politicized (as...

Blame: Human Error Occurs Even IF We’re Being Careful

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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...

Learning Not to Blame: Baseball Edition

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Following up my post about not blaming a bartender, here's another look at learning to cast aside our old habit of blaming individuals... this...

Lean Thinking: We Don’t Blame Individuals for Systemic Errors

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I saw this video last night on Paul Levy's blog and it's important enough that I want to share it here with a few...

Is it Lean’s Fault or the Old Management System’s?

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It's easy for an organization to say they are "doing Lean" or they have "started a Lean transformation." They might hire a consultant or...

A Whiteboard Accident Waiting to Happen – How to Error Proof?

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Yesterday, Jim Benson and I were facilitating a "Lean for Knowledge Work" class at Geekdom in San Antonio and had a great time with...

Parallels (and Differences) Between the Book “Traction” and Kaizen

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When I recently did a Healthcare Kaizen workshop near Detroit, I invited an old friend of mine to attend as a guest. Marisa Smith, an...

Medical Errors: The Names Change, but the Headlines Are Sadly the...

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When I started blogging here in 2005, I was still about six months away from my transition from "lean manufacturing" to "lean healthcare." It...

Learning Not to Blame: “Jerk Bartender”

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In the Lean methodology, building upon the teachings of Dr. W. Edwards Deming, we work hard to shift away from "naming, blaming, and shaming."...
"The Mistakes That Make Us" Receives Shingo Publication Award!Learn More
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