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."...