Tag: Just Culture

Thanks to Timothy R. Clark and Junior Clark for this excellent episode of their "Culture by Design" podcast from LeaderFactor: In the episode, they debunk...

Here is a story that was sent to me by a blog reader, who needs to remain anonymous. I know the blog reader fairly...

tl;dr summary: The blog post discusses the importance of reporting and solving problems for patient safety in Japan. It highlights stories from two hospitals...

This article made me smile the other day -- especially the comments about Lean, front-line staff, and systems: Q & A with Art Gianelli, president...

For a long time, I've been an advocate for the parallels between Lean and an approach called "Just Culture." See previous blog posts on this topic. Here's a good overview of Just Culture, which says, in part: "A just culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control. A just culture also recognizes that many individual or active errors represent predictable interactions between human operators and the system in which they work. However, in contrast to a culture that touts no blame as its governing principle, a just culture does not tolerate conscious disregard of clear risks to patients or gross misconduct, such as falsifying a record, performing professional duties while intoxicated, etc."

The cancelation of a meaningless NFL exhibition pre-season game is probably one of the least important problems in the world. But, it happened recently...

Listen: Episode #246 is my second episode in recognition of Patient Safety Awareness Week. My guest is Steve Montague, who talked about Lean and Crew Resource Management...

There’s no magic about the number five. I’ve seen some people write that five is somehow a “magic number.” No, that’s not really the case. Ask why more than once, probably more than twice…

In case you missed it, see Saturday's post: "Why Toyota is Eliminating the Andon Cord from its Factories." As I occasionally do, today's post is...

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...