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It’s not unusual to see individuals get blamed for systemic errors and problems.

Case in point, this article:

Delta Air Flight Attendant Makes Expensive Mistake After Emergency Slide is Accidentally Deployed Shortly After Landing in Dublin

It seems like a fact that the flight attendant deployed the slide. But is the mistake their fault?

To read the article and comment, click here or leanblog.org/audio340.

This is an article that I wrote, published on the Quality Digest website.

It begins: "I can’t count how many times during the past 20 years I’ve heard executives complain that their people aren’t enthusiastically participating in their lean program. Leaders lament that while the company has spent a small fortune to put everybody through continuous improvement training, hardly anybody submits ideas. The problem isn’t their employees; it’s a cultural problem and, therefore, a leadership problem."

Blog Post

I was very excited to learn about an event that is being produced by GE, next Wednesday, September 6th, in New York City. I'm thrilled to have been invited to attend in person, along with other "Lean Influencers," including my friends Katie Anderson and Jamie V. Parker. We will be fortunate to be there in person to share highlights from the event via social media, blog posts, podcasts, and more -- on Wednesday and beyond.

See the LinkedIn Event page:

The Lean Mindset: The Pursuit of Progress

Blog post

From the post:

This is really hard to write, as I was stunned and saddened by the recent passing of a good friend and colleague, Chris Burnham. Word had started to spread on LinkedIn and I feel bad about having to share this news here.

You can read his obituary here:

There will be a celebration of life event on Sunday that I will be fortunate to attend. Chris was, most recently, the Senior Director of Lean Strategy at KaiNexus, a company I have been involved with since 2011. Many of his colleagues will also be there to pay our respects, to honor him, and to support his loved ones.

I say this with all sincerity that Chris was one of my favorite people in the Lean community. I appreciated his positive and thoughtful approach to Lean and to our work. We shared a love of discovering new Bourbons to share and discuss, which then lubricated the social fun and work discussions.

Christopher Burnham Obituary

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When you do work related to processes, quality, improvement, and learning from mistakes… the universe has ways of testing you (or playing a prank on me). As I share at the end of the post, I failed that test in one way. A big way.

My wife and I had a 3-piece sectional couch that we've recently replaced, so we were looking to donate the old one to a good cause.

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This is something from my book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation, that I shared on LinkedIn recently.

Here's something I figured out thanks to education in a combination of fields, including Lean management and psychological safety. I wish I had understood this much sooner:

“Speaking up isn't a matter of character or courage–it's driven by culture. People feel safe to share when their leaders and colleagues treat them with respect. Instead of asking people to be brave, leaders must create conditions where people can feel safe.”

Visit our website: https://leanblog.org/audio

Blog post

This post shares a story I heard at the Michigan Lean Consortium annual conference earlier this week. They've been kind about sharing ideas and doing a book club discussion around my new book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation.

During a book signing session at the conference, an attendee, Cori, told me a story that's too good to not pass along. I'll do my best to be true to the details of the story.

Blog post page

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 my podcast. It was based on some interactions with some Veterans Administration Health Care leaders after giving a talk on learning from mistakes last November.

What is culture?

Some say it's simply how we do things in this organization.

The late Edgar Schein, a famed MIT professor, wrote that we can observe and describe culture through artifacts, espoused values, and assumptions.

One example of an artifact is a small card given to me by a U.S. Veterans Health Administration site leader who is building a culture of learning from mistakes.  

On one side, the card said the holder was “free to fail.” The card framed a “FAIL” as the:

“First Attempt In Learning.”

An Artifact from a Veteran's Administration Healthcare Site

Blog post with photos and more

I was saddened to learn today that Masaaki Imai passed away, as announced this week by the organization he founded, KAIZEN Institute. He was 92.

Mr. Imai was well known for his books, including KAIZEN, his follow up Gemba Kaizen, and his latest, Strategic KAIZEN™ (published in 2021). He traveled the world teaching people about continuous improvement.

I'd like to first express my deepest condolences to Mr. Imai's family, friends, and colleagues.

I had the fantastic opportunity to meet Mr. Imai a few times -- once in Seattle when he was visiting and speaking at a healthcare organization, and twice during Japan study tours organized by Kaizen Institute. Thank you for your contributions to the world, Mr. Imai!

Read the blog post and get links

My new book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation, is still only in a draft state before final proofreading (actually, the proofreading is taking place now).

Trying to get some proof copies printed by Amazon sure does open up the possibility of mistakenly hitting "Publish Your Paperback Book" instead of "Save as Draft."

Blog post link

The following material was found on the “cutting room floor” for my upcoming book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. And I've supplemented it with some new material to flesh it out into a post.

Come to the live book cover reveal event tomorrow (Tuesday, May 2) if you can!

I've asked more than 215 people the same question (releasing 208 episodes to date):

“What's your favorite mistake?“

You might wonder why I seem to be so obsessed with this question. It's not because I love embarrassing people or because I want to gloat about the mistakes of others. I ask this question to learn and improve myself as a person and leader. 

The book and the podcast series are meant to be reminders that we shouldn't mock people for their mistakes. We shouldn't be too hard on ourselves, even if that's easier said than done.

Link to the blog post at Value Capture's website

As we explore concepts like psychological safety and Diversity, Equity, Inclusion, and Accessibility (DEIA) in this blog post series, I’d like to kick things off with a look at some serious problem statements that we must address. I’m thankful for the organizations, including Value Capture clients, who aim to close these performance gaps in systematic and sustained ways.

Episode page and blog post

If you're interested in my upcoming book (available June XX, date TBD), The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation, the Kindle edition is available to be pre-ordered now through Amazon!

The date is set as June 27th, but it will likely be available sooner. Amazon (and their KDP platform) make it easier to pull a date forward… and they punish you for pushing a date back.

The book will also be available at the same time in paperback and hardcover formats. I'm going to work on an audiobook version over the summer.

Amazon also makes it more difficult for me to make a paperback or hardcover book available for pre-order. But again, I think it will be on sale early- to mid-June.

You can also enter this contest to win a free signed copy of the paperback edition.

Blog post for this episode

Here's another reader question, this one received from The Netherlands, a country I have loved visiting over the past eight years (see my blog posts about the country and Lean healthcare efforts there).

Here is the question, in part:

Your work has been an inspiration here, so I started to research the origin and dissemination of lean in healthcare in the USA. Your first book, can be considered a standard work in this field and won a number of awards. But what I couldn't found in my search, was your motivation to write it. Can you please answer that for me: what triggers made you decide to start practicing lean in healthcare?

In a nutshell, here's the answer...

Blog post for the episode

I'm happy to announce that I've finished the manuscript for my upcoming book (a real one, not an April Fool's Joke).

The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation

It's taken about a year from saying, “I'm going to write a book based on the My Favorite Mistake podcast” to completing the book writing.

Blog post including a link to buy the book

Tomorrow is the 4th anniversary of the paperback release of my book Measures of Success: React Less, Lead Better, Improve More.

Long story short, I'm running a limited-time sale to celebrate.

Looking back to the release, I took an odd approach, perhaps, in that the eBook and Kindle version were available first, in August 2018, I think.

I wanted to test my hypothesis about people being willing to buy the book. Once I saw eBook sales start coming in (and getting positive feedback), I made the investment in getting the paperback book created (a professional page design and layout process). By the way, the phrase “self-publishing” is a misnomer. My company is the publisher, but I didn't do it myself!

For my next book, The Mistakes That Make Us, my company will be the publisher again, but the plan is to launch Kindle and paperback versions together at the same time. Probably this summer. But I need to finish the manuscript first! I'm almost there. That's my main focus these days, finishing that up.

Amazon has sold over 5,000 copies to date (a total of both formats). A relatively small number of books have been sold through other channels, including direct sales through me. One advantage of being the publisher is that I can see real-time data from Amazon and IngramSpark. For previous books, I have to ask my former editor to run a report.

Blog post

  This article caught my eye today, and it's a change of pace to think about and write about mistakes other than my own (and I made more today — but healthcare mistakes are more important).

Penn Medicine hospital cited over wrong-site surgery

It's a mistake to perform surgery on the wrong leg. Not an “unintended mistake” (which is redundant). All mistakes are unintentional. Intentional harm could be called sabotage or assault....

Read the post for this episode

Following up on my blog post about GE CEO Larry Culp's AME keynote speech, I wanted to share some of the discussion from his "fireside chat, absent the fire" (as Larry called it) with Katie Anderson (as we discussed in our podcast episode).

Blog post

It was a real treat to hear Larry Culp, the CEO of General Electric and CEO of GE Aerospace, speak at the AME 2022 annual conference in Dallas. He recently reached the four-year mark of his tenure as GE's first-ever outsider CEO (read the 4-year update that Larry posted on LinkedIn).

Below are some highlights and quotes from his 15-minute remarks, along with some of my commentary and thoughts.

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A culture of learning makes the difference, not "low inventory"

Last year, I wrote a post that criticized those, including the Wall St Journal, who claimed that Toyota was "abandoning" the Toyota Production System or that strategically adding some inventory meant they were moving away from "Just in Time" approaches:

Toyota leaders, including my friend Jamie Bonini, were quoted in this new article by HBS professor Willy Shih in HBR:

What Really Makes Toyota's Production System Resilient

Did TPS hurt Toyota during the pandemic?

NO

Blog post - https://leanblog.org/audio321

Elon Musk tweeted this yesterday: "Please note that Twitter will do lots of dumb things in coming months. We will keep what works & change what doesn't."

Blog post: http://www.leanblog.org/audio320

Contact me to talk about psychological safety - measure, learn, improve

“Simply put, we cannot get to zero harm without psychological safety.”

I wrote that as part of this page on the Value Capture website:

I've come to understand that psychological safety is a precondition for “implementing #Lean” or however you might say. Toyota seems to strive for (if not have) a relatively high level of psychological safety.

Episode #319 -- read the blog post that contains video of the webinar

A contractor unplugged my WiFi router.

Or was there more to it than that? Instead of blaming somebody else, what mistakes did I make that led to the Q&A section of my webinar being knocked offline?

Blog post: https://www.leanblog.org/audio318

The Wall Street Journal has an epic track record when it comes to always getting it wrong when they write about Lean or the Toyota Production System. They always focus on just the “just in time” pillar, ignoring “jidoka” (built in quality) as the other pillar (per Toyota). They ignore many other aspects of TPS, like the culture and the management style.

See some of that track record, including recent pandemic supply chain articles.

You're normally better off reading about Lean from the source.

But, they did better in this recent article about General Electric and CEO Larry Culp (who knows Lean very well from his time as CEO of Danaher):

Blog post: https://www.leanblog.org/audio317

Oh, how I enjoyed this article a month ago when it was sent to me. It's from 2003, but it was new to me:

Blog post: https://www.leanblog.org/audio316

I received a question from a healthcare leader who had read about the “idea card” format and method that Joe Swartz and I shared in our Healthcare Kaizen books.

She's asking about the “Kaizen” style and approach to continuous improvement.

I'll share some of my reply along with some relevant excerpts from the book.

Blog post: https://www.leanblog.org/audio315

I'm really excited to be hosting and moderating this webinar next week, the second in our new Value Capture Webinar series.

The title is "Applications of Lean Leadership Methods in Home-Based Care."

Blog post: https://www.leanblog.org/audio314

In this era of Covid--19 vaccination, I'm still pretty much sidelined and not on site with any clients, although I did get to visit two mass vaccination sites (in addition to the one that vaccinated me).

I have tried really hard to be a cheerleader for continuous improvement and, in particular, for sharing continuous improvement ideas through the free VacciNexus platform and through other channels.

I believe, of course, in the power of many, many small improvements being driven by front line staff and their managers. That's the focus of my Healthcare Kaizen books. I also realize there's a time and a place for process re-design and for being innovative (thinking of it as step-change improvement.

In this post, I share and discuss improvements large and small.

https://www.leanblog.org/audio313

tl;dr summary: Lean isn't just efficiency... it's safety, quality, delivery, cost, and morale. People often misunderstand that -- they don't know or they were taught the wrong things

I often have the opportunity to teach a group of experienced healthcare professionals, from a wide range of disciplines, about Lean. My session is part of a longer professional development program that's framed as "clinical outcomes and patient safety."

Lean has a lot to contribute to those outcomes, and you can see a collection of results here or here.

Since my last session had to be virtual, due to the pandemic, I took advantage of the opportunity to use some interactive tools from Mentimeter.com. This is something I'll continue doing even when I have the chance to teach in person, as people can vote or give input from their phones, anonymously, while sitting in class.

One question I asked the group was:

https://www.leanblog.org/audio312

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 vague, so forgive me for that. It feels right to be less specific in this case, or at least that's the cautious (and maybe respectful) thing to do.

When wearing one of my different "hats" with one of the organizations I work with, something went wrong. It wasn't something I did (or I would own up to that in specific ways). But the mistake affected me and the work I was doing.

When a preventable process problem occurs, the engineer in me finds it relatively easy to be logical and think through "what happened?" instead of "who messed up?" A few deep calming breaths help, as well.

http://www.leanblog.org/audio311

I'm not a Buffalo Bills fan (a.k.a. "The Bills Mafia"), but I did attend one game at what was then called Rich Stadium in 1998 when I was a grad school intern at Kodak.

Even without being a fan, I wish I could have written a headline for this post that said "Buffalo Bills Kaizen Their Way to a Super Bowl." Readers of this blog, of course, know that "Kaizen" is a Japanese word meaning "good change" and it's framed as an approach to engaging everybody in small improvements to the way they do their work.

So what does this have to do with football? Football is a workplace, even if it's college. I blogged about my alma mater, Northwestern University, using the word "Kaizen" (and the mindset) within their football program.

This article about the Bills isn't new, but I recently discovered it on Twitter:

From the article...

https://www.leanblog.org/audio310

During this "let's try to get people vaccinated" phase of the Covid-19 pandemic, almost every article that I've seen about the vaccine and its distribution mentions the need to not waste precious doses.

There are many opportunities for error with the different vaccines. If some of them aren't stored properly at the correct temperature, the vaccine degrades and gets wasted (or worse, gets injected and gives a false promise of effectiveness).

Good process design (lessons I learned as an engineer) means being proactive and thinking about what could go wrong -- and then designing the process in a way that prevents errors or mistakes. The ideal would be "error proofing" that makes it impossible to make a mistake.

Or, we could make it more apparent that a mistake has been made (for example, a temperature-sensitive label on a vaccine bottle that would let you know if it's been out of the correct storage temperature too long). A countermeasure like this might prevent the mistake of using expired vaccine.

But how can we prevent the storage problem (and the waste of the vaccine) to begin with?

I wasn't planning on blogging over the holidays, but this article caught my attention:

(See the full post at the link https://www.leanblog.org/audio310)

https://www.leanblog.org/audio309 

Subscribe now to "My Favorite Mistake"

You might have heard of a "social media takeover" where a brand with a large following gives control of their social media feed to somebody who is promoting a cause or a social message.

One person I've followed on LinkedIn is Deondra Wardelle. She is a Lean practitioner (like me) and she's a Black woman (unlike me).

So, thinking back to the idea of a "social media takeover." I was inspired by Deondra, so I asked her to accept a "blog handover" as I'm calling it. My initial thought was to give a platform for her to write and talk about anything she wanted, to give more exposure to her voice.

http://www.leanblog.org/audio307

Today, I wanted to share an excellent article written by Dr. John Toussaint (of Catalysis) and Ken Segel (of Value Capture)...

I'm excited to announce that our book Practicing Lean is now available as an audiobook through Audible.

As we did with the paperback and Kindle versions of the book, 100% of royalties will be donated to the Louise Batz Patient Safety Foundation (it's been almost $5000 so far).

You can buy or subscribe through Audible.

It's possible that I could start traveling again for my healthcare consulting work next month... or maybe in July. My colleagues at Value Capture aren't sure yet how this will work out, but clients are sharing their current plans for starting to re-open -- to a new normal, not the old normal.

As I mentioned (if not buried) in a post last week, my wife and I relocated from Orlando to Los Angeles last week because she is starting a new job (we will still have our permanent home in Texas).

Anyway, as the consultants start to think about traveling again, I have compiled some thoughts from my own research and experience since I'm the only one who has flown or stayed in hotels over the past two months, due to the relocation.

I had the good fortune to meet and spend time with Mr. O'Neill on a few occasions and I'll share some reflections in this post. My condolences go out to his family and friends, and especially to my Value Capture colleagues who worked with him at Alcoa or at the firm over the past 15 years.

Here are his obituaries from the WSJ, the New York Times, and the Pittsburgh Post-Gazette. You can also read more about his life on a memorial page that his family set up and people are sharing memories there.

http://leanblog.org/audio303

This is from the 3rd edition of my book Lean Hospitals. I've copied and pasted from the book with no additional edits, although I'll bold italic some parts for emphasis. I'll some closing thoughts at the end.

For a more complete PDF excerpt, click here (requires Dropbox access).

Thanks to Elisabeth and the team at GoLeanSixSigma.com for inviting me to contribute some thoughts in this piece:

But back to the one manufacturing company that inspired this post. It was great to see this article (hat tip to Brad Miller):

See more in the blog post (link at top)

She had a number of frustrations to share and she doesn't really have an outlet (and doesn't want her name out there for fear of retaliation). More importantly, this isn't about one institution. She works in a well respected system. So this lack of preparedness and leadership could be widespread. When I posted my concerns about hospital preparedness for Covid-19, I guess they weren't unfounded.

I'm sharing these concerns in a public way because I think it's important to try to inspire other healthcare professionals and improvement specialists who CAN be on site to drive improvements.

I also hope it serves as a reminder to the public to NOT GO to the hospital unless it's a life-or-death emergency right now.  "When should I go to the hospital?" and more questions were be covered in a webinar that was done on Wednesday. Listen, watch, or read a synopsis here.

But, I was very disappointed with this recent piece, which you can read here:

Yes, many factories have been shut down in China, which disrupts global supply chains. However, if you're a company that decided to move all of your production to China (to then ship out to customers around the world), that wasn't a "Lean" strategy.

It's really difficult to support "just in time" delivery over such long distances. If it were a "Lean" approach to move all of your production to China, then Toyota would have done that. But, Toyota didn't.

I've been thinking a lot about hospitals and how they're preparing for the expected tsunami of Covid-19 patients who will need ICU beds and ventilators (when it's expected that there won't be enough of either).

There have also been recent preparations (and ongoing actions) to screen patients who arrive at emergency rooms and outpatient clinics.

I was at one organization last week that was in the process of installing new protocols and procedures in an outpatient clinic setting and I was able to have a tiny amount of input into that. Now, I'm home and trying to help remotely with the situation.

I hope this blog post helps more broadly.

Thanks to the Shingo Institute for inviting me to facilitate a half-day workshop at the Shingo Conference, being held this year in Orlando, April 16 and 17. The workshop covers concepts and methods from my book Measures of Success: React Less, Lead Better, Improve More.

I hope you can join us for the conference, as this is an event I have enjoyed in the past — and if you're going to be there, please say hi and, better yet, come to my session.

My workshop will be a concurrent session on Friday at 8:30 AM. Here is a video they asked me to make where I share a little bit about the workshop:

http://www.leanblog.org/audio295

Here's an article from Bloomberg BusinessWeek:

GE's Larry Culp Faces Ultimate CEO Test in Trying to Save a Once-Great Company

Very early on, the article mentions Culp's advocacy for "Toyota-style lean manufacturing." Or is he pushing "Danaher-style lean manufacturing" and is that different? And does that matter?

Culp was "in his element" visiting a GE factory in Pensacola -- can that be said about most CEOs?

http://www.leanblog.org/audio294

Today, I'm sharing a question from a reader who started their career at Toyota and now works at another company. See previous posts with reader questions.

The reader has given me permission to share this -- to get your input -- and there are no identifying details included:

I came across something interesting at work around goals that I wanted to share with you and perhaps get your thoughts.

At the beginning of the fiscal year, our manufacturing sites submitted their cost savings targets to me. I looked them over to make sure they both seem reasonable yet challenging and asked questions as needed. From there, I submitted them to the operations VP for final approval. The VP accepted them without question.

We're at the end of the first quarter, and 3 of the 9 sites are not meeting their run rate target...

From 2014 -- http://www.leanblog.org/audio293

We had an excellent English-speaking tour guide for our visit (she lived in Hawaii at one point). As we talked through the facility (up in a "catwalk" that gave good visibility down into the process), she would occasionally stop at pre-determined points to explain something about the process or about the Toyota Production System and its elements.

At each stop, there was a box with a microphone and other audio/visual equipment and speakers. She didn't have to carry a microphone with her.

The guide was carrying a bag, something between a briefcase and a large purse.

One of our sharp-eyed tour attendees, a Chief Medical Officer from a Canadian hospital, noticed a hook that she would hang her bag on while stopped and talking. He asked her about the hook.

Sure enough, it was a Kaizen improvement! And, it was her idea.