The blog post

IMAGE: A sign that reads "CAUTION: DON'T OPERATE ON THE WRONG SIDE"

It's silly, right? I've never seen a sign like this in an operating room. And I'm not advocating for them. It's not the right approach for quality and patient safety.

If warning signs actually prevented mistakes, and given that a vast majority of mistakes are caused by human factors (like fatigue) and systemic factors (like being behind schedule because instruments were delivered late to the O.R.)…
1) A sign like this would be posted in every operating room

and
2) Wrong-site, wrong-side, and wrong-patient surgeries would never occur
But, of course, it's not that simple.
What works?
Mistake-proofing works.

The blog post

TODAY marks the centennial of one of the most significant innovations in quality management: the control chart. 🎂 🎉 🎆

In the early 1920s, Walter A. Shewhart, working at Bell Labs, recognized the need for a statistical method to monitor and control manufacturing processes.

On May 16, 1924, Shewhart created the first “control chart,” a tool that distinguished between common cause variation (inherent in the process) and special cause variation (due to specific, identifiable factors). This simple yet powerful distinction laid the foundation for modern statistical process control (SPC). Control charts were dubbed “Process Behavior Charts” by Donald J. Wheeler Ph.D.)

The latest and greatest of the control charts is the “XmR Chart” — as Wheeler wrote about in Understanding Variation and I wrote about in Measures of Success (a book that has a foreword written by Wheeler).

The blog post

Research by Ethan Burris shows that the top two reasons employees choose to keep quiet in the workplace are:
1️⃣ Futility
2️⃣ Fear
Fear of getting in trouble is a big problem. But there are also many workplaces where people say, quite literally, “I'm not afraid to speak up, it just isn't worth the effort.”
That's the Futility Factor.
Please answer this poll question via LinkedIn. And I'd love to hear your thoughts in a comment here on the blog post or LinkedIn. Please check out people's comments and stories that they shared on Linkedin.

Episode page with links and more info

I'm very happy to announce the release of my new Mistake-Proofing course, available NOW through Karen Martin and TKMG Academy.

You can buy the course individually at TKMGAcademy.com for $129. Volume discounts are available for large teams or your entire workforce (for more information, email info@tkmgacademy.com).

The course is also part of the wonderful collection of courses in the all-access annual subscription. The annual price of $529 goes up significantly at 11:59 pm CDT on May 31st, so act now for the best value pricing.

Other TKMG Academy instructors in the series include Karen Martin, Elisabeth Swan, Mike Osterling, Tracy O'Rourke, Brent Loescher... and more.

And if you subscribe to TKMG Academy, you can participate in Karen's "Community of Practice" meeting with me on Wednesday, June 26th.

Blog post

I love Steve Spear‘s emphasis on a Toyota-based Lean model of:

“See, Solve, Share”

See problems, solve problems, and share what worked as countermeasures. That's the ideal, and it's powerful where it exists.

At Toyota, and companies like it, there's an understanding that speaking up about problems leads to a constructive response from leaders.

That's not always true at other companies that are starting or attempting their “Lean Journey.”

The Psychological Safety that might be taken for granted at Toyota must be actively cultivated in a company before continuous improvement can really take root, let alone take off.

I think the model could also be stated as:

“See, Share, Solve, Share”

Blog post

Research by Ethan Burris shows that the top two reasons employees choose to keep quiet in the workplace are:
1️⃣ Futility
2️⃣ Fear
Fear of getting in trouble is a big problem. But there are also many workplaces where people say, quite literally, “I'm not afraid to speak up, it just isn't worth the effort.”
That's the Futility Factor.
Please answer this poll question via LinkedIn. And I'd love to hear your thoughts in a comment here on the blog post or on LinkedIn.

The blog post

You don't find the root cause of a problem in a conference room.

OK, so we've gotten away from the whiteboard. Now what?

You might not even KNOW the root cause by thinking and talking out where the work is actually being done.

That's one of the most powerful lessons I've learned from former Toyota people I've been able to work with.

Blog Post

Professors Robert H. Hayes and William J. Abernathy have harsh words about a common, if not typical style of American management:

“…an overdependence on analytical detachment – what they call ”managerial remote control.”

They say it is an approach that exalts financial analysis, not line operations. It rewards executives who see their company primarily as a competing set of rates of return, who manage by numbers and computer printouts.

Further, they say, it is a seductive doctrine that promises the bright student a quick path to the top and that piles its rewards on executives who force through impressive short-term performance, at indeterminate cost to long-term health.

Fearing any dip in today's profits, American companies keep research and technology on short rations, skimping the investment critically needed to insure competitiveness tomorrow.”

These are warnings about:

• Prioritizing financial analysis over an operations focus
• Emphasized and rewarding short-term performance over long-term perspectives

Is that from a recent article that I've read? Yet another article about Boeing's troubles?

No. It's a 1982 article in the New York Times. Hat tip to Tom Ehrenfeld for sharing it with me.