I participated today in a webinar hosted by eHI. My slides arrived (ahem) too late to be broadcast, so I posted them online, with comments, on my site.
In case you don’t click through to the whole thing, here’s a quick excerpt:
Long ago in another career I learned about Thomas Gilbert (1927-1995), a real guru of performance improvement, and author of Human Competence: Engineering Worthy Performance. Long before the development of Lean, he methodically analyzed what we now call the root causes of failure, and published the matrix shown here.
Healthcare can learn a lot from this. It’s about solving the problem, not casting blame.