Errors are systemic. And that's why they're systemically preventable. But the cost isn't just some rework; a substantial portion of most organizations exists just to deal with errors. And it's not just a cost problem; it's a capacity problem. Every error creates work that wasn't in the plan. Rework, re-inspection, re-setup, re-order (with overnight expedite), injuries, broken machines, scrap replacement, the extra changeover to go back and fix a run. None of it adds value,

Change management and organizational resistance are constant topics for anyone trying to lead change. I hear all the time how resistant people are to change, but I disagree. People aren’t resistant to change, they are resistant to consequences. Their habits are resistant to change. We treat these as the same problem but they aren’t. Most management teams don't have the tools in place to help people change, which is a large part of why it's so hard to do. A habit is a brai

We've all heard of the butterfly effect. It's real and it's important. Here's a fact: you're more likely to make errors when you're rushing, frustrated, fatigued, or interrupted. And errors make you rushed, frustrated, fatigued, and interrupted. That's a loop... and it compounds. This is how small errors change the world. But you can absolutely beat them with the right systems. It starts small. A scheduling error: one patient double-booked into a 30-minute slot at 9:00 on an

Paint the fence. Sand the floor. Wax on, wax off. If you've seen The Karate Kid, you remember Daniel's frustration. He shows up wanting to learn karate, and instead Mr. Miyagi has him doing chores for days. Daniel thinks he's being used for cheap labor. Then Mr. Miyagi throws a punch at him, and Daniel blocks it perfectly with the motion he learned by sanding the floor. That scene works because it's not just a movie trick. It's a correct description of how the brain actually

Somewhere along the way, "leader" became the junk drawer of the org chart. Develop people. Set direction. Coach performance. Manage conflict. Hit the number. Communicate the strategy down and the reality up. And, quietly tucked in underneath all of it, inspect and catch every process deviation before it becomes a problem and deliver accountability and retraining as needed. Oh, and as you do all that, we want your people to be happy too. So you better go build some strong re

For years, one machine dominated my downtime report. Not because it was old, or exotic, or particularly complicated... it dispensed a single component into the product. The machine's job was to cut this component from a web and drop it into the product. That's all it did. But it produced two failure modes which appeared on the daily report almost every day: it would cut the component in the wrong spot, or the line would have been down and this machine's name would be listed

Walk any plant floor eighteen months after a new SOP rollout and you'll find the same story: the binder is still on the shelf, the laminated job aid is still on the wall, and nobody follows either one anymore. Leadership calls it a discipline problem. Retrain, write someone up, rework some bad product, deal with the personnel fallout, explain it up the chain, move on. But it isn't a discipline problem. It's really not even willful. The workers are departing from expectation