
231Executives and Lean
faiR and Just CuLtuRe
11
The Lean cultural change needs to include what used to be called a “blame-free” culture. This is
probably not practical since a blame-free culture is not practical. The new terminology is more
accurately called a “just” culture. This is a culture where, when things do not go right, they are
looked at critically from an operational standpoint. If it is a hospital systemic process issue, it
is dealt with at that level. If it is truly an individual person’s accountability, such as the person
refuses to follow the standard work or abide by the new system, then appropriate action should
be taken. Thus, ...