Toward a Lean Hospital: A Cultural Transformation [Video]


Earlier this year, I was invited to give a recorded virtual presentation for a conference in Malaysia on the subject of Lean in healthcare. More specifically, they asked me to present on the theme of “Spearheading change toward a lean healthcare organization.”

I used this as an opportunity to experiment with a relatively new PowerPoint feature called “Cameo,” which allows you to insert your talking head video into the slides. I ended up recording this in a hotel room, as you can tell by the wallpaper, perhaps. That wasn't ideal, but it worked.

I'm sharing the recording here, broken up into shorter videos, but grouped together into this playlist. You can click the upper right icon with “1/8” below it if you want to see the eight component videos to select one. Or you can just press the Play icon below and the videos should run together seamlessly like it's a single video.

Below, you can find an AI-generated summary by (and then edited by me). And a full transcript follows that.

Spearheading Change Toward a Lean Healthcare Organization

The increasing complexity and diverse needs of healthcare systems demand transformative methodologies to improve service efficiency, patient satisfaction, and positive health outcomes. One such methodology that has had profound effects since its integration in healthcare during the 1990s is Lean. Emerging from traditional manufacturing companies like Toyota, Lean has now transcended industries and continents to become an indispensable part of healthcare systems worldwide, especially with the recent support from automotive giants like General Motors and Ford.

The True Essence of Lean in Healthcare

Contrary to the conventional notion of Lean being a dispatch of tools or methods, it is, at its core, an adolescence of multifaceted systems and a cultural orientation. Lean within an organization signifies a cultural revolution that enables an environment for its employees to be innovatively involved in problem-solving, ultimately enhancing performance.

One significant contribution in elucidating the true concept of Lean comes from Jamie Bonini, an American senior leader at Toyota North America. His definition of Lean as an organizational culture of highly engaged individuals striving to problem-solve and drive performance could be applied to envision the idea of a Lean hospital.


Thus, a Lean hospital can be seen as an institution that harnesses an organizational culture that thrives on engaging people in constant innovation and problem-solving.

Why Lean in Healthcare?

In addition to posing the question about ‘what' and ‘how', it's equally pivotal to address the ‘why'; why should healthcare transition towards Lean? This is where the acronym “SQDCM” comes in. In the Lean context, its common framework revolves around Safety, Quality, Delivery, Cost, and Morale; five key pillars that significantly influence the goals and performance of a healthcare organization. The prime emphasis within this framework is on ‘Safety,' placing patients and healthcare workers as the top priority, followed by Quality, Delivery, and Cost. These outcomes, combined with improved Employee Morale, cultivate a virtuous cycle of increased engagement and performance.


Engagement and Psychological Safety

While understanding the core principles and philosophy of Lean is integral for implementing it in healthcare, active engagement of the frontline staff in the Lean process is paramount for yielding significant improvements. This necessarily involves creating a psychologically safe environment where employees, including nurses, physicians, and administrative staff, can feel safe to challenge the status quo, ask questions, make suggestions, and openly express their concerns or mistakes without fear of retribution. Such an environment promotes innovation and continuous learning, leading to improved systems and processes.

Leadership's Role in Fostering Lean Culture

A successful transformation toward Lean healthcare lies in the hands of an organization's leadership. As per the views of respected leaders from Toyota, managers, and leaders should develop their teams to identify and solve problems within a supportive environment. Fostering this kind of culture and environment isn't about forcing change but engaging each individual in the process of continuous improvement, or Kaizen.

The leaders need to model and reward the vulnerable acts, align with organization values, and demonstrate the value of psychological safety. This will inspire the staff to learn from mistakes, improve, and ultimately contribute to the organization's success.

Examples of Lean Transformations in Healthcare

Organizations like UMass Memorial Health and those led by Dr. Rick Shannon have shown how embracing Lean can bring about dramatic improvements in health outcomes, patient experience, and financial performance. They demonstrate that Lean is not primarily a cost-cutting strategy, but a holistic approach to process improvement and organizational development that can lead to better results in all areas, including safety, quality, delivery, cost, and morale.

These practical examples reaffirm Lean's importance in healthcare and bust the myth surrounding Lean as a cost-cutting methodology. Instead, Lean is a comprehensive ideology focused on continuous improvement, collaboration, and high-performance culture that contributes significantly to the betterment of healthcare systems, positively impacting patient care and safety.

Embracing Lean Culture: Learning from Mistakes

Learning from mistakes forms an integral part of the Lean culture, a philosophy embedded in the Toyota models of operation.

In Lean healthcare, the focus is on constructive action towards the prevention of future mistakes. Transformational stories related to mistake learning experiences in organizations like Toyota introduce crucial insights on mistake handling practices. Whether the mistake occurred in Japan in the 1960s or in Kentucky in the 1980s, Toyota cultivates a culture that doesn't punish error makers, but rather empathizes and works collectively to foresee repeated errors.

The Mistakes That Make Us – A Guide to Learning from Mistakes

In his most recent book The Mistakes That Make Us, Mark Graban presents practical guidance on handling mistakes, leveraging them as learning opportunities. The book transitions through eight prescriptive chapter titles aimed at encouraging a positive mindset towards mistakes, admitting mistakes while ensuring safety, practicing constructive kindness in the face of mistakes, and suggesting systemic ways to prevent future ones. Additionally, it highlights the significance of giving everyone a voice and a choice in improving situations rather than facing punishment.

In the book, nurturing a supportive culture is compared to farming a garden. It's not an overnight process but requires constant upkeep and nurturing, much like plants or crops.

Learning from a Wrong Decision: A Key to Lean Transformation

We all make mistakes — even when we try to prevent them — so learning from them is key, and Lean culture speaks volumes about this transformative philosophy. Insights from “The Toyota Way 2001,” an internal document from Toyota, underscore errors as learning avenues, whether individually or as a team.

The practical scenario of a ‘wrong side surgery' provides concrete evidence of this learning approach. The admission of a mistake serves as the platform to various questions, the answers to which could reform operative processes, procedures, and methodologies, thus ensuring such errors don't recur.

The two broad categories of mistakes as decoded by Toyota include recurring errors – surgical and medication errors, for instance, that can effectively be prevented by strict adherence to procedures. The other category comprises failed attempts to enhance the patient experience–a room for innovative ideas that might not turn out as expected.

The book further emphasizes the importance of thoughtful analysis of mistakes, especially near misses, for a proactive approach to improving processes that could potentially give rise to grave errors in the future.

A Dynamic Shift in Perspective: Lean Culture in Healthcare

In his concluding reflections, Mark Graban invites readers to appreciate the growth potential provided by mistakes and urges individuals to ensure a safe environment for mistake admissions. This nurtures an organizational culture of continuous improvement coursing into Lean transformation.

Infusing kindness and constructive action in response to errors substantiates progress toward better operational systems. And the culture, much like a gardened plant, continues to be nurtured and cultivated for dynamic shift in healthcare systems propelling them towards the Lean model.

Mark Graban's multiple books, including Lean Hospitals and Healthcare Kaizen serve as a comprehensive trail to continuous improvement, providing monumental guidance to the enhancement of performance measures across various healthcare domains such as safety, quality, delivery, cost, and morale.

Automated Transcript:

Mark Graban: Hi, I'm Mark Graban. Thank you for the invitation to share some thoughts with you today about Lean in healthcare. My talk is titled Spearheading Change toward a Lean Healthcare Organization. It's not just about using Lean methods or Lean is certainly not an approach where we try to force change on people, but it's really more a matter of how do engage them and why would they choose to participate in Lean? People might ask, what is Lean if they're not familiar with this methodology and the origins of it now, it's been used in healthcare since the late 1990s in the United States.

Mark Graban: Healthcare organizations in Michigan in particular, received a lot of help and assistance from automakers, including companies like General Motors and Ford. Toyota has provided assistance to healthcare organizations in the United States and Japan and Brazil and other countries. But one thing I want to emphasize, and I think this is an important point, is that Lean is not just a collection of tools. Sometimes people refer to Lean as a toolbox. I don't think that's a complete definition of Lean.

Mark Graban: Using Lean tools without the context of the broader system is unlikely to have the same benefits as those same tools would bring in an organization that's embracing more than tools. We'll come back to that in a minute. It's really about culture, not just the right tools, but what is the quote unquote right culture that brings the results that we are looking for and that we need in healthcare? Pictured here is Jamie Benini. He's an American who is a senior leader in Toyota North America.

Mark Graban: He's the head of a group called TSSC, or the Toyota Production System Support Center. They work with not only Toyota suppliers, but they do a lot of work for free for healthcare organizations and nonprofits in the United States. So Lean has its origins in what Toyota calls the Toyota production system and Jamie Benini defines TPS. And I would propose therefore, we define Lean as follows it's an organizational culture of highly engaged people solving problems or innovating to drive performance. How do we spearhead people's participation in Lean?

Mark Graban: If we want people to be highly engaged as leaders and as change agents, and as Lean teachers and facilitators, we need to actively engage them in the improvement process. That's a big part of Lean and the Toyota production system. Now, Jamie and Toyota further describe the Toyota production system using this diagram. They mention. You see at the base of the diagram that Lean is first and foremost an integrated system.

Mark Graban: It's an organizational culture. When organizations try to copy one piece of an integrated system, we wouldn't expect to get the same benefits and results as we would by trying to embrace and adopt an integrated system at Toyota, this took many decades for this integrated system to be initiated, for it to evolve, for the different pieces to fall into place. So an integrated system with its complexity is not something we can install like a piece of equipment. It takes time. Now we don't want it.

Mark Graban: We can't have this take decades in a healthcare organization. We can learn from the example of Toyota and from other healthcare organizations that have used this methodology in their own context. It's an organizational culture. It's built around three kind of key interconnected concepts. In the middle, we see this core of what Toyota describes as people development.

Mark Graban: Improving the way we do our work, in a way that engages and develops people's problem solving skills and improvement capabilities. Developing people for the benefit of their own job progression and career, not just for the benefit of the health system. This integrated system is built upon a philosophy. It's built upon a managerial system and it's built upon technical methods. Or we might use the word tools.

Mark Graban: These are all interconnected and mutually supporting. These philosophies include the idea of what Toyota described as customer first in healthcare. We might say patient first. This philosophy includes the idea that we should engage everybody in the organization in improvement, that we should be systems thinkers, that we should try to put quality first. Things like that are part of the Toyota the Toyota production system philosophy.

Mark Graban: And I would argue that's part of the Lean philosophy. So if we were to talk about what is a lean hospital, I would fall back on the same definitions from Toyota, just applied in different ways. That a lean hospital. And it's not a case of binary lean or not lean. There are degrees of leanness, if you will.

Mark Graban: There are degrees of results. But we could define a lean hospital as Jamie Benini and Toyota do. A lean hospital has an organizational culture of highly engaged people solving problems or innovating to drive performance. And a lean hospital would be working toward the same integrated system of an organizational culture, a philosophy, a management system with technical methods that all support people development. Now, if we want to engage people in healthcare or any setting, we need to shift quickly from the what, not just what is lean and how do we get there.

Mark Graban: We should really start with the why. Why lean in healthcare? Why is this important? How does this support the goals that a healthcare organization and the healthcare professionals working in that organization, these goals that the organization of people already have? In Lean, there's a common framework.

Mark Graban: It's an acronym that doesn't really spell anything in English, but makes it a little harder to remember. But it is a common construct that's used in various industries. I was exposed to it first in the automotive industry when I worked there more than 25 years ago. The goals that matter, including in healthcare, start with safety. Not just for patients, but for the people working in the healthcare organization.

Mark Graban: That's first and foremost priority number one. Or some might call it a precondition, where a priority implies a choice, a precondition is something that must exist for anything else to happen. Safety really comes first. Quality. The quality of care, the quality of outcomes, the quality of the patient experience.

Mark Graban: We can orient ourselves and our teams around working to improve all of that using lean methodologies delivery. We can think of this as access the timely delivery and access to the needed care, safe care, high quality care without delay. Cost. This is listed fourth and very intentionally, specifically so. Lean is not a quote unquote, cost cutting methodology where cost is the primary objective.

Mark Graban: In the lean methodology, cost is seen as the end result of doing everything else well. When we improve safety, when we improve quality, when we improve the delivery timeliness and access to care, lower cost follows. Improving patient flow has connections to quality and to lower cost. And when we can do all of these things, and when we emphasize all of these goals again, not only cost, we can find improvements to employee morale. And then we get a really beneficial cycle of people trying to participate with lean methodologies and improvement.

Mark Graban: They see positive results. They feel good about that. They feel good about their involvement. They want to do more. It becomes a virtuous cycle of increased engagement and improved performance.

Mark Graban: We can see examples that are maybe not distributed evenly across healthcare, but there are dramatic improvements to be found solving problems that people might otherwise say are sad but unsolvable. One of those leaders in the United States is Dr. Rick Shannon, who has had leadership roles. He's currently in many organizations. He's currently the Chief Quality Officer at Duke Health in North Carolina.

Mark Graban: He learned these methodologies from Toyota and applied them in hospitals in Pittsburgh. And this chart shows results from Pennsylvania. He repeated the same results using the same methodology, different people at the University of Virginia. This is a very repeatable process of using lean methods, the tools and the mindsets and the leadership style to reduce, as we see in this chart, central line associated bloodstream infections, or Klapses. One thing Dr.

Mark Graban: Shannon did was, I think this is helpful, is to state the number of infections, not a rate of infections. Like the number of infections. The number of patients, I think is easier for people to wrap their heads around and through the lean methodology of studying how the work is done, making sure that everybody has the right supplies to do central line insertion and maintenance and removal the right way. Every time. It's from an improvement to what we might call the standardized work.

Mark Graban: It's not about telling people to be more careful or to try harder or to care more. They saw almost immediately a 90% reduction in these collapses. And we can see reductions in other forms of causes of patient harm. There was a 17 day shorter length of stay per case. When you don't get a collapse, your hospital stay is shorter.

Mark Graban: And this led to a $1.7 million reduction in cost. Now we can break down trade offs. Better quality does not cost more when we improve the way the work is done. Another organization that's done great work in this regard is the University of Massachusetts, UMass, Memorial Health in the state of Massachusetts, as this chart shows, through Lean improvement, by engaging people in improvement. And their goal is to have everybody everywhere, every day, involved in improvement.

Mark Graban: And this is driven by their CEO, Dr. Eric Dickson. We can see increases in patient experience scores. At the same time, we can see reductions in inpatient mortality. These types of improvements go hand in hand when we engage people in improving how the work is done and when we lead and manage them in a different way, when we equip them with tools and methods they can use to improve.

Mark Graban: We can see dramatic results in all of these key areas safety, quality, delivery, cost and morale. As an example of improving patient flow, this is a chart that shows results from a hospital in Wisconsin in what they call door to balloon time. Patients arriving to the emergency department with chest pain and a suspected heart attack. Door to balloon time. The end to end time, from arrival to having the blockage cleared in the cath lab is a key measure of key predictor of outcomes, the quality of outcomes and survivability and recovery for patients steadily over the course of four years.

Mark Graban: Through a number of different process improvements. They got the average time down from 91 minutes to 37 minutes. And they, at least, as this chart shows, were able to pretty much sustain that for a five year period. They went from that time being longer than the standard for good care to being much shorter. Engaging people in improvement leads to more improvement.

Mark Graban: It also leads to a better sustainment of those improvements because, again, they're involved in the change instead of having change forced on them. So I've been really happy to see in the last 15 years, since the publication of the first edition of my first book, Lean Hospitals, that not only has my book been translated into, I think, eight different languages in different parts of the world, but that the lean methodology has been applied in a wide range of health systems, not just in North America, not just in Japan, but in countries all around the world. And I know there are people in Malaysia working on this in their hospitals. In fact, some of them have been part of study trips with me to Japan to go visit Japanese hospitals and to go visit companies like Toyota. Not because we are trying to turn the hospital into a factory.

Mark Graban: We just want to learn lessons from other organizations, other industries that we can apply to improve the way we do our work in healthcare. And these are kind of long standing problems. Like to share an example from the United States from Detroit, Michigan. Henry Ford. You probably know as the founder of Ford Motor Company.

Mark Graban: He in 1922 owned a hospital. And this is now part of what's still called Henry Ford health system. He saw from his observation and study of the hospitals, as he described in one of his books, in what he called an ordinary hospital, the nurses must make useless steps. More of their time is spent in walking than in caring for the patient. And I've seen studies in recent years that nurses in different countries around the world generally only get about 30% of their time at the bedside with the patient.

Mark Graban: And this is not anything we would blame the nurses for. We would ask, why are they having to be away from the direct patient care activities so we can look at the structure of support systems? Why do they not have the supplies, the equipment, the medications that they need readily available? Why are nurses spending time searching for what they need to provide the right care in the right place at the right time? In the lean mindset?

Mark Graban: We're not focused on telling nurses to try harder, to work harder. It's about making work easier for them. When we look at inefficiencies or quality problems, the lean methodology really emphasizes that the cause of these problems is not the so called bad apples. Dr. Don Berwick, the founder of the Institute for Healthcare Improvement in the United States, an organization that's had global impact, he's been teaching this for decades, as have other leaders in the healthcare quality and patient safety movements.

Mark Graban: Instead of blaming and punishing or trying to remove, quote, unquote, bad apples, we need to improve processes. We need to improve communication. We need to break down silos across departments. We need to better support the people doing the work. And along those lines, I'd like to quote and cite another friend of mine, a former Toyota leader from the United States, Daryl Wilburn, who says quite clearly, and I think this is something worth emulating in other settings, including healthcare.

Mark Graban: As Daryl says, it's the responsibility of leaders to provide a system in which people can be successful. It's the responsibility of leaders. And I think that's a really important point. That doesn't mean leaders have all the answers. It doesn't mean leaders fix everything, but it means that leaders engage and support everybody in the organization in the important work of safety, quality, delivery, cost, and morale.

Mark Graban: Change cannot be forced on people in a top down way. If we want it to be accepted and sustained, leaders have to lead. But they engage people at different levels of the organization in problem solving, kind of engaging or trying to find solutions at the right point, in the right place. And generally about 80% of these improvements will come from frontline staff and their immediate managers when they're in a supportive environment, when they're in what we might call a lean culture. So how do we engage people in change, we have to do so very actively and we can learn how to do so as frontline leaders, as managers, as middle managers, as executives.

Mark Graban: There are different roles that each of these leaders play, as Toyota defines, and we could choose to use the Japanese word or not kaizen. That word translates roughly to mean good change. The two core elements of that word, kai, which means change, and Zen, which means good. So we can say kaizen is change for the better, or it's often used in the context of continuous improvement. So, as Toyota describes, kaizen is the relentless pursuit of perfection through innovation that drives continuous improvement.

Mark Graban: The pursuit of perfection doesn't mean we demand perfection or that we expect perfection tomorrow, but we have to engage people in that in an ongoing way. We can use methods like this that I've taught hospitals in different departments how to implement what we might call an improvement board. And more importantly, it's not just about the board, it's about the culture. It's about the way leaders engage everybody in identifying problems and solving problems on a board like this. And I'll show some examples of what might be written on these blue cards.

Mark Graban: They can go up on the board and they progress from left to right, new ideas, things we plan to do, things we're currently doing, and things that are completed. When I've worked with hospitals and nursing units to engage people in identifying problems that matter to them, some of the first things they write down are simple and that's great. Small problems, many small problems, helps move us forward when we identify and solve those. The first example written down by a nurse was that patients are asking for ginger ale when they're nauseous, and it's not available on our unit, so we have to go walk to another floor. So here's the Henry Ford problem again of all this time away from the bedside, all of this walking, all of this.

Mark Graban: You could call it wasted time. Again, not blaming the nurses for wasting time. This is a system problem and it was easily solved by making sure ginger ale was available right there on that unit, on that floor where the nurses and the patients needed it. A second card that was filled out required a little bit deeper level of problem solving. They wrote down an important problem that two of the hand sanitizer dispensers were empty.

Mark Graban: And this is a common problem in different hospitals now. Their idea said very vaguely, improve the process for quickly replacing an empty canister. So this was a type of problem that really got more into what we might call root cause analysis to really understand, well, what is the current process? Why is that perhaps not working? Well, this might involve now a team of people and not just a relatively simple quick fix.

Mark Graban: So those two cards kind of help illustrate different levels of what we might call the three levels of kaizen starting at the top. Every organization has large projects, large strategic initiatives that executives tend to select and drive. Electronic medical record implementation, new construction, big expensive projects. We can only do so many of those at a time. Now, looking at the base of the diagram, we can call these small kaizen improvements or daily kaizen, making sure ginger ale is available.

Mark Graban: Examples like that. Research shows across industries, 80% of the improvement potential in an organization is found at this level of what we call small kaizen. It's not a project. It might not require root cause analysis. These small kaizens should be quick and timely, generally inexpensive, where the hand sanitizer dispensers might fall.

Mark Graban: In this range of what we could call medium kaizen, we might do projects in the context of lean or a related methodology perhaps called Six Sigma. We might use what's called a three problem solving. And that's something that you can search the Internet for if you'd like to learn more about. But all three of these levels of kaizen have one thing in common, and that commonality is a model called PDSA. Or sometimes people call it PDCA.

Mark Graban: I like the language of plan, do, study, and adjust. It's an incremental improvement model. We're not going to necessarily completely solve a problem with one small improvement. We might need iterative changes, change upon change. That's part of the kaizen philosophy.

Mark Graban: Now, if we can find a large root cause solution that eliminates 90% of a particular problem, that's great, and we should look for that. But it's difficult to engage people if we are demanding large projects with large benefits and large return on investment. The best way to start engaging people is to really start small, ask them to see, solve and share small problems in the course of their work. And that's how we can build a foundation for what we might then describe or aspire to as a culture of continuous improvement. So the final thing I want to talk about is back to the question of engagement.

Mark Graban: How do we engage people in this process? I would believe people want to participate in improvement, whether we're using the word lean or not. I believe people want to be engaged, they want to be involved, they want to be able to use their creativity. And the foundation for this really comes down to a concept and the practices that build psychological safety. A lot of it comes down to leadership, as Toyota describes, and I think this applies well in healthcare.

Mark Graban: The manager's role is to develop people to surface problems and solve problems. And I think this bottom bullet point is key. Create an environment where this happens. Or we could extend that to say, create an environment where people feel safe participating, where they feel safe to surface problems, and where they feel safe to try to improve. We can look at the literature about Toyota, including the book toyota culture that very directly and specifically talks about the importance of psychological safety.

Mark Graban: It says here that Toyota uses a holistic way of looking at the safety of all stakeholders, which includes employees. It involves providing for the physical and psychological safety of each member of the team. It's an intentional value that drives subsequent action. So we can't just demand that people feel psychologically safe. We need to take action.

Mark Graban: As Tim Clark, the author of the book The Four Stages of Psychological Safety, defines, psychological safety can be defined succinctly as a culture of rewarded vulnerability. Vulnerability means when we take an action, when we speak up, when we do something that there's the exposure to the risk of harm or loss. That risk of harm or loss could include punishment. So instead of telling people that they should be brave or that they have a professional obligation to speak up, a culture of improvement reduces the perceived risk. It reduces the fear factor so that people feel safe and they can choose to participate.

Mark Graban: Clark's longer definition says that psychological safety is a social condition in an organization, we would say, in which you feel, and again, this is an individual perception or feeling. And this will vary within a team, across different people. The level of perceived psychological safety will vary across a broad and diverse organization, across different teams. But when you feel psychological safety, you feel included, you feel safe to learn, you feel safe to contribute, and you feel safe to challenge the status quo. All without the fear of being embarrassed, marginalized or punished in some way.

Mark Graban: So when organizations attempt to engage people in improvement in kaizen and continuous improvement, without that foundation of psychological safety, we may see an improvement board that sadly looks like this. A board that's been copied from a different healthcare organization that had active participation in continuous improvement. But in this other organization we see months later, after this was installed on the wall, the board is not being used. I would never expect that the employees working here don't know about the problems and that they don't have ideas. It's more likely a lack of psychological safety that prevents them from speaking up.

Mark Graban: If they feel like they are going to be blamed or attacked or punished in some way, they will choose to protect themselves. Even when they're highly motivated. Intrinsically, the organization may teach them that it's either unsafe or just not worth the effort to speak up. The two main reasons people choose not to speak up are either due to fear or futility. So even if people aren't afraid to speak up, if they think speaking up doesn't lead to constructive supportive action and improvement, people might conclude it's not risky, it's not dangerous, it's just not worth the time.

Mark Graban: So again, this comes back to leadership and their role and their responsibility in trying to help create or cultivate this culture. So what can leaders do? Again, going back to Tim Clark in his excellent book the Four Stages of Psychological Safety. It really comes down to two key high level actions on the part of leaders at all levels, really starting with the chief executive and other senior leaders. That those leaders, first off, model these vulnerable acts.

Mark Graban: That could include things like admitting a mistake, saying things like I could be wrong, so let's go test my idea. In practice, that all sets a good example for others to perhaps follow. Leaders can't just tell others to do these certain things. Leaders need to lead the way. They need to lead by example.

Mark Graban: And when they do so, if people feel a high enough level of psychological safety, they may try to follow their lead. And when they do, leaders need to then reward these same vulnerable acts. This creates, again, more positive cycles through the organization. Leaders can't just say the right things. They can't just encourage people to speak up.

Mark Graban: They certainly can't say you should feel safe to speak up. Leaders need to demonstrate that that is actually true by modeling and rewarding vulnerable acts. So we would see a couple of key progressions. When leaders model vulnerable acts, then people working for them may choose to follow their lead. When leaders reward these vulnerable acts, that builds a higher feeling and a higher perception of psychological safety.

Mark Graban: Higher levels of psychological safety mean people are more likely to speak up. That means more learning from mistakes. That means more improvement. And that leads to more organizational success along the lines of sqdcm safety, quality, delivery cost and morale. I want to share a final thought, and this comes from UMass Memorial Health, who I mentioned earlier.

Mark Graban: Again, I give a lot of credit to their chief executive, Dr. Eric Dickson, who really spearheaded this Lean culture when he became CEO, I think it was eight or nine years ago. UMass Memorial was in a very bad financial situation. And Dr. Dickson's embrace of Lean and leadership of Lean has really made a huge difference in turning around results in all of these key categories.

Mark Graban: And they say their goal. Again. This sounds like Toyota. Kaizen language. Everyone every day working to provide the best care.

Mark Graban: That's really what Lean is about. So with that, those are my remarks about Lean and healthcare. I have a few thoughts to share about learning from mistakes related to my most recent book, The Mistakes That Make US. If you'd like to learn about that, you can go to If you have follow up questions for me about this or any other question that you think I might be able to help answer, email me at and I will certainly commit to getting back to you as soon as I can.

Mark Graban: So let's talk a little bit more about learning from mistakes. I think this is a key part of a Lean culture. This is an important part of the Toyota culture as demonstrated by a number of guests on a podcast that I started in September 2020 called My Favorite Mistake. A couple of former Toyota leaders have shared stories, one from Japan in the 1960s, another story from Kentucky in the 1980s about a very similar mistake, that they were a part of a systemic error. And instead of blaming and punishing these two individuals, the leaders again Japan, Kentucky, separated by halfway around the world, a couple decades apart.

Mark Graban: The consistent culture not only refused to punish them because the mistake wasn't their fault, it would have been unjust to punish them. It's also counterproductive. The more constructive thing to do is to work with them and make sure we're learning from a particular mistake so that we can focus on improving our processes and systems so that we do not repeat that same mistake. So some of those stories and from others are included in my book The Mistakes That Make US. When I asked people what's your favorite story inspired his career as being a patient safety advocate, that he is improving the lives of far more patients in that role than he would protecting the patients who are directly in front of him in the operating room.

Mark Graban: So I appreciate his willingness to learn from that story and to share it in a way that hopefully inspires others to work toward this culture change. Because, again, all of us, including the best surgeons, we all make mistakes, large and small. And that's one of the focus points in the theme of the book we all make mistakes. What's optional but clearly preferable is that we learn from our mistakes. We all make mistakes.

Mark Graban: Not everybody learns from them. Not every organization really makes it safe and possible for people to learn from their mistakes. So the structure of my book, I try to be a little prescriptive with the chapter titles. Chapter one think Positively how do we turn a mistake into something positive? How do we focus on learning and improvement in the prevention of repeated mistakes?

Mark Graban: That's a function of culture and individual practice, in a way. Chapter Two Admit Mistakes But again, we need to make sure that it's safe for people to do so. Chapter Three be Kind, be kind to yourself and to others. When mistakes occur, and I use the word kind very intentionally, I would make the case, and the book does so that we shouldn't be punitive, but we also shouldn't just be nice, where I think a nice reaction to mistakes is comforting when people use language like, well, it's okay, I know you didn't mean to do it. It's not your fault.

Mark Graban: That doesn't help prevent future errors. Being kind is more constructive and action oriented, where we use the methods I talk about in chapter four around how to prevent mistakes in a systemic way. Chapter Five help everyone to speak up. This again comes back to psychological safety. Chapter six.

Mark Graban: Choose improvement, not punishment. So. We try to prevent mistakes, but we realize when they do occur, we need to react to them in a way that's kind and constructive instead of punitive. Chapter seven iterate Your Way to Success. This is basically that iterative PDSA model again.

Mark Graban: And then chapter eight, cultivate Forever. That culture in an organization is like a garden. You don't install a culture. You don't implement a culture. It's really something that you have to continuously nurture over time the way you would plants again.

Mark Graban: Learning from mistakes is a core part of the Toyota mindset and philosophy. Their internal document from the company called The Toyota Way 2001 says in part, we view errors as opportunities for learning and as individuals or as a team. I think one way we can learn from these mistakes is to think through a set of questions. When we've made a mistake, when a mistake has occurred, a wrong decision, a wrong action, and we only know that it's wrong after we've made the initial decision. A mistake is something that seems right in the moment, but then as we learn more or as time passes, we recognize maybe there was a bad assumption, bad information, something that led to a decision that later turns out to not be correct.

Mark Graban: So we can think through, what decision did I make? What did I expect to happen? What actually happened? So if there's a gap between what we expected to happen and what actually happened, we could ask we might also ask, why was there that gap? But the core question around that is, what do I learn from that gap?

Mark Graban: What would I do differently in the future? Including how might we prevent that mistake? What would I expect to happen? So even in the case of that wrong side surgery, the decision was to make an incision on I think it was the right side. What the resident surgeon expected to happen was to find the hernia that that was the correct side.

Mark Graban: What actually happened was they learned it was the wrong side. And I think a lot of organizations then miss this opportunity to learn from the gap, what would I do differently? This leads to practices like surgical timeouts, marking surgical sites, making sure that people are not rushed for time. What would I expect to happen through a change in practices? A reduction, if not an elimination of the mistake called wrong side or wrong site surgeries?

Mark Graban: Not all mistakes are the same. There are some mistakes that we should absolutely work really hard to prevent. These would include surgical errors, medication errors, things that we mistakes that we can prevent when we follow known procedures and when we're able to do so. Then there are other mistakes that we might described as failed attempts to improve the patient experience. So when we you know, there's there's, I think, two broad categories.

Mark Graban: One are kind of routine work and mistakes that, in theory, we know how to prevent. So let's turn that theory into practice. And then there are things that are more a matter of improvement and innovation. We had a hypothesis. We thought making a certain change would lead to higher patient experience scores that could turn out to be untrue.

Mark Graban: And we can go back through those same questions and think about our mistake. Instead of refusing to admit the mistake, instead of blaming or punishing people for the mistake, we need to make sure that we learn part of that learning involves using small mistakes to prevent big ones. A friend of mine who I work with and he was interviewed in the podcast and this story is in the book. He's an emergency medicine physician, and he talked about what's sometimes the lost opportunity to learn from a small mistake. So, for example, let's say an order had been written to give 600 milligrams of Ibuprofen to a patient, and the nurse is coming up about to give the medicine, and maybe it's what some would call a good catch.

Mark Graban: The nurse discovers it at the last minute by double checking the medication or scanning a barcode. Oh, I'm holding 800 milligrams. I almost gave the wrong dose to the patient. At a lot of organizations. That's the end of the story.

Mark Graban: The nurse goes and gets the correct dosage, administers it, that's the end of the story. And that creates a situation where there's a lost opportunity. Even though there wasn't really a mistake that reached the patient, even though there wasn't harm, and even if the wrong Ibuprofen dose had been given, probably not harmful. If we took advantage of the opportunity to learn, why did we have a near miss medication error? We need to learn from that, improve our processes in ways that would prevent the same process problem in the future from creating a different form of this mistake that could be harmfully, deadly, right?

Mark Graban: So instead of kind of throwing that opportunity for improvement away, we need to make sure, again, for one, that people feel safe saying there's a mistake has been made, we've had a near miss, or we've just identified a risk. If people don't feel safe to point that out, we can't solve a problem that we don't know about. So that's why psychological safety is such an important core to the Lean approach and to the Toyota production system when we can react constructively to mistakes. And again, I think there's kind of a progression. Punitive is counterproductive and unjust.

Mark Graban: A nice reaction might be unhelpful in terms of reducing future mistakes, being kind, which means being more constructive, action oriented. Again, around preventing future mistakes, I think that's the best approach. It's not good that a mistake happened, but we can turn it into something positive. That's the thinking positively part of the book. And again, recognizing that culture is something that we have to constantly cultivate.

Mark Graban: It's not enough to plant seeds or to plant a seedling. This idea I think applies to our lean culture efforts. This is something we have to continually cultivate and nurture. It applies to a culture of continuous improvement. And as a subset of that, how do we get a culture of continuous improvement?

Mark Graban: A key piece is cultivating a culture of learning from mistakes. So again, I would invite you to reach out. If you have questions, my email address is I would invite you to check out the podcast that is, of course, free, as most podcasts are my favorite Mistake podcast. It's available internationally.

Mark Graban: My most recent book, again, The Mistakes That Make US, should be available through Amazon, worldwide and hopefully through other retailers. If you're having trouble finding the book, you can email me about that and then my previous books are shown here. My first book, Lean Hospitals, Again, has been translated into many languages. Healthcare Kaizen, that I co authored with Joe Schwartz, is about this culture and practice of continuous improvement. And then a previous book of mine, Measures of Success, is about basically the application of statistical methods to performance measures that we could apply to charts around safety, quality, delivery, cost and morale.

Mark Graban: So, again, thank you for the invitation. It's an honor to be asked to speak to you. I hope what I shared today day has been both interesting and helpful to you and your future improvement work. Bye. Thank you.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


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