Popular Posts
GE Aerospace’s Greenville Plant Proves Larry Culp’s “Safety First” Wasn’t Just Talk An Insulin Error Killed a Hospital Patient. How Does Every Other Hospital Learn From It? “Most People Wouldn’t”: Fear, Gratitude, and Reporting Medical Errors Larry Culp on Success Theater, Embracing Red, and the GE Turnaround What If Every Hospital Learned From Every Other Hospital’s Safety Incidents? Four Patients Got the Wrong Drug in Nashville. Ask a Better Question. Toyota Doesn’t Call It Lean? Its Own Websites Say Otherwise Ten Psychological Safety Outcomes, and What They Do and Don’t Prove The Independent Double Check and the Risk of Human Error
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Mark Graban

Lean Leadership, Psychological Safety, and Continuous Improvement

Since 2005, LeanBlog.org has shared practical insights from real-world work in healthcare, manufacturing, and beyond.

Books Keynote Speaking Coaching / Advisory Podcasts
Books by Mark Graban on Lean, Leadership, and Learning (4)

Lean Blog Interviews Podcast

Ken Pilone, the Author of Lean Leadership on a Napkin; Toyota Says “Lean” and More

Ken Pilone, the Author of Lean Leadership on a Napkin; Toyota Says “Lean” and More

ByMark Graban August 24, 2022 2841
Podcast interview with Ken Pilone, author of Lean Leadership on a Napkin, discussing Toyota, TPS vs. Lean, leadership humility, and common misconceptions about Lean management. Scroll down for how to...
Why Damon Baker Thinks Lean Has a Marketing Problem; the Need to Speak the CEO’s Language

Why Damon Baker Thinks Lean Has a Marketing Problem; the Need to Speak the CEO’s Language

ByMark Graban August 16, 2022 4071
Scroll down for how to subscribe, transcript, and more My guest for Episode #454 of the Lean Blog Interviews Podcast is Damon Baker. He is the founder and CEO of the firm Lean Focus. He's also a...
Sarah Boisvert on New Collar Careers and the Need for 21st Century Apprenticeships

Sarah Boisvert on New Collar Careers and the Need for 21st Century Apprenticeships

ByMark Graban August 9, 2022 2011
Scroll down for how to subscribe, transcript, and more My guest for Episode #453 of the Lean Blog Interviews Podcast is Sarah Boisvert. She is the founder of New Collar Network and Fab Lab Hub. ...
Luke Szymer on Agile, Testing Hypotheses, and Process Behavior Charts

Luke Szymer on Agile, Testing Hypotheses, and Process Behavior Charts

ByMark Graban August 2, 2022 1624
Scroll down for how to subscribe, transcript, and more My guest for Episode #452 of the Lean Blog Interviews Podcast is Luke Szyrmer. He's the founder of “Launch Tomorrow.” He helps new...

More Blog Posts

Brandi Carlile and her band rehearse during sound check before their show near Chicago, working on specific improvements to their setlist.

What a Brandi Carlile Concert Teaches About Practicing Continuous Improvement

Mark GrabanByMark Graban February 24, 2026 1360
TL;DR: A sound check, live song requests, and a naming regret — what watching Brandi Carlile perform taught me about specific problem-solving, vulnerability, and continuous improvement. My wife...
Dr. Deming Fujio Cho Demotivating Workers

What Deming and Fujio Cho Agreed On: Stop Demotivating People

Mark GrabanByMark Graban February 22, 2026 1934
lean operational excellence mixtape

Ryan McCormack’s Operational Excellence Mixtape: February 20, 2026

Ryan McCormackByRyan McCormack February 20, 2026 4508
lean coffee talk episode 7

How to Choose the Right KPIs, Manage Change, and Understand Customer Value (Lean Coffee Talk Ep. 7)

Mark GrabanByMark Graban February 20, 2026 8871
fujio cho 1993 BAMA speech on Lean and TPS

Create Your Own Lean System — But Don’t Lose Sight of These Three Things

Mark GrabanByMark Graban February 18, 2026 1317

Webinars

karen martin ask the expert webinar kainexus

Ask Karen Martin Anything on Operational Excellence: A KaiNexus Webinar

March 5, 2026
Karen Martin is one of those people I've been lucky to know and learn from for a long time. She's...
1. Professor with glasses in front of EMS 20th anniversary logo and KaiNexus logo on blue background.

Unlock the Power of Leadership: A Preview of the Electrolux Manufacturing System (EMS) Webinar

December 4, 2025
KaiNexus recently hosted a webinar I was especially looking forward to: “Unlock the Power of...
Breaking Through Cultural Friction: Respect for People and Sustainable Performance

Breaking Through Cultural Friction: Respect for People and Sustainable Performance

June 9, 2025
When organizations struggle to sustain Lean transformation, people often look first at tools...
Driving a Culture of Patient Safety: Lessons for Healthcare and Beyond

Driving a Culture of Patient Safety: Lessons for Healthcare and Beyond

April 28, 2025
Recently, I had the pleasure of moderating a webinar titled “Driving a Culture of Transforming...
Why Lean Fails Without Psychological Safety

Why Lean Fails Without Psychological Safety

April 16, 2025
TL;DR: Lean tools don't fail because people resist change–they fail because people don't feel...
Preview: Driving a Culture of Accountability – Transforming Patient Safety with KaiNexus (Webinar, April 15)

Preview: Driving a Culture of Accountability – Transforming Patient Safety with KaiNexus (Webinar, April 15)

April 8, 2025
One of the most powerful elements of continuous improvement is the ability to learn from each other...
My Upcoming Webinar on Mistake-Proofing Across Industries

My Upcoming Webinar on Mistake-Proofing Across Industries

February 3, 2025
I'm excited to be presenting this webinar on February 12th at 1 pm ET as part of the KaiNexus...
Top 5 Takeaways from my KaiNexus Webinar: Psychological Safety as a Precondition for Continuous Improvement

Top 5 Takeaways from my KaiNexus Webinar: Psychological Safety as a Precondition for Continuous Improvement

January 8, 2025
TL;DR: Psychological safety isn't optional for continuous improvement. This KaiNexus webinar...
Creating Leader Standard Work (LSW) Across a Distributed Business Model — Webinar Preview

Creating Leader Standard Work (LSW) Across a Distributed Business Model — Webinar Preview

November 7, 2024
I'm happy to be hosting and moderating this webinar that will be presented by Brent Loescher, a...
Embedding Change Management into your Continuous Improvement Initiatives – Webinar Preview

Embedding Change Management into your Continuous Improvement Initiatives – Webinar Preview

September 25, 2024
I'm happy to be hosting and moderating this webinar that will be presented by Melissa Sherman, a...
View Our “Ask Us Anything” Event on Psychological Safety and Lean

View Our “Ask Us Anything” Event on Psychological Safety and Lean

August 20, 2024
Psychological safety is often described as “feeling safe to speak up.” In Lean...
From Strategy to Execution: Webinar with Karen Friedenberg

From Strategy to Execution: Webinar with Karen Friedenberg

July 17, 2024
Are you looking to transform your business strategy into actionable results? Join us for our...

Videos

Video: What is Kaizen?

Video: What is Kaizen?

ByMark Graban July 30, 2014 Comment (0) 1654
I made this short three-minute video for KaiNexus where I try to succinctly answer the question...
Weird Al’s Hilarious “Mission Statement” Song & Video Mocks Corporate Buzzwords

Weird Al’s Hilarious “Mission Statement” Song & Video Mocks Corporate Buzzwords

ByMark Graban July 25, 2014 Comments (10) 2285
“Weird Al” Yanokvic skewers corporate buzzwords in this new song and music video. He...
What Does Lean Flow Look Like in Healthcare? Check Out These Two Videos

What Does Lean Flow Look Like in Healthcare? Check Out These Two Videos

ByMark Graban July 1, 2014 Comments (4) 1422
It's easy for people to think that Lean is about cost-cutting. That would be wrong, but many people...

Mark Graban on YouTube

Michael Chaleff spent a year working as a restaurant magician before law school, in rooms where something went wrong almost every night. In his first week, he opened his best card routine with "imagine you have a deck of cards in your hands," and the woman at the head of the table said, "I don't have hands." He lost the ability to speak. The rule he took from that year: the sin is not the mistake, the sin is what you do after it. 🔵 Why the recovery, not the error, is what an audience actually judges you on 🔵 How a mistake can be something you didn't cause but are still responsible for handling 🔵 What "don't draw attention to your mistake" means for a performer, and where it stops being useful for a leader 🔵 Why anticipating the ways a moment can go wrong is a skill you build before you need it 🔵 What cross-examination teaches about never asking a question blind 🔵 Why giving people more facts makes your case weaker, not stronger 🔵 The four-act structure for micro storytelling, and the fourth act Michael added himself Michael Chaleff served as a Naval officer during the Gulf War, went on to become a DOJ trial attorney, and has performed as a professional magician and mentalist for more than three decades. He now delivers keynotes and workshops on influence and storytelling through Practical Influence. Practical Influence: https://www.practicalinfluence.com/ LinkedIn: https://www.linkedin.com/in/michael-chaleff-9269305/ Full show notes and transcript: https://markgraban.com/mistake363 Subscribe for new episodes of My Favorite Mistake, where leaders share what they got wrong and what they learned. Chapters 00:00 Meet Michael Chaleff 00:54 A year as a restaurant magician 03:31 The card routine, performed live 07:41 "I don't have hands" 10:25 When the mistake isn't yours 13:36 The sin is not the mistake 19:30 Never ask a question you don't know the answer to 29:25 The four-act structure for micro storytelling 38:27 The book in progress
What Magicians Know About Mistakes | Michael Chaleff
Carl Pradelli and his wife Beth were about a year and a half into building Nature City when the Home Shopping Network offered to co-brand a skincare line with them. Eighteen months of work, a great product, packaging designed, launch date set. Then the first production run came back from the contract manufacturer -- and the formula was wrong. Ingredients meant to be at five percent came in at one. Ingredients meant to be at one came in at five. The women who had tested the original samples said the product no longer worked. Episode page with links and more: http://markgraban.com/mistake362 The manufacturer had been an acquaintance of a partner. Carl had visited, checked the certifications, and assumed the rest. When he brought the batch records back to them, they did not offer to remake it. They tried to convince him it was not that bad. Then their accounting department called about the invoice. In this episode of My Favorite Mistake, Carl talks about what he now does differently on any decision that can make or break the business, why he has used the same manufacturer for over 20 years instead of putting every job out to bid, and how he handles it when someone on his own team makes a mistake. What you will learn: 🔵 Why a contract manufacturer is a partner, not an order filler -- and how to tell the difference before you place an order 🔵 The difference between checking credentials and doing real due diligence 🔵 What it tells you when a supplier argues about the severity instead of fixing the problem 🔵 Why quoting every job to three vendors quietly costs more than it saves 🔵 How low barriers to entry reshaped the supplement industry over the last decade 🔵 Where fraud can enter a supply chain -- supplier, manufacturer, and brand owner 🔵 Why Nature City's 365-day guarantee lowered return rates instead of raising them 🔵 Carl's distinction between a mistake made with good intentions and one made twice 🔵 Why fixing the process beats telling people to be more careful Chapters: 00:00 Meet Carl Pradelli and Nature City 01:14 The favorite mistake: a co-branded launch with HSN 02:16 Picking a contract manufacturer on a referral 03:00 Warning signs from the early testers 03:41 What the batch records revealed 04:56 A manufacturer should be a partner, not an order taker 07:00 When a supplier will not own the mistake 08:49 Doing your own due diligence on make-or-break decisions 11:15 Why the cheapest supplier is rarely the cheapest 13:44 Regulation, low barriers, and a flood of new brands 24:12 Where fraud enters the supply chain 26:31 US manufacturing and knowing who made your product 30:08 Leaving private equity to start Nature City 32:41 Empowering employees to make customers happy 34:39 The 365-day guarantee that lowered returns 37:44 What to do when an employee makes a mistake 39:43 Fixing the process instead of saying "be more careful" About the guest: Carl Pradelli is co-founder and CEO of Nature City, a direct-to-consumer nutritional supplements company he and his wife Beth started in 2002. Before becoming an entrepreneur, he spent 12 years in investment banking and private equity focused on consumer goods. He holds an MBA from the Wharton School and a BS from NYU. Nature City: https://www.naturecity.com Subscribe for new episodes of My Favorite Mistake, where leaders share the mistakes that taught them the most -- and what they do differently now. More at https://www.markgraban.com/mistake362 #MyFavoriteMistake #Leadership #SupplyChain #DueDiligence #Entrepreneurship #QualityManagement #SupplierRelationships #ContinuousImprovement #LearningFromMistakes #Podcast
The Supplier Mistake That Sank a Major Launch | Carl Pradelli
Tiffany Auvil spent more than twenty years inside the U.S. healthcare system, starting as a volunteer firefighter, then EMT, then LPN, then registered nurse, and eventually System Director of Outpatient Clinics for a three-hospital health system. Then her husband Dave was diagnosed with cancer, and she found out how little that experience protected them. Her favorite mistake: trusting the system she had worked in for so long. Episode page with links and more: http://markgraban.com/mistake361 The night before Dave's first immunotherapy infusion, the clinic called to say insurance had denied it. Tiffany knew the denial did not make sense. She looked up the J code for the drug and the ICD-10 code for the diagnosis, called the insurer, and traced it back to the source. A prior authorization specialist had entered a diagnosis code in the field meant for the procedure code. Not a real code, so the portal kicked it back as a denial. The oncologist was relieved when Tiffany figured it out, because she had been watching authorizations get denied for a while without knowing why. That was the first failure, not the last. A Gamma Knife authorization sat unsubmitted in a portal because no one attached the clinical notes or hit submit. And the cancer in Dave's brain turned out not to be renal cell carcinoma at all. It was central nervous system lymphoma, a separate primary cancer that had been treated as something else. Tiffany and Mark talk about diagnostic error and the cognitive bias that makes a second primary cancer nearly invisible, about the difference between filing a grievance and actually closing the loop, about what it costs to be the employee who questions things, and about why "good catch" is where learning usually stops instead of where it should start. Dave died at home in April 2025. Tiffany wrote "The No BS Guide for Caregivers: How to Survive the Healthcare Maze" so that families without a Tiffy have something to work from. It is a practical book: scripts for talking to doctors, how to read a bill, how to appeal a denial, and a section on the part most people avoid, the end of life. Chapters 00:00 Introducing Tiffany Auvil 00:59 Her favorite mistake: trusting the system she worked in 01:49 Dave's 2016 renal cell diagnosis and the 2023 recurrence 03:22 The night before immunotherapy: a denial that made no sense 05:00 Tracing it back: a diagnosis code in the procedure code field 07:11 Filing the grievance so it would not happen to someone else 08:37 The Gamma Knife authorization nobody submitted 10:29 Asking insurance CEOs to build error-checking into the portal 11:29 "What do people do who don't have a Tiffy?" 12:28 What the health system did with her feedback 13:09 Brain swelling, an emergency craniotomy, and a second cancer 15:51 Diagnostic error, cognitive bias, and two primary cancers 17:52 A heart attack, an 80 percent blockage, and silos between cardiology and oncology 19:24 Code Help: the escalation tool nobody told them about 21:05 On being the "pain in the butt" employee 22:45 "Don't you worry about that, that's billing's issue" 24:15 Leading so people feel safe speaking up: "Did they die?" 25:58 Why "good catch" is not the end of the learning 27:27 The book: what exactly is the BS? 29:45 Organization, scripts, bills, and appeals 30:16 Hospice earlier than you think, and what she calls "decaf hospice" 33:52 How to actually talk to a doctor in a 15-minute visit 36:44 Nobody in healthcare is superhuman #MyFavoriteMistake #Caregiving #PatientSafety #Healthcare #CaregiverSupport #PriorAuthorization #DiagnosticError #PsychologicalSafety #HealthcareLeadership #CancerCaregiver #Nursing #ContinuousImprovement
One Wrong Code Nearly Stopped His Cancer Treatment | Tiffany Auvil, "The No BS Guide for Caregivers"
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