Popular Posts
Workplace Deaths by Age: Why Counts and Rates Tell Different Stories Where Was Toyota’s First Andon Cord? If This Were Assembly Line Medicine, You Could Stop the Line Outcome Bias, Near Misses, and Two Vials of Vecuronium Highlights From Five Conversations With Karen Martin Toyota Copied Ford’s Suggestion System–and Got Far Better Results GE Aerospace’s Greenville Plant Proves Larry Culp’s “Safety First” Wasn’t Just Talk “Most People Wouldn’t”: Fear, Gratitude, and Reporting Medical Errors An Insulin Error Killed a Hospital Patient. How Does Every Other Hospital Learn From It? What If Every Hospital Learned From Every Other Hospital’s Safety Incidents?
Conceptual illustration of one hospital reporting a safety incident, with the warning transformed into shared learning that spreads through connected pathways to multiple hospitals, each shown with safety shields and improvement symbols.

What If Every Hospital Learned From Every Other Hospital’s Safety Incidents?

ByMark Graban August 14, 2026 Comment (0) 64
On Thursday, I wrote about the death of Donald Gough at the University Hospital of Wales in Cardiff...
A single open door stands alone in a wide, empty slate-blue space, with warm light spilling through the doorway and casting a long beam across the floor.

An Insulin Error Killed a Hospital Patient. How Does Every Other Hospital Learn From It?

ByMark Graban August 13, 2026 Comment (0) 146
A vintage “Suggestion Plan” booklet sits between a dark, top-down factory culture and a bright, collaborative improvement team, illustrating how the same formal system can produce very different results.

Toyota Copied Ford’s Suggestion System–and Got Far Better Results

ByMark Graban August 12, 2026 Comment (0) 245
nursing error medication syringe

“Most People Wouldn’t”: Fear, Gratitude, and Reporting Medical Errors

ByMark Graban August 11, 2026 Comment (0) 178

Mark Graban

Welcome to my blog!

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

Alan Robinson on Continuous Improvement for All and Practical Innovation in Government

Alan Robinson on Continuous Improvement for All and Practical Innovation in Government

ByMark Graban July 26, 2022 4595
Scroll down for how to subscribe, transcript, and more My guest for Episode #451 of the Lean Blog Interviews Podcast is Dr. Alan G. Robinson. He specializes in managing ideas, building...
Torbjorn Netland, PhD on Company Production Systems, Lean & Technology, and More

Torbjorn Netland, PhD on Company Production Systems, Lean & Technology, and More

ByMark Graban July 12, 2022 2476
Scroll down for how to subscribe, transcript, and more My guest for Episode #450 of the Lean Blog Interviews Podcast is Professor Torbjorn Netland, Ph.D. Tor is the chair of production and operations...
Interview with Lisa Yerian, MD On The Cleveland Clinic’s Improvement Journey And How Lean Got Them Through COVID

Interview with Lisa Yerian, MD On The Cleveland Clinic’s Improvement Journey And How Lean Got Them Through COVID

ByMark Graban June 28, 2022 2962
My guest for Episode #449 of the Lean Blog Interviews Podcast is Lisa Yerian, MD. She joined Cleveland Clinic in anatomic pathology in 2004, and has held several pathology and...
Just the Lean Talk — Mark Graban & Jamie Flinchbaugh Discuss Lean Supply Chains

Just the Lean Talk — Mark Graban & Jamie Flinchbaugh Discuss Lean Supply Chains

ByMark Graban June 7, 2022 1195
Listen: Here is the episode if you want to stream the audio: As I did two weeks ago, when Jamie Flinchbaugh and I talked about “Lean 101” training (and should you skip it), I'm sharing...

More Blog Posts

A man speaking up during a workplace discussion, representing a culture where employees feel safe to raise concerns.

Why “Speak-Up Culture” Might Be Better Language Than Psychological Safety

Mark GrabanByMark Graban February 4, 2026 4473
TL;DR: People speak up at work only when it feels safe and worth it. Psychological safety reduces fear–but without effective problem solving, speaking up quickly feels futile. A true speak-up...
ge annual report ceo letter tape

Larry Culp’s 2025 CEO Letter: Why Safety and Lean Leadership Drive GE Aerospace’s Results

Mark GrabanByMark Graban February 2, 2026 3554
ray zinn CEO mistakes failure

Ray Zinn on Learning from Mistakes — and Why “Fail Fast, Fail Often” Misses the Point

Mark GrabanByMark Graban February 1, 2026 1205
1981 newspaper headlines showing mixed reactions to Ford and UAW learning from Japanese auto plants

What Ford and the UAW Saw in Japan in 1981 — and Why Some Leaders Missed the Lesson

Mark GrabanByMark Graban January 28, 2026 1020
Automated valet request process contrasted with personal hotel valet service, highlighting added steps and waste.

When “AI Improvement” Adds Waste Instead of Value: A Hotel Valet Example

Mark GrabanByMark Graban January 28, 2026 892

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

What Salem Health Leaders Learned from Visiting Japan About Lean and Kaizen

What Salem Health Leaders Learned from Visiting Japan About Lean and Kaizen

ByMark Graban February 1, 2012 Comments (2) 1461
TL;DR: Salem Health leaders and frontline staff visited Japan to study Lean and Kaizen–and...
KaiNexus Education Video #5 – Moving Beyond Suggestion Boxes

KaiNexus Education Video #5 – Moving Beyond Suggestion Boxes

ByMark Graban January 30, 2012 Comment (0) 1023
Here is the fifth in our series of short, simple Kaizen education videos  from KaiNexus, a software...
The Office’s Paper Sales Gimmick–and What It Reveals About Bad Metrics

The Office’s Paper Sales Gimmick–and What It Reveals About Bad Metrics

ByMark Graban January 19, 2012 Comments (6) 2610
A Vivid Example of Gaming the Numbers on “The Office” NBC's “The Office” is...
Kaizen Videos from a Franciscan “Kaizeneer”

Kaizen Videos from a Franciscan “Kaizeneer”

ByMark Graban January 9, 2012 Comments (3) 854
My Healthcare Kaizen  co-author Joe Swartz works in Indianapolis in the Franciscan St. Francis...

This Commercial is Not Exactly the “Five Whys”

ByMark Graban January 7, 2012 Comment (0) 916
If you're watching college football bowls or the NFL playoffs, it's hard not to see this commercial...

Mark Graban on YouTube

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"
"Patients are not cars." People say that to me in hospitals, with complete seriousness. I'd like to think I look a little smarter than that. In this clip from my conversation with David J. Bland on the How I Tested That podcast, I talk about why preconceptions about manufacturing get in the way. Play word association and you get old, dirty, dangerous, outdated, what my grandpa did. Fred Flintstone, Homer Simpson, and Peter Griffin all worked in something manufacturing adjacent. It isn't a world people admire, so the question becomes "what could we possibly learn from it?" Quite a lot, once you look at processes, systems, mindsets, behaviors, and culture rather than equipment. Those transfer. Part of the objection is a defense mechanism and part of it is professional pride, and I'm empathetic to both. But it argues against something nobody proposed. No one is putting the operating table on a slowly moving conveyor belt. Anyone who suggested that should get thrown out of the hospital, because they'd be copying a tool instead of helping people adapt the thinking. That's what the Lean startup movement has generally done well. Full episode: https://www.youtube.com/watch?v=d5MgFuM3y2Q More from me: https://www.markgraban.com/ LinkedIn: https://www.linkedin.com/in/mgraban/
"Patients Are Not Cars" and Other Arguments I Hear in Hospitals
The Andon cord at Toyota works because pulling it is safe. People are taught that flagging a problem is the job, and within seconds someone shows up asking what's going on and what would help. Psychological safety is the foundation underneath the tool. In this clip from my conversation with David J. Bland on the How I Tested That podcast, I get to the comparison that makes the point. According to the BBC's reporting from inside both plants, the Andon cord was pulled roughly 2,000 times a week at a Toyota plant and twice a week at a Ford truck plant. I would never read that as Toyota employees being better at spotting problems or braver about speaking up. Take a Toyota team member, drop them into that Ford plant, and they would learn quickly not to pull the cord. Same person, different fishbowl. The transferable idea isn't the cord. It's that people can ask for help or admit a mistake without being punished, and that Toyota doesn't blame individuals for systemic problems. Healthcare does that constantly, and nurses burn out and quit. Full episode: https://www.youtube.com/watch?v=d5MgFuM3y2Q More from me: https://www.markgraban.com/ LinkedIn: https://www.linkedin.com/in/mgraban/
Toyota's Andon Cord: 2,000 Pulls a Week vs. 2 at Ford
Psychological safety does not happen by accident. At KaiNexus, where I'm a senior advisor, the co-founders set out to build culture on purpose instead of letting it happen, and the surveyed scores are high because of how leaders behave day to day. In this clip from my conversation with David J. Bland on the How I Tested That podcast, I talk about co-founder and CEO Greg Jacobson, an ER doctor by training, who is usually the first to say "I don't know," "I might be wrong," or "I made a mistake." That isn't false modesty from someone with nothing to prove. It sets the tone, and other leaders there reinforce it. I also push back on a common misreading. High psychological safety is not a place where everyone is coddled and nobody disagrees. It usually produces more disagreement, handled professionally and aimed at the mission. The best idea wins by being tested, not by who said it. None of the Lean tools work well without it. Full episode: https://www.youtube.com/watch?v=d5MgFuM3y2Q More from me: https://www.markgraban.com/ LinkedIn: https://www.linkedin.com/in/mgraban/
Psychological Safety at KaiNexus: Why Our CEO Says "I Don't Know"
Bill Rasmussen got fired by the Hartford Whalers, then had an idea for sports television around the clock. He funded it by burning through his own money, his credit cards, his son's money, his father's, his sister's, his brother's. A venture capitalist kept it alive for a while. Six months before launch, he was out of cash and did a deal with Getty Oil. Getty took financial control. That part may have been unavoidable -- Mike Soltys, who Bill hired as an intern, says a better financial deal probably wasn't there to be had. 🔵 The loose end nobody tied up: employment contracts 🔵 Bill's son Scott was shown the door at launch 🔵 Other early key figures were pushed out even earlier 🔵 Bill himself was gone a year later 🔵 Scott says the Getty experience taught him how to negotiate, and he did far better afterward Bill says he doesn't look back and doesn't name regrets. Mike, who has tried to pin him down on one, points to this. When you're negotiating away control, the terms that protect the people are the ones easiest to defer and hardest to recover. Subscribe for conversations with leaders about the mistakes that taught them the most. #Leadership #Entrepreneurship #ESPN #Negotiation #MyFavoriteMistake
He Founded ESPN And Had No Employment Contract | Mike Soltys on Bill Rasmussen
No show in television history has aired more often than SportsCenter. Do live TV that many times and mistakes are guaranteed. The question isn't whether they happen -- it's what the organization does next. Mike Soltys spent decades running communications at ESPN. His answer: they put the bloopers in the anniversary shows. 🔵 The brand promise was to take the sports seriously, not themselves 🔵 Innocent on-air flubs got celebrated rather than buried 🔵 Blooper reels became a fixture of anniversary programming 🔵 A sense of humor was a hiring trait, not an accident 🔵 The audience got to laugh along a second time Most organizations say they want people to admit mistakes. Far fewer put them on a highlight reel. The difference between those two postures is what people actually learn to do when something goes wrong. Subscribe for conversations with leaders about the mistakes that taught them the most. #PsychologicalSafety #Leadership #ESPN #LearningFromMistakes #MyFavoriteMistake
ESPN Celebrates Its Bloopers On Purpose | Mike Soltys
The "This Is SportsCenter" campaign ran on one premise: that Bristol, Connecticut was somehow the center of the sports universe, with athletes casually wandering the halls. One Friday afternoon, the crew needed what they called a "network suit." Mike Soltys was known around the building for keeping a blue blazer on the back of his door in case a TV interview came up on short notice. He got the call. 🔵 The bit: musicians turned sportscaster agents 🔵 Kenny Rogers the singer (not the pitcher) and Dee Snider of Twisted Sister were in the campaign 🔵 Mike's scene was Davy Jones of The Monkees negotiating a contract for Karl Ravech 🔵 His job was to sit there and get screamed at, take after take 🔵 His one line, delivered as flatly as possible: "We love Karl" Not every story on this show is a hard-won lesson. Sometimes it's just what happens when you keep a blazer on your door. Subscribe for conversations with leaders about what they've learned, including from their mistakes. #ESPN #SportsCenter #Leadership #MyFavoriteMistake
Getting Yelled At By Davy Jones For ESPN | Mike Soltys
ESPN's very first SportsCenter was supposed to prove the network could go live to a remote interview. They lined up Chuck Fairbanks, about to debut as Colorado's head coach. They tested the connection. It worked. Then they went to air and got a picture with no audio. Mike Soltys spent decades at ESPN and helped tell the story of its founding. Two lessons stand out here: 🔵 Preparation lowers the odds of failure -- it doesn't remove them 🔵 What separates teams is the next ten seconds, not the checklist 🔵 Nearly fifty years later, everyone in the room that night remembers it differently 🔵 Mike's tiebreaker is Bill Rasmussen's business diary, written in the moment If you wait to review what went wrong, you don't get facts. You get folklore. Subscribe for more conversations with leaders about the mistakes that taught them the most. #Leadership #ESPN #LearningFromMistakes #PsychologicalSafety #MyFavoriteMistake
ESPN's First Live Remote Failed On Air | Mike Soltys
Bill Rasmussen burned through his own money, his credit cards, his son's money, and his family's money to get a 24-hour sports network to the edge of launch. Then he signed the Getty Oil deal that funded ESPN and cost him control of it. Employment contracts for himself, his son Scott, and the early team were left as loose ends to settle after the contract. They never got settled. Two early leaders were pushed out almost immediately, Scott was shown the door at launch, and Bill was gone a year later. Mike Soltys was ESPN's first PR intern, hired in 1980. He stayed 43 years, the last 20 as a vice president in corporate communications, and he is now the network's official historian. He tells Bill's story on his behalf, because Bill still refuses to call it a mistake. What you'll hear: 🔵 Why financial control and employment protection are two separate negotiations, and why founders lose the second one 🔵 What Scott Rasmussen changed about how he negotiates after watching the Getty deal 🔵 How the 1970s oil crisis put a sports network on an oil company's balance sheet next to a logging operation 🔵 The penny-per-subscriber-per-day idea that got Bill laughed out of cable company meetings and became the industry's revenue model 🔵 Why ESPN's first live remote interview failed on opening night, and why everyone who was there remembers it differently 🔵 How Mike used Bill's 1978-79 business diary to settle disputes between people's memories 🔵 Why ESPN puts its bloopers in anniversary specials instead of burying them 🔵 What Jimmy Pitaro and George Bodenheimer say has lasted at ESPN since 1979 Mike Soltys is the producer of the documentary "Sports Heaven: The Birth of ESPN" and a co-author of the book of the same name with founder Bill Rasmussen, with a foreword by Chris Berman. The audiobook features 22 interview voices alongside narrator Will Damron. #MyFavoriteMistake #ESPN #Entrepreneurship #Leadership #SportsBusiness Timestamps 00:00 Meet Mike Soltys, ESPN's first PR intern 01:01 The mistake: a deal signed without employment contracts 03:03 Bill Rasmussen's ventures before and after ESPN 05:27 Why an oil company bought a sports network 07:31 Getty to Texaco to ABC to Disney 09:00 "Intentional Optimism" and the original book title 10:54 The cable business model everyone got wrong 15:14 The go.com era and the value of four letters 16:12 Launching ESPN2 to reach an audience they already had 19:21 Filling the hours: darts, Aussie rules football, and The Ocho 24:35 The first live event: slow pitch softball and a beer sponsor problem 27:05 The first live remote interview failed on opening night 28:57 Why ESPN celebrates its bloopers 30:36 Inside a "This Is SportsCenter" commercial 33:16 The hardest PR moments in 43 years 34:39 What still remains from 1979 36:42 Why the "Sports Heaven" audiobook is worth hearing
The Deal That Saved ESPN and Cost Its Founder Bill Rasmussen Everything | Mike Soltys
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