Lean Blog: Lean Management & Continuous Improvement

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

ByMark Graban August 14, 2026 Comment (0) 67

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) 148

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) 250

“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)

Interview with Jamie Flinchbaugh On “People Solve Problems” – His New Book

ByMark Graban November 16, 2021 2955

My guest for Episode #432 of the Lean Blog Interviews Podcast is Jamie Flinchbaugh, an old friend of mine and a frequent guest (Episodes 5, 6, 10, 64, and 261...

Sonia Singh: From Lean Coach to Leadership Coach, From Consultant to Coach

ByMark Graban November 9, 2021 1602

Scroll down for how to subscribe, transcript, and more My guests for Episode #431 of the Lean Blog Interviews Podcast is Sonia Singh, a certified Lean Six Sigma Master Black Belt, executive...

The Power of Process: Interview With Matt Zayko and Eric Ethington

ByMark Graban November 2, 2021 1966

Scroll down for how to subscribe, transcript, and more My guests for Episode #430 of the Lean Blog Interviews Podcast are Eric Ethington and Matt Zayko, the authors of the new book The Power...

John Chacon on Continuous Improvement and the Dangers of Paying People to Think

ByMark Graban October 26, 2021 2316

Scroll down for how to subscribe, transcript, and more My guest for Episode #429 of the Lean Blog Interviews Podcast is John Chacon, the Director of Construction Excellence at Black &...

Blank chart showing metrics for success, impact over time. Two concerned employees review blank chart, lacking metrics.

Don’t Start the New Year with Blank Charts: A Better Way to Manage Metrics

ByMark Graban January 1, 2026 4542

Charts like this always make me wonder why we throw away the additional context of data from 2016 when we start the 2017 chart. It's unlikely that January 1st in any given year is the magical...

Play button icon next to Santa riding a tricycle with a large red sack, against a plain wall background.

Gemba Claus Is Comin’ to Town: A Lean Christmas Song Parody

ByMark Graban December 23, 2025 6158

LeanBlog.org 2025 Second Half Top 10: Most-Read Articles on Lean, Leadership, and Improvement

ByMark Graban December 23, 2025 3581

Vaccine vials labeled for measles, mumps, and rubella, with a cartoon syringe character waving.

U.S. Measles Cases Over Time: Signal or Noise in the Data?

ByMark Graban December 18, 2025 1223

A Christmas Tale That Explains Process Behavior Charts

ByMark Graban December 18, 2025 12553

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...

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

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

April 28, 2025

Recently, I had the pleasure of moderating a webinar titled “Driving a Culture of Transforming...

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)

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

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

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

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

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

August 20, 2024

Psychological safety is often described as “feeling safe to speak up.” In Lean...

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...

Preventing Brain Surgery Errors… Not Exactly Rocket Science

ByMark Graban June 24, 2011 Comments (16) 1486

Thanks to those of you who sent me the link to this Washington Post article called “The Pain...

A Thoughtful Commencement Message from Stephen Colbert

ByMark Graban June 20, 2011 Comments (2) 1706

I'm a proud graduate of Northwestern University, industrial engineering class of 1995. Our '95...

Introducing Dr. Les Muda: The World’s First Lean Healthcare Comedian

ByMark Graban June 15, 2011 Comments (5) 1979

In today's post, I'm happy to introduce Dr. Les Muda, the World's First Lean Healthcare Comedian...

Summit 2011: Lean Transformation Videos from St. Boniface Hospital

ByMark Graban June 9, 2011 Comment (0) 840

We had a great first day at our Lean Healthcare Transformation Summit in Seattle (with lots of...

Lean Lessons for Healthcare from a Boeing 737 Factory Video

ByMark Graban June 3, 2011 Comment (1) 1249

Podcaster Cali Lewis (a fellow DFW-area Texan) hosts a show called GeekBeat.tv, where she normally...

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"

He Founded ESPN And Had No Employment Contract | Mike Soltys on Bill Rasmussen

ESPN Celebrates Its Bloopers On Purpose | Mike Soltys

Getting Yelled At By Davy Jones For ESPN | Mike Soltys

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

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

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

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

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

Mark Graban

Welcome to my blog!

Lean Blog Interviews Podcast

Interview with Jamie Flinchbaugh On “People Solve Problems” – His New Book

Sonia Singh: From Lean Coach to Leadership Coach, From Consultant to Coach

The Power of Process: Interview With Matt Zayko and Eric Ethington

John Chacon on Continuous Improvement and the Dangers of Paying People to Think

More Blog Posts

Don’t Start the New Year with Blank Charts: A Better Way to Manage Metrics

Gemba Claus Is Comin’ to Town: A Lean Christmas Song Parody

LeanBlog.org 2025 Second Half Top 10: Most-Read Articles on Lean, Leadership, and Improvement

U.S. Measles Cases Over Time: Signal or Noise in the Data?

A Christmas Tale That Explains Process Behavior Charts

Webinars

Ask Karen Martin Anything on Operational Excellence: A KaiNexus Webinar

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

Breaking Through Cultural Friction: Respect for People and Sustainable Performance

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

Why Lean Fails Without Psychological Safety

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

My Upcoming Webinar on Mistake-Proofing Across Industries

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

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

Embedding Change Management into your Continuous Improvement Initiatives – Webinar Preview

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

From Strategy to Execution: Webinar with Karen Friedenberg

Videos

Preventing Brain Surgery Errors… Not Exactly Rocket Science

A Thoughtful Commencement Message from Stephen Colbert

Introducing Dr. Les Muda: The World’s First Lean Healthcare Comedian

Summit 2011: Lean Transformation Videos from St. Boniface Hospital

Lean Lessons for Healthcare from a Boeing 737 Factory Video

Mark Graban on YouTube

Mark Graban

Welcome to my blog!

Lean Blog Interviews Podcast

More Blog Posts

Webinars

Videos

Mark Graban on YouTube

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