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)

Billy Taylor on Lean Leadership, Culture, and Ownership (Part 1)

ByMark Graban November 29, 2017 2527

My guest for Episode #293 of the podcast is a dynamic speaker and manufacturing leader, Billy R. Taylor. I saw him speak a few years ago at a Shingo Prize Conference and I've wanted to get him on the...

Podcast #292 – The Co-Authors of “Motivational Interviewing for Leadership”

ByMark Graban November 9, 2017 3272

My guests for Episode 292 are the three co-authors of an excellent book, Motivational Interviewing for Leadership: MI-LEAD: Jason Wilcox, Director of Education and Connected Care at VA...

Podcast #291 – Jeff Roussel on the Current #Lean (and P.I.) Landscape

ByMark Graban October 24, 2017 1343

My guest for Episode 291 is my friend and colleague, Jeff Roussel (@jeff_roussel on Twitter). Jeff is the VP of Sales at KaiNexus, a technology company that I have been involved with for over six...

Eric Ries on The Startup Way, Lean Startup, and Corporate Innovation

ByMark Graban October 16, 2017 9162

Joining me again for episode 290 is a three-time guest, Eric Ries. When we first talked, in episode 115 six years ago, his New York Times bestselling book The Lean Startup was being published. In...

The Mistakes That Make Us Wins the Shingo Publication Award

ByMark Graban February 10, 2025 6301

I'm very excited to announce that my latest book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation, has been officially selected as a recipient of the Shingo Publication...

Lean Whiskey #50: The Final Episode… or Is It?

ByMark Graban February 7, 2025 6816

Ryan McCormack’s Operational Excellence Mixtape: February 7, 2025

ByRyan McCormack February 7, 2025 5978

Goethe’s Timeless Wisdom: Lessons for Lean Thinking and Continuous Improvement

ByMark Graban February 5, 2025 5027

An Experiment with AI Book Translation: “The Mistakes That Make Us” in 31 Languages

ByMark Graban February 4, 2025 2414

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...

Teachable Moments from PRHI

ByMark Graban March 15, 2010 Comment (0) 793

Hat tip to my friend Jack for pointing out these short videos from the Pittsburgh Regional Health...

My Lean Healthcare Talk at MIT, 2009

ByMark Graban March 10, 2010 Comment (1) 787

Last July, I was fortunate to be invited to give a guest lecture at the MIT EdNet / Lean Advancement...

Video Interview with LEI’s Jim Womack

ByMark Graban March 8, 2010 Comments (24) 1549

Jim Womack visited Lantech, a manufacturer of stretch wrappers and other packaging equipment. While...

Mark Graban on YouTube

Retired Navy pilot and airline captain Steve Montague describes a month of flying with a captain who shut down every suggestion he made. Then, descending into Albuquerque, Steve saw the airspeed at 300 knots below 10,000 feet, where the limit is 250. He decided to say nothing.

The captain caught it himself and slowed down. Steve calls it one of his least professional days, and he owns it plainly: he let his pettiness exceed his professionalism.

I find this more useful than the usual speaking-up story, because the person who stayed silent is the same person who teaches hospitals how to speak up. A trained, motivated professional went quiet after enough repetitions of being told his input was not wanted. That is worth thinking about the next time someone concludes their people just need more courage.

Watch the full conversation: https://youtu.be/vfVTIKqi45I

Why This Pilot Stayed Silent About a Speed Violation

Steve Montague watched his captain fly 50 knots over the speed limit below 10,000 feet, and he said nothing on purpose. Speaking up in the cockpit is trained, expected, and required -- and after a month of having every suggestion shut down, he decided to let the man be wrong.

Episode page: http://markgraban.com/mistake364

The captain caught it himself and chewed him out. Nothing bad happened. Montague still calls it the least proud professional moment of his career, and what bothers him is not the chewing out. It's that he let his pettiness exceed his professionalism. He came away with two commitments: never do that again, and never build an environment where somebody wants to withhold help from him.

🔵 Why deliberate silence and fear-driven silence look identical from the outside
🔵 What a captain can say before every flight that turns challenging him into compliance rather than courage
🔵 Why "fear or futility" is an incomplete list, and what embarrassment and role confusion add to it
🔵 Why letting people report mistakes without punishment is not permissiveness
🔵 The four-step assertion script Monty teaches in operating rooms, and why "I have a concern" is nearly impossible to argue with
🔵 What happened when a first officer stopped the airplane on a taxiway because he thought Monty had misheard a clearance
🔵 Why aviation moved to a first-name rule in the 1980s, and what that has to do with speaking up
🔵 The black line and the blue line: what happens when a rule is written to be ignored

Timestamps

00:00 Meet Captain Steve "Monty" Montague
01:58 The mistake: choosing not to speak up
06:40 Where crew resource management came from
07:51 The black line and the blue line
11:47 The only name he put on the do-not-pair list
15:27 Fear, futility, and what else keeps people quiet
23:43 What he told every crew before every flight
28:19 The first officer who stopped the airplane
31:20 Why near misses make the news
34:09 First names in the operating room

The Pilot Who Decided to Let His Captain Be Wrong | Steve Montague

Cruel and unfriendly bosses are far too common, and companies usually had a hand in creating them. I started my career in the auto industry working for yellers and screamers who blamed and shamed workers for company performance that was never theirs to control.

In this clip I describe two categories. The first is people promoted into management for the wrong reasons. Companies tend to pick their strongest individual performers, which does not predict much about leading people, and the promotion is often the only route to higher pay. Those new managers then get little leadership training and feel pressure to act like they have all the answers.

The second is the founder CEO. It takes a healthy ego to start a business at all, given the survival odds. The founders whose companies last are usually the ones who accept that they cannot have all the answers and who draw ideas out of employees regardless of rank or tenure.

🔵 How common bad management really is
🔵 Why strong individual performers get promoted into the wrong job
🔵 What happens when new managers get no training
🔵 Ego, founders, and knowing what you do not know

Watch the full interview: https://youtu.be/b4Z9RdjgTp8

Why Bad Bosses Are So Common: Promotion, Training, and Ego