Popular Posts
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 Somebody Pulled the Cord and the Chairman of Radiology Showed Up
No posts found.

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

Podcast #281 – Julie Firman, a CNO’s Role in Lean Transformation

Podcast #281 – Julie Firman, a CNO’s Role in Lean Transformation

ByMark Graban May 10, 2017 1938
Joining me for Episode #281 of the podcast is Julie Firman, DNP, RN, FACHE, the Vice President/ System Chief Nursing Officer (CNO) at Southern Illinois Healthcare...
John Dyer on Dr. Deming’s Red Bead Experiment, Word by Word (Podcast #280)

John Dyer on Dr. Deming’s Red Bead Experiment, Word by Word (Podcast #280)

ByMark Graban May 3, 2017 2262
A returning guest today for episode #280 is John Dyer, president of his consulting firm, JD&A, Inc., and a contributor for IndustryWeek.com. Today, our focus is the famed "Red Bead Experiment." We'll...
A Psychologist’s Use of Kaizen and What We Can Learn

A Psychologist’s Use of Kaizen and What We Can Learn

ByMark Graban April 27, 2017 2234
Back in 2012, I did a podcast interview (Episode 153) with a psychologist and family therapist, Robert Maurer, PhD. It's been almost five years since the discussion, but I'm often reminded of what I...
Podcast #278 – Tom Bouthillet, Lean in Fire Fighting (the Real Kind) and EMS

Podcast #278 – Tom Bouthillet, Lean in Fire Fighting (the Real Kind) and EMS

ByMark Graban April 12, 2017 1904
People often talk about “fire fighting” in a colloquial way. Today, my guest for episode #278 of the podcast is an actual professional fire fighter, Tom Bouthillet, who serves as Fire Captain /...

More Blog Posts

From Noise to Clarity: How KaiNexus Learned to Focus on What Matters

From Noise to Clarity: How KaiNexus Learned to Focus on What Matters

Mark GrabanByMark Graban January 15, 2025 2037
KaiNexus uses Process Behavior Charts and Deming's principles to separate signal from noise, helping leaders avoid reactive decisions and focus on improvements that truly matter. When I first began...

Forget the Template: Why Lean Success Depends on Scientific Thinking and Action

Mark GrabanByMark Graban January 15, 2025 2399

Ryan McCormack’s Operational Excellence Mixtape: January 9, 2025

Ryan McCormackByRyan McCormack January 10, 2025 5113

Safety First: GE Aerospace’s Lynn Facility Demonstrates True Lean Leadership

Mark GrabanByMark Graban January 9, 2025 3041

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

Mark GrabanByMark Graban January 8, 2025 1838

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

“Strategy Deployment” Online Video Education from John Toussaint

ByMark Graban January 27, 2010 Comments (2) 1701
One project I'm involved with at the LEI is an online video education event on the topic of...

Lean Healthcare Overview Video from Americans in Sweden

ByMark Graban January 26, 2010 Comment (1) 922
As I'm currently in Sweden, I was reminded of this video I found recently featuring John Black, a...

Video No Longer Available

ByMark Graban January 22, 2010 Comment (0) 838
Sorry, the hospital had reconsidered and they asked me to take the video down. I'm sorry for any...

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
Subscribe