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The discussion centers on Ford's Process Coach role: what it's supposed to be, what it often is in practice, and why the gap between those two things is a leadership system problem, not a training problem. Mark also looks at why Toyota's Group Leader model works where Ford's equivalent often doesn't — and why a senior UAW worker has rational, concrete reasons to turn down a promotion to Process Coach even if they're the most qualified person on the floor.

If your organization has rebranded its supervisors without redesigning the conditions those supervisors work in, this episode is worth your time.

Three years ago, The Mistakes That Make Us came out. Around the same time, Elisabeth Swan published Picture Yourself a Leader. Both books' third birthdays felt like a decent reason to get together and talk.

On Thursday, May 7, at 1 PM ET, Elisabeth and I are co-hosting a live event on LinkedIn called “Still Learning: Mistakes and Leadership Lessons.” We will talk about what readers have shared with us, what has held up, what we might write differently now, and the leadership questions that keep coming back. Attendees will have a chance to win books and a few other things.

Check out the blog post

In this episode, Mark walks through how the tool works, why it runs on Claude instead of ChatGPT, and what makes coaching mode fundamentally different from the "here are 7 steps" approach that every other AI defaults to. He also covers the two knowledge sources (Book Search and Book Plus), the two response styles (Tell Me and Coach Me), and how the combinations create different experiences depending on what you need.

Mark is opening 50 founding memberships at $49/year -- price locked for life -- and hosting a LinkedIn Live demo on Tuesday, March 10 at 11 AM ET where he'll take audience questions and run them through the coach on screen, unscripted. You can also try the full product free for 48 hours at leanhospitalsbook.com/start.

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 and I got to see the amazing Brandi Carlile perform near Chicago on Friday night.

She is a multi-Grammy award-winning singer, musician, and songwriter — though calling her a solo artist would be a mistake...

TL;DR: Deming and Toyota's Fujio Cho asked the same uncomfortable question: why do management systems destroy motivation in people who started out wanting to do good work? The answer points to practices leaders can actually change.

Check part 1 of this series in episode 464,

TL;DR: In a 1993 speech, Toyota leader Fujio Cho said organizations can create their own Lean systems, but success depends on three principles: leaders going to the gemba, asking “why” to learn from problems, and respecting and motivating people — not copying Lean tools.

What if a book could become an interactive coach instead of a static reference?

In this episode, Mark Graban shares a behind-the-scenes look at his experiment turning the award-winning book Lean Hospitals into an AI-powered chat assistant embedded directly on his website. What started as a Friday afternoon curiosity quickly evolved into a working WordPress plugin, a subscription model, and a new way to deliver improvement knowledge on demand.

Mark walks through how non-developers can use AI tools to write functional software, what he learned comparing different AI coding assistants, and why the real breakthrough isn’t the technology — it’s the ability to access proven Lean thinking at the moment of need.

He also explores the broader implications for leaders and organizations: Could AI assistants trained on your own standards and practices reinforce daily management, support problem solving at the gemba, and scale coaching without more training sessions?

This episode is both a practical case study in rapid experimentation and a thoughtful discussion about the future of learning, leadership, and continuous improvement in the age of AI.

Key themes include:

• Turning expertise into on-demand guidance

• Using AI to prototype software without coding experience

• Subscription models for knowledge delivery

• Point-of-use support for leaders and frontline teams

• Why technology alone won’t create a Lean culture — but can reinforce the right behaviors

If you care about scaling improvement capability, preserving organizational knowledge, or simply experimenting with new ways to learn, this episode offers a candid look at what works, what broke, and what might come next.

In this episode, I explore the 1987 NUMMI Management Practices Executive Summary — a confidential General Motors report that documented why the joint venture between GM and Toyota was succeeding so dramatically.

What’s striking is how clearly GM’s own study team understood the real drivers of NUMMI’s performance. It wasn’t tools. It wasn’t discipline. It wasn’t copying Toyota’s production techniques.

It was leadership.

The report describes a management system built on mutual trust and respect, problem-solving at the source, quality built into the process, and supervisors acting as coaches rather than enforcers. Nearly 40 years ago, GM documented that NUMMI’s success came from management philosophy — not Lean tools.

And yet, insight proved easier than action.

In this episode, I walk through the document’s key sections, including NUMMI’s basic principles and five major management strategies, and reflect on why translating those lessons into broader cultural change proved so difficult.

If you’re interested in Lean leadership, psychological safety, or the origins of what we now call continuous improvement, this historical document offers powerful — and still relevant — lessons.

In this audio version of the post, Mark Graban reflects on a rare kind of CEO message—one that treats safety not as a compliance checkbox or slogan, but as a core leadership responsibility and a living example of Respect for People.

Drawing from the 2025 annual report and CEO letter from GE Aerospace and its leader Larry Culp, Mark explores what it means when safety truly comes first in SQDC—and how that ordering signals what leaders value most, especially under pressure.

This episode looks at how safety is embedded into systems, structure, incentives, and daily management through GE’s FLIGHT DECK operating system, rather than being isolated in a department or reduced to culture talk. You’ll hear why safe systems surface problems, why speaking up must be protected (not just encouraged), and why safety is one of the strongest leading indicators of psychological safety and continuous improvement.

For leaders working to build trust, learning, and real operational excellence, this is a practical example of what “Respect for People” looks like in action.

The post examines a rare example of a Fortune 50 CEO—Larry Culp of GE Aerospace—describing operational excellence not through slogans or dashboards, but through safety, trust, and small frontline improvements that compound into real results.

This episode explores:

• What it looks like when a CEO truly understands the work

• Why Respect for People shows up in system design, not values statements

• How safety, trust, and daily improvement drive performance

• Why Lean leadership is about behavior, not buzzwords

A practical and concrete example of Lean leadership in action—told through the words, stories, and operational details that CEOs rarely share this openly.

Many improvement efforts stall not because of poor strategy or missing Lean tools, but because people don’t feel safe speaking up.

In this Lean Blog Audio episode, Mark Graban explains why psychological safety is a foundational requirement for continuous improvement. Drawing from his book The Mistakes That Make Us and decades of experience in healthcare, manufacturing, and other industries, Mark explores how fear, blame, and leader reactions silence learning — and how different leadership behaviors make improvement possible.

The episode also previews themes from Mark’s upcoming workshop at Shingo Connect 2026, including what psychological safety is (and is not), how it supports accountability rather than lowering standards, and why learning from mistakes depends on creating environments where people can speak honestly without fear.

When Ford and UAW leaders traveled to Japan in 1981, they expected to find better machines, tighter processes, and technical secrets. What they found instead was something far more powerful: a management system built on listening, trust, and respect for people.

In this Lean Blog Audio episode, Mark Graban revisits the 1981 Ford–UAW study trip to Toyota, Nissan, and Mazda through the reflections of Don Ephlin, one of the UAW’s most thoughtful leaders. The visitors didn’t discover better workers or superior discipline — they discovered a system that expected people to think, speak up, and improve the work.

From the meaning of the andon cord to the lessons that later shaped NUMMI, this episode explores why Lean was never really about tools — and why respect, listening, and psychological safety remain the foundation of sustainable improvement today.

Twenty years after Toyota Culture was published, Jeffrey Liker’s lessons still expose why so many Lean efforts stall — and why Toyota’s thinking continues to matter in 2026.

In this episode, Mark revisits a three-part podcast series recorded in 2008 with Professor Jeffrey Liker, author of The Toyota Way and Toyota Culture. Together, they explored what most organizations miss when they try to “implement Lean”: culture is not an add-on. It is the system.

This reflection connects Liker’s insights to today’s leadership challenges — high turnover, pressure for speed, tool-driven transformations, and the temptation to replace leadership with dashboards and templates.

Key themes include:

• Why Lean fails when it’s treated as a toolbox instead of a management system

• The “people value stream” and why development and retention are leadership work

• Servant leadership, the manager-as-teacher role, and the idea of “no power” at senior levels

• Why stability, trust, and psychological safety are prerequisites for continuous improvement

• How turnover, silence, and disengagement are system problems — not people problems

The conclusion is clear: technology has changed, but the hard work has not. Sustainable improvement still depends on leaders willing to invest in people, create stability, and build systems that allow problems to surface and learning to occur.

If you’re serious about improvement in 2026, this episode is a reminder that Lean is still a leadership test — not a tools deployment.

How should organizations think about using AI in Kaizen and continuous improvement? In this AudioBlog, Mark Graban argues that there are no clear answers yet—and that uncertainty is exactly why AI should be approached through small, disciplined PDSA cycles rather than big bets or hype-driven rollouts.

Instead of treating AI as an expert or decision-maker, Mark frames it as a thought partner—a tool that can support brainstorming, reflection, coaching feedback, and clearer documentation. Used this way, AI becomes another input into the learning process, not a replacement for judgment, gemba observation, or human relationships.

The episode emphasizes what AI can’t do—build trust, observe real work, or validate improvement—and why those limitations reinforce the need for small tests of change. When AI is used with curiosity, restraint, and real-world validation, it can support learning without undermining the purpose of Kaizen itself.

The takeaway: treat AI like any other countermeasure. Start small. Learn quickly. Keep humans firmly in charge of thinking and improvement.

Why do Lean practices like pull systems and heijunka fail to take hold in so many organizations? In this AudioBlog, Mark Graban argues that the problem isn’t the tools—it’s how Lean is applied. Too often, organizations cherry-pick visible practices like 5S, huddles, or kaizen events while avoiding the harder work of adopting Lean as a complete management system.

This episode explores why foundational elements such as leveling, pull, and continuous improvement only work when supported by long-term thinking, aligned leadership behaviors, and psychological safety. Mark explains how these methods surface uncomfortable truths about variation, instability, and decision-making—and why organizations that lack a learning culture tend to avoid them. Drawing on Toyota Way principles, he makes the case that Lean fails when it’s treated as a toolkit for short-term results instead of a system designed for sustained learning and improvement.

If Lean hasn’t delivered the results you expected, this episode invites a more fundamental question: are you practicing Lean as a system—or just using the parts that feel convenient?

In this Lean Blog Audio episode, Mark Graban reflects on an unexpected leadership lesson learned on the pickleball court. As a beginner unlearning decades-old tennis habits, Mark experiences firsthand how execution errors, muscle memory, and self-criticism can quietly undermine learning. A kind instructor and supportive playing partners provide timely feedback—without blame—turning mistakes into moments of growth.

The story becomes a practical metaphor for leadership, psychological safety, and continuous improvement. Mark connects a missed serve, an illegal volley, and other rookie mistakes to familiar workplace dynamics: fear of speaking up, hesitation to give feedback, and cultures that confuse mistakes with incompetence. Drawing on themes from his book The Mistakes That Make Us, he explores the difference between judgment errors and execution errors, why unlearning is often harder than learning, and how leaders set the tone for Kaizen through their reactions.

Whether in sports, healthcare, manufacturing, or office work, improvement depends on environments where people feel safe to surface mistakes, reflect, and adjust—one learning cycle at a time.

In this episode, Mark reflects on a visit he made twenty years ago to the NUMMI plant in Fremont, California — the Toyota-GM joint venture that became legendary in Lean circles. What stayed with him wasn’t flashy tools or so-called Lean perfection, but a series of small, human moments that revealed how Lean actually works as a management system.

Through six short stories — a broken escalator, aluminum foil, an explanatory safety sign, a pull-based gift shop, imperfect 5S, and visible audit boards — Mark explores the deeper principles behind Lean thinking: asking “why” before spending money, respecting people enough to explain decisions, encouraging small frontline ideas, and reinforcing standards through daily leadership behavior. Long before the term was popular, NUMMI demonstrated psychological safety in action.

The episode also contrasts NUMMI’s management system with what came after, when the same building became Tesla’s first factory — underscoring a central lesson: buildings and technology don’t create quality. Culture does. These NUMMI lessons remain just as relevant today for leaders trying to build systems that support learning, accountability, and continuous improvement.

Explore the original NUMMI Tour Tales:

• NUMMI Tour Tale #1: Why Fix the Escalator?
• NUMMI Tour Tale #2: The Power of Reynolds Wrap
• NUMMI Tour Tale #3: The Power of Why
• NUMMI Tour Tale #4: The Pull Gift Shop
• NUMMI Tour Tale #5: Nobody Is Perfect
• NUMMI Tour Tales #6: “You Get What You Inspect”

Dwayne “The Rock” Johnson once joked that his incredible physical transformation came from one simple routine: working out six hours a day, every day, for twenty years. In this episode, Mark explores why that line from Central Intelligence mirrors how organizations misunderstand Lean. Many admire the “after” picture of Toyota, ThedaCare, or Franciscan St. Francis Health, but far fewer commit to the steady, everyday habits that make those results possible.

This short reflection looks at the gap between wanting improvement and practicing it, the risks of “instant pudding” thinking, and what real diligence looks like in organizations that sustain progress year after year. Continuous improvement doesn’t require six hours a day—but it does require showing up, consistently, over time.

In this episode, Mark Graban flips roles and becomes the guest—answering five core Lean questions posed by longtime Lean thinker Tim McMahon of the A Lean Journey blog. These questions have been answered by many practitioners over the years, and they cut straight to the purpose, the misconceptions, and the future of Lean.

Mark shares how he first encountered Lean as an industrial engineering student, and how the system came alive when he worked inside the GM Livonia Engine Plant under a NUMMI-trained plant manager. That contrast, and the mentoring from former Toyota and Nissan leaders, shaped his views on what Lean really is: a management system rooted in respect, not a collection of tools.

He discusses the most powerful (and most overlooked) aspects of Lean today, including the central role of psychological safety and why tools fail without the right leadership behaviors. Mark also explores where he sees the biggest opportunity for Lean—particularly in healthcare, where preventable harm, burnout, and broken processes remain stubbornly persistent.

The conversation closes with why these foundational questions still matter. Lean evolves as we learn, and the answers shift as our experiences expand. Mark reflects on how continuous improvement requires an environment where people feel safe to speak up, experiment, and improve their work every day.

If you’re interested in the human side of Lean, how culture and leadership shape results, and where Lean thinking needs to go next, this episode offers a grounded and candid perspective.

In this episode, Mark Graban explores one of the most misunderstood — and most essential — principles of Lean: the commitment to no layoffs due to improvement. Drawing from his work with Johnson & Johnson’s ValuMetrix Services team and stories from Lean Hospitals, Mark explains why Lean cannot thrive in a culture of fear and why protecting people’s livelihoods is foundational to psychological safety.

Through examples from ThedaCare, Silver Cross, Avera McKennan, NorthBay Healthcare, and more, Mark illustrates how a visible “no layoffs” pledge builds trust, accelerates improvement, and strengthens both culture and performance. He also addresses the common misconception that Lean equals cost-cutting, emphasizing instead how freed-up capacity can be reinvested into better care, better service, and better access.

Whether you work in healthcare, manufacturing, tech, or any industry undergoing change, this episode offers a clear lesson:
When leaders protect people, people protect the organization — through creativity, engagement, and continuous improvement.

Perfect for listeners interested in Lean management, psychological safety, culture change, and leadership practices that sustain improvement without sacrificing people.

In this episode, Mark Graban explores why so many organizational change efforts stall—not because people are resistant, but because leaders rely on telling instead of asking. Drawing from his recent Lean Blog article, Mark introduces five Motivational Interviewing questions that shift conversations from compliance to genuine commitment.

He explains how MI, a framework rooted in empathy and autonomy, helps leaders uncover intrinsic motivation, build psychological safety, and coach more effectively. Mark also shares a personal example of self-coaching through these same questions, illustrating how they move us from guilt to growth.

Listeners will learn how to use these questions in team huddles, one-on-ones, and moments of cultural transformation — and why respectful curiosity often outperforms pressure in sustaining continuous improvement.

If you’ve ever struggled to “get people on board,” this episode offers a practical, human-centered alternative.

This episode looks at how GE Aerospace CEO Larry Culp grounds Lean leadership in two fundamentals: safety and respect for people. Drawing on his recent appearance on the Gray Matter podcast, we explore how Culp applies the core habits of the Toyota Production System—not as slogans, but as daily practice.

Culp traces his Lean development back to Danaher, where he learned kaizen directly from consultants trained by Toyota’s Shingijutsu pioneers. That early exposure shaped his belief that improvement is a behavior, not a program. He still invites those same advisers, including Yukio Katahira, onto GE Aerospace’s shop floors—reinforcing that the real expertise lives with the people doing the work.

He describes how he “kaizens himself” after board meetings and plant visits, using the same PDSA cycle expected throughout the organization. His message is blunt: Lean fails when leaders try to drive improvement from conference rooms instead of going to the work.

The conversation also highlights GE’s SQDC focus—Safety and Quality before Delivery and Cost—and why Culp begins every leadership meeting with a safety moment. Given that three billion passengers fly each year on GE-powered aircraft, he frames safety as a responsibility, not a dashboard metric.

Culp’s turnaround work emphasizes cultural change as much as operational results. He’s pushing GE from a finger-pointing culture toward a problem-solving culture, where issues are surfaced early and treated without blame. Psychological safety is essential to that shift.

The throughline is simple and consistent: continuous improvement requires humble leadership, curiosity at every level, and a commitment to getting closer to the work. Culp’s approach is a reminder that Lean endures not because of its tools, but because of the behaviors it cultivates.

In this episode of Lean Blog Audio, Mark Graban reads and reflects on his post “Fred Noe of Jim Beam: Leadership Lessons on Mistakes, Innovation, and Long-Term Thinking.”

What can a seventh-generation master distiller teach us about leadership, experimentation, and learning from mistakes? Quite a lot, as it turns out. Drawing on two in-person encounters with Fred Noe—at the Jim Beam Distillery in Clermont, Kentucky, and at a Bourbon Society event—Mark shares timeless lessons from a leader who practices Lean principles without ever using the jargon.

Fred’s stories about 4,000-gallon “small batch” experiments, revisiting brown rice Bourbon years later, and guiding his son Freddie through failed blends show how humility, patience, and long-term vision create both great whiskey and great organizations.

🎧 In this episode, you’ll hear insights on:

• How to design systems for learning, not perfection

• Why small-scale experiments fuel large-scale innovation

• How psychological safety allows teams to take smart risks

• Why Suntory’s decade-long mindset echoes Toyota’s long-term philosophy

• How legacy leadership means passing on curiosity, not certainty

Whether you’re leading a distillery, a hospital, or a startup, Fred Noe’s approach reminds us that the best results come from respecting the process—and the people—behind it.

Hashtags:
#Leadership #LeanThinking #Innovation #Mistakes #PsychologicalSafety #ContinuousImprovement #Bourbon #JimBeam #Suntory #LearningCulture

In this episode of the Lean Blog Audio podcast, Mark Graban reads and reflects on one of his classic posts: “The Biggest Lean Six Sigma Myth: ‘Lean Is Just About Speed.’”

Far too often, consultants and trainers claim that “Lean is for speed” while “Six Sigma is for quality.” Mark calls out this false dichotomy and explains why both Lean and Six Sigma—when properly understood—aim to improve quality, flow, safety, cost, and morale together.

Drawing on his own experience in manufacturing and healthcare, Mark reminds listeners what Toyota has always taught: quality and productivity go hand in hand. If someone tells you Lean is about “making bad stuff faster,” that’s your cue to run the other way.

🎧 Listen to learn:

• Why the “Lean = speed” narrative misrepresents Toyota’s intent

• How “quality at the source” and “flow” reinforce one another

• Why misunderstanding Lean leads to failed transformations

• How to correct common Lean Six Sigma misconceptions

Lean is not about efficiency alone—it’s about building systems where people, quality, and improvement are inseparable.

Hashtags:
#Lean #SixSigma #ToyotaProductionSystem #ContinuousImprovement #QualityAtTheSource #PsychologicalSafety #LeanThinking

In this episode of Lean Blog Audio, Mark Graban reads his reflection, “I’m Still Dreaming About My Meal at Sukiyabashi Jiro’s Sushi in Tokyo.”

Join Mark as he shares a rare dining experience at the legendary Sukiyabashi Jiro — the Michelin-starred Tokyo restaurant made famous by Jiro Dreams of Sushi. Beyond the extraordinary craftsmanship and taste, Mark explores what this meal revealed about efficiency, flow, and the subtle trade-offs between speed and hospitality.

Was the meal a marvel of Lean precision, or a reminder that even the best systems can become too efficient for the human experience?

This thoughtful story connects sushi-making to leadership, quality, and the meaning of service in any industry — from restaurants to hospitals to manufacturing floors.

Listen for insights on:

• The difference between cycle time and takt time — and how it shapes customer experience

• Why optimizing for efficiency can unintentionally reduce satisfaction

• The balance between process excellence and personal connection

• What Jiro’s disciplined craftsmanship can teach us about Lean thinking

In this Lean Blog Audio episode, Mark Graban explores two silent killers of improvement—fear and futility—and how leaders can dismantle both to unleash the full potential of their teams.

Drawing from his book Lean Hospitals and more recent research by organizational psychologist Ethan Burris, Mark explains how fear (“What will happen if I speak up?”) and futility (“Why bother? Nothing will change.”) combine to silence ideas, suppress learning, and stall continuous improvement.

Through real-world healthcare examples—including Virginia Mason Medical Center’s Patient Safety Alert system and Allina Health’s Kaizen program—Mark shows what it looks like when organizations replace fear with trust and futility with action. The results? More engagement, faster problem-solving, and safer care for patients.

Key themes include:

• Why “Respect for People” must go beyond posters and become daily practice

• How psychological safety grows when leaders respond with curiosity, not criticism

• The link between timely follow-up on staff ideas and sustained Kaizen participation

• How Lean thinking offers practical antidotes to fear and futility

This episode is a reflection on what’s still holding many organizations back—and how leaders can make it safe and worthwhile for people to speak up, share ideas, and improve the systems around them.

Listen and ask yourself:
What invisible barriers might be silencing improvement in your workplace?

In this episode of the Lean Blog Audio podcast, Mark Graban shares a story that perfectly captures the human side of Lean leadership—how a CEO’s shaved head became a powerful symbol of trust, empowerment, and respect for people.

At IU Health Goshen Hospital, Lean wasn’t just a set of tools; it was a cultural transformation. Starting in 1998, their staff-driven improvement program generated over $30 million in savings by 2012. But one moment in 2009 stood out: CEO James Dague’s promise to shave his head if employees could achieve $3.5 million in improvement savings. They didn’t just hit the goal—they doubled it.

That public act of humility wasn’t about theatrics. It represented a deep cultural shift where improvement was owned by staff, not dictated from above. For more than 17 years, Goshen avoided layoffs, reinforcing psychological safety and building a workforce that trusted leadership enough to take risks, speak up, and continuously improve.

Mark reflects on what organizations everywhere can learn from Goshen’s story:

• How leadership visibility builds credibility

• Why psychological safety drives real innovation

• And how celebrating small wins every day sustains a culture of improvement

Lean isn’t about tools—it’s about people. And sometimes, it’s about hair.

Listen and reflect on what your leaders might do to show their true commitment to continuous improvement.

Halloween might be about ghosts, zombies, and monsters -- but those same creatures sometimes show up in our organizations all year long. They lurk in old processes, mindless routines, and fear-based management habits. Here's how to spot the spooky stuff in your systems -- and how Lean thinking helps us drive the fear out of improvement.

Halloween monsters are fun when they stay in movies. They're less fun when they show up in your workplace.

• Ghosts of outdated processes.
• Zombie routines that waste energy.
• Monsters born of fear and blame.
• Frankenstein systems cobbled together without purpose.

Too many organizations treat Leader Standard Work (LSW) as a scheduling tool — a calendar filled with Gemba walks, meetings, and routines. But Lean leadership isn’t about how you plan your time — it’s about how you show up.

In this episode, Mark reads and reflects on his LeanBlog.org article, “Leader Standard Work Is About Behavior, Not Just Your Calendar.” He explores what it means to make leadership a daily practice of intentional behaviors — listening, asking, thanking, reflecting — instead of just checking boxes.

You’ll hear about:

• Why a color-coded schedule doesn’t make someone a Lean leader

• How mindset and presence define real Leader Standard Work

• A behavior-based checklist for leaders to use as daily reflection

• The connection between psychological safety and consistent leadership habits

Read the full post: leanblog.org/2025/10/leader-standard-work-is-about-behavior-not-just-your-calendar

Learn more about Mark’s work, books, and speaking: MarkGraban.com

#LeanLeadership #LeaderStandardWork #LeanCulture #PsychologicalSafety #ContinuousImprovement

⁠The blog post⁠

With Brian Kelly recently fired as LSU’s head coach, it’s worth contrasting his sideline outbursts with the calmer, teaching-oriented approach of Northwestern’s Pat Fitzgerald. Years ago, Kelly’s tirades at Notre Dame raised questions about what real coaching looks like—and those questions still matter today. Whether it’s football or the workplace, leaders who coach build confidence and learning; those who berate only create fear.

In this solo episode, I explore the contrast between two powerful management cycles — PDCA (Plan, Do, Check, Act) and its dysfunctional cousin, PDCYA (Plan, Do, Cover Your A**).

Dr. W. Edwards Deming’s PDCA framework was meant to bring the scientific method into management — to help teams learn, experiment, and improve. But in too many organizations, fear and blame have quietly replaced learning and accountability. That’s when PDCYA takes over.

I share examples from healthcare and beyond that show how psychological safety, not heroics or perfection, determines whether PDCA thrives or dies. Leaders who react to mistakes with curiosity instead of punishment create systems that learn. Those who don’t end up with teams who stay silent and stuck.

If your organization seems to be running on PDCYA, this episode offers a way back — one safer question, one better response, and one small cycle of learning at a time.

📘 Related reading: The Mistakes That Make Us

#Lean #Leadership #PsychologicalSafety #ContinuousImprovement #Deming #PDCA #LearningCulture

In this audio edition of the Lean Blog, Mark Graban revisits a 2014 case study co-authored with Gregory Clancy about Allina Health’s early Kaizen journey. What began as four pilot units became a model for engaging everyone in improvement—from nurses to leaders. Mark reflects on concrete examples that still resonate today: reducing wasted motion, improving safety, and building psychological safety so staff feel safe to speak up with ideas.

Ten years later, the lessons endure: small ideas create big impact, leaders must coach not control, and improvement thrives only where people feel respected and safe to experiment.

Learn how Allina’s story connects to enduring principles from Healthcare Kaizen and The Executive Guide to Healthcare Kaizen, and how psychological safety remains the foundation for continuous improvement in healthcare today.

In this episode of Lean Blog Audio, Mark Graban reads and expands on his article, Leader Standard Work Is About Behavior, Not Just Your Calendar.

Too many organizations treat “Leader Standard Work” (LSW) as a scheduling exercise—a calendar full of gemba walks, huddles, and recurring meetings. But true Lean leadership isn’t about where you go or how often you show up—it’s about how you show up.

Mark explores the deeper intent behind LSW: to make leadership behavior intentional, consistent, and aligned with the principles of respect for people and continuous improvement. He contrasts superficial routines with authentic engagement, drawing on a real complaint from a hospital employee who saw a painful disconnect between a CEO’s Lean rhetoric and their daily behavior.

The episode also introduces Mark’s Behavior-Based Leader Standard Work Checklist—ten daily reflection questions to help leaders practice curiosity, humility, and genuine respect, from “Did I listen without interrupting?” to “Did I follow up on yesterday’s concern?”

Whether you’re a frontline supervisor or a CEO, this reflection-driven view of LSW will challenge you to think less about your calendar and more about your conduct.

Lean leadership isn’t a set of appointments—it’s a set of habits.

Listen now and consider: what does your behavior say about the kind of culture you’re building?

In this episode of Lean Blog Audio, Mark Graban reads and reflects on his recent article, From Know-It-All to Learn-It-All: Leadership Lessons from Mistakes.

Drawing from themes in his Shingo Award–winning book The Mistakes That Make Us and interviews with leaders Phillip Cantrell and Damon Lembi on My Favorite Mistake, Mark explores the transformative shift from being a leader who must always be right to one who is willing to learn.

You’ll hear stories of humility in action—from Cantrell’s reinvention of Benchmark Realty after the housing collapse to Lembi’s recovery from near-bankruptcy during the dot-com bust. Both leaders learned that progress doesn’t come from certainty, but from curiosity, reflection, and the courage to say, “I might be wrong.”

Mark also connects these lessons to healthcare leader Dr. John Toussaint’s evolution from “all-knowing” executive to facilitator and coach—showing how psychological safety, experimentation, and evidence-based learning drive true continuous improvement.

If you’ve ever felt pressure to have all the answers, this episode is a reminder that the best leaders aren’t know-it-alls—they’re learn-it-alls.

Listen, reflect, and consider: how might humility strengthen your own leadership practice?

In this episode, Mark Graban shares a small but revealing story from a local post office — and what it teaches us about bad metrics and broken systems. When a clerk tapped the “green smiley face” on a customer feedback device for the customer, it raised an important question: was this about genuine service, or just gaming the system?

Mark explains why the issue isn’t the clerk, but the system around him — a system that encourages scoring over substance, compliance over improvement. Drawing on Lean thinking and Deming’s philosophy, he explores how poorly designed metrics push people to protect themselves instead of serving customers.

You’ll hear why:

• Metrics without context mislead more than they inform

• People naturally adapt to meet incentives, even if it means gaming the numbers

• Most performance is a function of the system, not individual effort

If you’ve ever wondered why “customer satisfaction scores” or other simplistic measures don’t always match reality, this episode will resonate. Leaders everywhere — in healthcare, government, and business — need to ask not “why did they do that?” but “what about the system made that behavior the best option?”

Because when we fix the system, we don’t need people to game it.

In this episode, Mark Graban shares a powerful story from an operating room that highlights the importance of culture, leadership, and psychological safety in healthcare. A nurse noticed a small break in sterility, spoke up, and apologized. The surgeon’s response? “Don’t be sorry, you’re being safe.”

That short exchange changed the tone of the entire room. Instead of discouraging or shaming, the surgeon encouraged and reinforced the nurse’s action — preserving not only sterility, but also trust.

Mark unpacks why moments like this matter so much, how leaders’ real-time reactions shape culture, and why “you’re being safe” should be the norm in every hospital. He connects the story to key themes from The Mistakes That Make Us and Lean Hospitals, emphasizing that safety and respect for people aren’t abstract ideals — they’re daily practices that save lives and build better systems.

Whether you work in healthcare, manufacturing, or any high-stakes environment, this episode challenges you to reflect: How do you respond when someone speaks up? Do you reward their courage — or risk silencing it?

Are 95% of enterprise AI pilots really “failing”? And how does that compare to the long-repeated claim that 70% of Lean initiatives fail? In this episode of Lean Blog Audio, Mark Graban examines what’s really behind these numbers. He explains why many so-called “failures” stem not from flawed tools or technologies, but from leadership gaps, unrealistic goals, and a lack of psychological safety.

Drawing lessons from Lean practice and his book The Mistakes That Make Us, Mark highlights the importance of experimentation, learning from setbacks, and creating an environment where people feel safe to try, adjust, and improve. Whether you’re implementing AI, Lean, or any transformation, the key is shifting from fear of failure to a culture of continuous learning.

The blog post

The discussion takes us back to MIT in 1987, when Womack and his colleagues were analyzing data from auto plants around the world. Toyota and Honda were clearly operating in a fundamentally different way—faster design cycles, fewer errors, less capital, less space, and more value. But they needed a name for this system. That’s when researcher John Krafcik suggested a term that captured the essence of “less”: Lean.

Womack reflects on how the word solved one problem—it shifted attention away from “Japanese manufacturing” or “the Toyota Production System” to something more universal. But the name also created challenges: because Lean rhymes with “mean,” too many managers misused it as shorthand for cutting jobs rather than creating more value while respecting people.

Mark reads Womack’s timeless warnings and lessons: Lean was never about headcount reduction; it was always about eliminating waste, improving flow, and engaging people in problem-solving. And while the term has traveled in many directions since that 1987 “naming moment,” its underlying principles—value for customers, respect for people, and continuous improvement—remain as important in 2025 as ever.

Listen in to hear Jim’s words from that original 2007 interview, plus Mark’s reflections on why this conversation still matters today.

In this episode, I share a reading of my recent blog post, based on a Catalysis webinar where I explored what we can learn from Lean in Japan. Since 2012, I’ve been fortunate to travel to Japan six times with study groups, including those led by the Kaizen Institute, Honsha, and Katie Anderson. Each trip has reinforced the paradox that Lean is both easier and harder in Japan—and that the deepest lessons are not about tools, but about mindsets, culture, and leadership.

What You’ll Learn in This Episode

• Why Lean in Japan isn’t about “being Japanese,” but about cultivating long-term thinking and respect for people.

• How Ina Food practices “tree-ring management” and why profit is seen as a byproduct, not the goal.

• How Toyota reinforces its role as a “people development company” through problem-solving and Kaizen.

• The double-edged role of Japanese culture: precision and standardization on one hand, but reluctance to speak up on the other.

• How mechanisms like the andon cord create safer ways to surface problems.

• What Japanese hospitals are learning from American health systems—and vice versa.

• Why Kaizen isn’t about cost savings alone, but about making work easier and building capability.

• Memorable lessons from leaders like Dr. Shuhei Iida of Nerima General Hospital: “If you keep doing Kaizen, you will get innovation.”

Key Quotes from the Episode

• “Profit is like excrement produced by a healthy body. Nobody’s goal is to wake up and produce excrement — it’s just the natural result of living and doing things well.” — Chairman of Ina Food

• “The role of the leader is to set the vision — that cannot be delegated.” — Japanese executive

• “If you keep doing Kaizen, you will get innovation.” — Dr. Shuhei Iida, Nerima General Hospital

Why It Matters
Lean is not a set of tools to copy, but a system of beliefs and practices rooted in respect, learning, and long-term thinking. Speaking up about problems isn’t easy—whether in Japan or elsewhere—which is why leaders must create psychological safety and model improvement themselves.

Resources & Links

• Catalysis webinar recording (available soon)

• Learn more about upcoming Lean Healthcare Accelerator Experience in Japan

Work With Me
If you’re a leader aiming for lasting cultural change—not just more projects—I help organizations:

• Engage people at all levels in sustainable improvement

• Shift from fear of mistakes to learning from them

• Apply Lean thinking in practical, people-centered ways

📩 Let’s talk: mark@leanblog.org

When Mark applied for a burglar alarm permit, he accidentally sent the form to the wrong Newport — Rhode Island instead of Kentucky. The voicemail he got back was kind, clear, and even funny: pointing out that an 845-mile police response probably wasn’t going to work.

In this story, Mark reflects on:

• Why small mistakes are easier to handle with humility and humor

• How Toyota’s “expected vs. actual” lens helps frame errors

• Why psychological safety and kindness matter more than blame

• How to turn a minor error into a “favorite mistake” — one you can laugh about and learn from

It’s a reminder that even harmless slip-ups can reinforce bigger lessons about improvement, culture, and how we respond to mistakes.

In this episode, Mark explores how the Dunning-Kruger effect shows up in Lean—especially after a first belt course, workshop, or book. Early enthusiasm can turn into overconfidence, creating blind spots and stalling growth.

Drawing from his book Practicing Lean, Mark shares stories (his own and from contributors like Paul Akers and Jamie Flinchbaugh) about mistakes made early on, what they taught us, and why Lean should be treated as a practice, not a project.

Key themes:

• Why certifications are a starting point, not the finish line

• How psychological safety helps keep overconfidence in check

• Lessons learned from early Lean missteps

• Practical tips for avoiding common training pitfalls

All royalties from Practicing Lean benefit the Louise H. Batz Patient Safety Foundation, supporting safer care for patients and families.

Sometimes an “improvement” makes things worse. The Germans even have a word for it: verschlimmbesserung.

In this episode, Mark Graban shares the story of how a well-intentioned fix to Europe’s vineyard fungus problem in the 19th century nearly wiped out the continent’s wine industry. The introduction of American grapevines solved one issue but unleashed a far bigger one: phylloxera, a microscopic pest that devastated vineyards, economies, and cultures across Europe — including Mallorca, where wine production lay dormant for nearly a century.

This historical case offers powerful lessons for today’s leaders:

• Why most of the time small, contained tests are best

• When risks are irreversible, testing may not be safe at all

• How to balance experimentation with rigorous risk assessment

• Why good intentions aren’t enough if you create tomorrow’s crisis while solving today’s problem

From vineyards to hospitals, factories, and offices, the challenge is the same: how do we solve problems without making things worse?

Too often, leaders think that if they simply “get everyone doing Kaizen,” performance will automatically improve. While daily improvement is essential, some problems are too deeply rooted in the system for frontline staff to fix on their own.

In this episode, Mark Graban explores why Kaizen is necessary but not sufficient — and why leaders must take responsibility for changing the systems that shape performance. Drawing on Dr. W. Edwards Deming’s reminder that “a bad system will beat a good person every time,” Mark shares real-world examples, including a hospital laboratory redesign that transformed results once leadership tackled systemic constraints.

You’ll learn:

• Why leaders can’t delegate away system-level change

• The difference between local improvements and structural redesigns

• How system fixes and daily Kaizen reinforce one another

• Practical lessons for avoiding frustration and building real, sustainable improvement

The message is clear: frontline staff can’t Kaizen their way out of a broken system. Leaders must create the conditions where Kaizen can truly flourish.

Albert Einstein once called the “cosmological constant” the biggest blunder of his life. But what if that so-called mistake actually holds timeless lessons for leaders today?

In this episode, Mark Graban explores Einstein’s “favorite mistake” — why he altered his equations to fit prevailing beliefs, what he missed in the process, and how the story connects directly to Lean thinking, Toyota Kata, and continuous improvement.

You’ll hear how Einstein’s cautionary tale mirrors what happens in organizations when:

• Data contradicts long-held assumptions

• Teams run pilots that outperform the old way, but leaders resist change

• People hesitate to speak up because it feels unsafe to challenge the consensus

The conversation highlights the importance of scientific thinking, experimentation, and psychological safety — and why the real mistake isn’t being wrong, but failing to learn.

Whether you’re leading change in healthcare, manufacturing, software, or beyond, you’ll come away with practical insights to help you trust the data, encourage dissent, and model learning from mistakes.

In this episode, Mark Graban previews his upcoming half-day workshop at the AME St. Louis 2025 International Conference: The Deming Red Bead Game and Process Behavior Charts: Practical Applications for Lean Management.

If you’ve ever felt stuck in the exhausting cycle of reacting to every up and down in your performance metrics—or frustrated by red/green scorecards that drive pressure and finger-pointing more than improvement—this session is for you.

Mark explains why Process Behavior Charts provide a more thoughtful, statistically sound alternative to arbitrary targets and binary dashboards. He also shares how the famous Deming Red Bead Game makes visible the ways that systems set people up to fail—and how leaders can do better.

What you’ll learn in this episode:

• How to distinguish between signal and noise in performance data

• Why Process Behavior Charts help leaders react less and improve more

• The pitfalls of red/green scorecards and arbitrary targets

• How to connect better data interpretation to Lean management and strategy deployment

Whether you’re a leader, manager, or improvement professional in any industry, you’ll come away with practical takeaways to reduce firefighting and improve decision-making.

What does Lean healthcare really mean? It’s more than tools like 5S, A3s, or huddle boards. Lean is a management system that depends on two pillars: respect for people and continuous improvement. Without both, attempts to copy Lean practices in healthcare fail.

In this episode, Mark Graban—author of Lean Hospitals, Healthcare Kaizen, and The Mistakes That Make Us—explores how the Toyota Way philosophy applies to hospitals and health systems. He shares lessons from Toyota, Franciscan Health in Indianapolis, and other organizations proving that Lean leadership in healthcare is not about cost-cutting—it’s about creating a culture of improvement.

What You’ll Learn About Lean Healthcare:

• Why Lean is a system, not a toolbox of methods

• How respect for people means designing systems that prevent mistakes, not blaming staff

• How Kaizen in healthcare develops people while improving quality and safety

• Why suggestion boxes fail and daily improvement succeeds

• The four goals of Kaizen: Easier, Better, Faster, Cheaper (in that order)

• How Lean leadership means coaching, not controlling

• Why psychological safety and trust are essential for sustainable improvement

Key Quotes from Mark:

• “Improvement happens at the speed of trust.”

• “The primary goal of Kaizen is to develop people first and meet goals second.”

• “A Lean environment doesn’t cut costs through layoffs. It invests in people and meaningful work.”

If you’re a healthcare leader trying to reduce errors, engage staff, and build a lasting culture of improvement, this episode provides practical insights you can apply today.

Accurate data is essential in any system–for diagnosing problems, guiding decisions, and driving improvement. But when leaders react poorly to uncomfortable data, the message often gets buried, and the system loses its ability to learn.

When the truth becomes dangerous to report, people stop sharing it. That's when improvement stops too.

Just recently, a senior government statistician in the U.S. was abruptly dismissed following the release of a disappointing jobs report. The data was valid. The revisions were routine. But the report didn't support the preferred narrative. So the messenger was blamed.

It's hard to believe, but it's been almost 17 years since the first edition of Lean Hospitals was published–an effort that eventually received the Shingo Research and Professional Publication Award and has since reached tens of thousands of healthcare professionals around the world.

When I wrote that first edition, Lean in healthcare was still new territory. Many leaders were still asking, “Will Lean work in healthcare?” Today, the better question is “How can we make it work–and sustain it?”

To mark the occasion, I've been reflecting on some of the key ideas from the book–concepts that continue to resonate with readers, leaders, and improvement professionals.

When I first came across the word kakorrhaphiophobia, I thought it might be one of those obscure terms you learn once and never use again.

But the meaning stopped me in my tracks:

an irrational, intense fear of failure or defeat.

It turns out, this fear is more common–and more consequential–than we might admit, especially in workplaces that say they support continuous improvement but don't act in ways that support it.

During my most recent visit to Japan (as part of a tour hosted by Katie Anderson), we spent time in several remarkable organizations where the focus wasn't just on performance or process… but on people.

One company in particular introduced me to a word I hadn't encountered in this context before: kaiteki.

Roughly translated, kaiteki means “comfort,” “ease,” or a “pleasant working environment.” But what stood out was how deeply embedded this idea was in the company's culture–and how it shaped their entire approach to leadership and improvement.

When someone on your team makes a mistake, what happens next?

Do they speak up–or stay quiet?

Do leaders give feedback that demonstrates curiosity–or do they blame employees?

After interviewing over 200 leaders and contributors for my podcast “My Favorite Mistake” and book, The Mistakes That Make Us, one truth has become clear:

Speaking up isn't about character–it's about culture.

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And if you're looking for a practical way to bring this conversation into your workplace, I created a free resource:
Download The Mistake-Smart Leader's Checklist

I'm honored to share that my workshop, "The Deming Red Bead Game & Process Behavior Charts: Practical Applications for Lean Management," has been accepted for the 41st Annual International AME Conference, taking place this October in St. Louis.

The conference theme--Gateway to the Future: AI and Beyond--is both timely and forward-looking, and I'm grateful to contribute a workshop that brings us back to foundational thinking: systems, variation, and learning.

While AI is the shiny new thing, timeless management principles still matter--perhaps now more than ever.

We all say mistakes are a part of learning. Or at least many of us do, as individuals.

But how many organizations actually act that way?

Too often, people are punished for systemic errors. So, problems get hidden.

When problems are discovered, blame is assigned instead of learning being shared. And we wonder why our teams hesitate to speak up.

That's why I created a simple new resource:

The Mistake-Smart Leader's Checklist
[Download it here]

Thanks to NPR for their recent story about how today, April 23, 2025, marks the 40th anniversary of what is considered one of the biggest business or product marketing failures of my lifetime — the failed introduction of “New Coke.”

Are your improvement efforts falling flat, or are you constantly chasing red dots? Are you interested in improving the way we improve?

I've had to re-tool my Cincinnati workshop (June 17th) since my collaboration partner is now, unfortunately, unable to make it.

Join me for a practical and thought-provoking day exploring two essential foundations for sustainable performance: psychological safety and modern leadership metrics.

LEARN MORE AND REGISTER

In the morning, we'll explore how psychological safety fuels continuous improvement–not just as a “nice to have” but as a must-have.

In the afternoon, we'll untangle data confusion and overreaction by learning to apply Process Behavior Charts and other concepts from my book Measures of Success.

There's a phrase I've been thinking about a lot lately:

"You get your say, not always your way."

It's a short sentence, but it says a lot. It's about voice, it's about respect, and it's about the kind of culture we're building--especially when we aim for continuous improvement.

In The Mistakes That Make Us, I wrote about the characteristics of learning organizations. One of the most important is encouraging people to speak up--not just about mistakes, but also about ideas, concerns, and potential risks.

But here's the nuance:

Psychological safety doesn't mean consensus. It doesn't mean you'll get your way every time.

Since 2012, I've had the opportunity to visit Japan six times, each trip a deep learning experience–rich with lessons about Lean, Kaizen, leadership, culture, and continuous improvement.

This June, I'm heading back for my seventh visit–and what makes this one especially exciting is that it will be my fifth trip focused on Lean in healthcare… and the first that I've helped design from the ground up.

It's my first trip in this format, but I was invited to partner up with two amazing individuals who have a great deal of experience in organizing and facilitating such tours — Dave Fitzpatrick, a Canadian who has lived and worked in Japan for a long time, and Reiko Kano, who I know as a translator on my earliest trips — and she's highly experienced with Lean and TPS implementations in healthcare in both the U.S. and Japan.

And I want to personally invite you to consider joining us. If not from June 23 to 29, in a later trip. We're also planning on the week of October 26, 2025 along with trips in April and October of 2026.

Nearly 30 years ago, I had my first real encounter with what not to do as a leader. I was working in a General Motors factory where the culture was one of daily disrespect. Leaders--if you could call them that--were quick to belittle, yell, scream (with spittle flying) at employees on the floor. The lesson I learned wasn't the one they thought they were teaching.

This behavior wasn't "tough love" or "just how things are done in manufacturing." It was toxic. And it didn't lead to improved results. It didn't drive engagement. It didn't foster continuous improvement. It certainly didn't build trust. At best, that type of leadership creates short-term compliance. At worst, it drives costly mistakes, disengagement, and deep cultural scars.

It was management by intimidation--and it failed. Repeatedly.

Fast forward to today, and the evidence is no longer just anecdotal. Organizational psychologist Adam Grant recently wrote in The New York Times:

"The evidence is clear: Leadership by intimidation and insult is a bad strategy. Belittling people doesn't boost their productivity; it diminishes it. Disrespect doesn't just demotivate. It also disrupts focus, causing costly mistakes [including in operating rooms]."

Read the full article (free link)

Before I departed for my recent workshop tour of Australia and New Zealand, I knew that I would learn things in the process of teaching and facilitating on my favorite topics. I didn't expect to learn about flying koalas, though!

I did expect to learn something when I had the opportunity to meet up for lunch with a friend, former Toyota Australia leader Barry McCarthy. Barry's also the chair of this year's AME International Conference in St. Louis. I first met Barry back in 2018 when I went on a Japan Study trip with Barry and the Honsha Consulting team, and I learned a lot from him on that trip (check out my podcast with him about these topics).

Toyota and Psychological Safety–A New Book

In recent years, I've come to believe that Psychological Safety is the oft-unheralded foundation of the Toyota Production System and Lean Management. Former Toyota Kentucky leader Mike Hoseus agrees, as we discussed in this Lean Blog Interviews episode — and as mentioned in the book Toyota Culture, that Mike co-authored with Jeff Liker.

I've learned a lot from Barry about Toyota as a “human development company,” as we discussed in his episode.

He agrees with me about the direct importance of Psychological Safety at Toyota — and that it's something they intentionally nurture.

One new piece of direct evidence of this is a book that was published, in Japanese, back in late 2023. The title can be translated to English as:

Two kata that realize psychological safety and speed up work that supports Toyota-style DX: “How to speak” and “How to proceed with work” that resonate with young people

Barry shared his summary of the book (as translated by him via Google) and I ordered it from Amazon Japan based on his recommendation. When I got home, the book was waiting for me.

“DX” is jargon (an abbreviation) for “digital transformation,” something that's increasingly important to Toyota.

Back to the title — I suspect that “make work flow better” might be a better translation since we don't normally try to “speed up work” directly through the Lean methodology. Lean is more about reducing and eliminating barriers to flow and not a matter of pressuring people to work faster.

The ChatGPT translation of the title says:

“Supporting Toyota-Style DX: Two Kata That Achieve Psychological Safety and Speed in Work”
“A way of speaking that resonates with young workers” and
“A way to move work forward”

I've been running pages through ChatGPT as a translation tool. It's incredibly fast. You take a photo of a page (or pages) and out comes the translation. I've been uploading photos in a batch size of “chapter” so ChatGPT can perhaps look at the full context of the chapter instead of only seeing page by page.

Before jumping into what Psychological Safety is, the book poses a problem statement:

“A diagnostic list for managers–if you mark 3 or more “yes,” you should seriously reconsider your current management style. Examples include:

• “I've never said ‘thank you' to a team member today.”
• “I find the word ‘challenge' cringeworthy.”
• “I haven't talked to anyone outside my own department.”
• “I tend to suppress my real opinions at work.”

I think a good question for leaders is: “Do you remember the last time an employee disagreed with you?” If the answer is “no,” then you have a problem.

(1) What is Psychological Safety?

“Being able to express honest opinions, candid doubts, and even disagree with others for the sake of organizational or team results–without fear.”
— Atsusuke Ishii, 2020, Japanese Management Skills Association

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 Award by the Shingo Institute (the home of the Shingo Prize for organizations).

I'm excited to be presenting this webinar on February 12th at 1 pm ET as part of the KaiNexus Continuous Improvement webinar series:

The webinar description:

“Are you looking for practical ways to eliminate errors and enhance efficiency in your organization? Join us for “Mistake-Proofing in Action: Real-World Examples Across Industries,” an insightful webinar showcasing how organizations across healthcare, manufacturing, and service sectors have successfully implemented mistake-proofing techniques.

Discover innovative solutions that prevent errors before they occur, improve safety and quality, and save valuable time and resources. Through inspiring case studies and actionable takeaways, you'll learn how to adapt these proven approaches to your unique challenges. Don't miss this chance to gain practical tools and insights to drive continuous improvement and operational excellence.

Register today and see mistake-proofing in action!”

You can also register to win a signed copy of my book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation, which has a chapter about preventing mistakes.

Mistake-Proofing in Action: Real-World Examples Across IndustriesEnter to Win!

Last Sunday, in Frankfurt, Germany, I took part in a guided walking tour of the city.

Our group included a young professional from Australia in his early 20s. He has taken leave from work to travel, backpacking across Europe.

We had an opportunity to chat over lunch and a local “apfelwein” (hard cider). He lamented his frustrations at work.

He said, “My boss thinks he is giving clear direction to us. Then we do the work our best way… only to be criticized for not understanding the direction.”

At its core, Lean is about people–respecting them, empowering them, and ensuring their well-being while driving continuous improvement. Recently, GE Aerospace's Lynn, MA, facility provided an inspiring example of what it means to put these principles into action, even under challenging circumstances.

Read more about this and/or watch a video at this link:

Keep the Line Moving: GE Aerospace's Lynn Facility Is Using FLIGHT DECK to Put Safety First

A sad but true leadership tale:

“Unlike most CEOs who rely on their executive team to keep them informed, [redacted] relies on his team to keep him feeling good about himself.

And so whenever somebody would tell him something that he didn't know and make it very clear that he wasn't the smartest person in the room on each and every topic, he generally fired them.”

During Katie Anderson‘s #JapanStudyTrip this past November, a participant shared an observation with me that resonated deeply:

“The biggest challenge is our blame culture. It's easier for people to do nothing because they don't get in trouble.

But if they make a mistake, they get punished.

And our company is successful enough that there's not a compelling reason for top leaders to change the culture.”

This isn't a story from the U.S., but the feeling is universal.

A workplace culture where individuals are punished for mistakes–especially when those mistakes have systemic causes–is a significant barrier to progress.

It's a global challenge, and addressing it requires rethinking how we approach leadership and learning.

I'm thrilled to be back in Japan for the first time in five years. Today is the start of Katie Anderson's Japan Study Trip (learn more about joining her in May 2025). It's great to be here for another week of learning and great experiences.

Little did I know, I'd kick off the trip by nearly losing my iPhone on the streets of Tokyo–a mistake that ended up teaching me a valuable lesson about Japan's culture of trust.

Just over a week ago, I got back from Katie Anderson's Japan Study Trip. It was amazing! I have so much to write about and share.

But first, Facebook reminded me of something from exactly ten years ago–the second time I visited Japan with the Kaizen Institute.

I asked 2024 ChatGPT to translate this 2014 news story that's pictured below (with me sitting there and taking notes in the front row of the meeting room). See the English text below the image:

At yesterday's Lean Global Connection event, I posed a straightforward yet revealing question to the audience:

“What keeps you from speaking up at work?”

The responses illustrated two of the common barriers. I posed the survey options based on the research of Prof. Ethan Burris, from the University of Texas at Austin, who has found that fear and futility are the top two reasons why people choose to stay quiet.

For some, fear stood in the way–the fear of reprisal, being judged, or being seen as a troublemaker.

For others, the obstacle wasn't fear but futility–the belief that speaking up wouldn't make a difference. Four people, sadly, said BOTH were barriers.

And yet, amidst these challenges, eight people shared that they felt no barriers at all, a testament to the environments they work in. That is the ideal we should all strive for.

The survey results line up with the Burris research that shows futility is actually the biggest reason, not fear.

My whole career, I have worked with the Lean methodology (aka the Toyota Production System).

I've just really never done much with Six Sigma. I've read about Six Sigma. I took a Green Belt course when I worked at Dell in the late 90s. I've studied and used statistical methods (especially what I learned in my Industrial Engineering studies and at MIT), but I've never done anything I would call Six Sigma in my career.

I have respect for Six Sigma as a discipline, just as if I were a chef, I would have respect for pastry chefs. They can co-exist in the kitchen. You might both use whisks, but you have slightly different training to do different things. These roles aren't interchangeable, and neither are Lean and Six Sigma. That's one reason I get riled up about so-called “Lean Sigma” or “Lean Six Sigma.”

Most of the “L.A.M.E.” (Lean As Mistakenly Explained) examples that I see on the interwebs come from “Lean Sigma” discussions, especially on LinkedIn.

What are the fallacies that are thrown around? They include, but are not limited to:

• Lean is about the average, Six Sigma is about the variation
• Lean is about internal processes, Six Sigma is customer-focused
• Lean is for efficiency; you need Six Sigma for quality (this one is the fault of Mike George and his books, many say)
• Lean and Six Sigma are just toolboxes, and you use whichever is appropriate for the problem at hand

These are all incorrect, as somebody with good Lean training or Lean experience would realize.

Read the blog post

It's a story I've heard too many times. An organization spends years, even decades, entrenched in a top-down, command-and-control culture. In this environment, employees are micromanaged, decision-making is reserved for those at the top, and when things go wrong, the finger-pointing begins. “Blame and shame” becomes the norm.

Then, someone decides,

“We're going to get Lean.”

On the surface, this should be great news. Lean offers proven strategies to improve safety, quality, and employee engagement. But here's the catch: the organization doesn't change how it leads. It still clings to the same top-down mentality that has suffocated the workforce for years.

What follows might be described as a superficial Lean transformation. It's probably more of a “Lean effort” (or “Lean hope”) than any sort of transformation.

Check out the blog post

I recently tried out the new “Notebook LM” tool from Google.

I uploaded a PDF of my latest book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation, and it was able to generate a realistic-sounding podcast episode about the book. It's like an NPR podcast in tone and style. There's a male A.I. host and a female A.I. host bantering about the book as they recap some of the key points and themes.

It's not perfect — they pronounce my name wrong in a few different ways — but it's a fascinating experiment in how to take a really long document and summarize it in a consumable way.

They definitely didn't say everything exactly the way I would have stated it. However, the podcast seems to perfectly simulate the discussion that two people might have after both reading and enjoying the book.

When discussing mistakes, it's common to hear terms like “stupid mistake” or “dumb mistake” thrown around, especially when reflecting on our own errors.

However, labeling mistakes in this way is unproductive.

In The Mistakes That Make Us, one of the key ideas is that we shouldn't label mistakes as “stupid” or “dumb.” Mistakes are a natural part of the human experience, and even the smartest, most capable people make them.

“I am never, ever wrong.”

That's a statement that should disqualify an applicant from ANY leadership position.
True leadership isn't about projecting infallibility–it's about fostering a culture where mistakes are seen as opportunities for learning and growth.
Leaders who claim they're never wrong create an environment where fear of failure stifles innovation, and team members are less likely to speak up or challenge ideas. This is the opposite of what effective leadership requires.

Today, I want to share a section from my book, The Mistakes That Make Us. I'm sharing an excerpt here in this post, and I'm also making it available as a podcast episode using an excerpt from the audiobook version.

In this book, I explore how mistakes can actually be one of the best ways we learn and grow—whether it’s in business or life in general.

The excerpt I’m about to share is from Chapter Three, where I talk about the importance of kindness. Often, we think that being "nice" is enough, but real kindness goes deeper. It’s not just about being pleasant or avoiding conflict; it’s about helping others—and ourselves—grow and improve through constructive action.

In this chapter, I also touch on self-kindness, especially after making mistakes. We tend to be our own harshest critics, but kindness towards ourselves is crucial if we want to learn and move forward.

If you find this excerpt helpful, I encourage you to check out the rest of the book, The Mistakes That Make Us (including this free sample offer). It’s packed with stories and lessons on how embracing mistakes can lead to greater success. So, let’s get into the reading.

Starbucks has a new CEO who is talking about how the coffee shop experience is broken. Many aspects of the Starbucks mobile ordering process are broken. Well, the ordering process is fine... it's the fulfillment process that needs improving.

In many organizations, moving away from a culture of punishment when mistakes are made is a significant leap forward. It signals a shift toward understanding, systems thinking, and improvement.

But once you've made that change, what's next? Do we need to replace punitive approaches with something better? If so, what? How do you ensure that your new approach leads to meaningful learning and continuous improvement?

A friend of mine–with a long history of Lean and Toyota Production System knowledge practice–recently shared a troubling story about a relative who works at a manufacturing plant. I'll call this factory team member “Guy.”

Call me cynical, if you must, but I totally believe this story, so I'm sharing it here. And my friend has zero reason to make this up.

Guy's factory has a bonus system in place that's supposed to reward employees for hitting key performance targets each month. That might sound like a good idea on the surface, but here's where it gets dysfunctional:

If there are any reported injuries, the entire bonus goes unpaid for the month.

I've shared this story verbally with a few people, and they always start smirking or chuckling. They know the answer to this question:

What could possibly go wrong?

I've been writing about learning from mistakes for a long time, including my previous books before my latest, The Mistakes That Make Us. This idea isn't new, but it's essential–especially in fields like healthcare, where the stakes are incredibly high.

From Lean Hospitals:

“Mistakes are a reality in healthcare, and while we strive to prevent them, it's crucial to create an environment where they are identified quickly, addressed effectively, and used as opportunities for learning and improvement.”

From The Executive Guide to Healthcare Kaizen:

“Leadership in a Kaizen culture means creating an environment where mistakes are seen as opportunities to learn, not as failures.”

In writing The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation, I wanted to challenge the way we think about mistakes, leadership, and organizational culture.

Throughout my career, I've seen firsthand how the traditional responses to mistakes–punishment, fear, and blame–can stifle growth and innovation. The ideas I present in the book are meant to provoke thought and, in some cases, to stir debate.

Here in this post, I'd like to share and dig into five of the most controversial quotes and concepts from the book, explaining why they're important and how they can transform the way we work.

Imagine an NFL team that has been on a decades-long streak of winless seasons. The owner, who has been at the helm for most of that period, always believes that finding the right coach will solve the team's woes. But it doesn't.

Every few years (or sometimes more often), the owner blames and fires the coach and hires a new one, but the team continues to lose.

In a desperate attempt to turn things around, the owner signs a decent (but inexpensive) free-agent left guard away from the previous Super Bowl champion. This player, hailed for their leadership on and off the field, is expected to be the sole “transformational leader” and bring winning tactics and a winning culture to the struggling team. All. By. Himself.

Would you expect that to work?

I would not.

Think about the last time you made a major career decision. I'm thinking of one of mine, in particular.

Was it about leaving a job for a new one? Changing directions in your career altogether?

Was it a debate about which of the job offers you would accept?

How easy was that? How long did it take you?

In hindsight, some of my career decisions took too long to play out. Afterward, my wife would ask, "Why didn't you do that sooner?"

I'm also thinking of a major decision that was in the news today—it's been drawn out over the past few weeks, and it's a more important decision than one I've ever considered.

During my career, one of the most helpful concepts I've learned about is "motivational interviewing." See more blog posts about this approach. This approach has roots in addiction counseling, developed by William R. Miller and Stephen Rollnick in the 1980s to help individuals struggling with substance abuse find their own motivations for change. Its principles can be applied far beyond addiction, proving invaluable in leadership and coaching.

Lessons from Motivational Interviewing

This post draws upon and summarizes content in my book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation.

Senior leaders must prioritize psychological safety and continuous improvement to foster an environment conducive to learning and innovation. Psychological safety is crucial for enabling employees to speak up about mistakes and ideas without fear of punishment. This executive summary outlines key strategies for cultivating psychological safety and leveraging it to drive continuous improvement.

“Psychological safety is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes.”

Hear my podcast with Amy on these topics.

Prof. Amy Edmondson

Two data points are not a trend. Two-data-point comparisons can be mathematically correct but practically meaningless.

This is true in workplaces and news articles like this one.

Multiple two-data-point comparisons (comparing last month to the previous month AND comparing it to the year before) don't paint the full picture the way a simple run chart would.

If a hospital's margin is "23% higher" than the year before, is that a difference between 1% and 1.23% or the difference between 10% and 12.3%?

Give me more data points. Better yet, create a chart that shows trends (or the lack thereof) over time. Otherwise, we're just celebrating (or bemoaning) every little up and now.

23% sounds like a big change. But that doesn't mean it's statistically meaningful. Was it down 27% the previous month? Possibly. Some metrics simply fluctuate around a stable average.

On NPR recently, the hourly news update covered economic indicators, including the truth and data points that say:

• Gas prices are UP 5 cents from a week ago
• Gas prices are DOWN 10 cents from a month ago

So, gas prices are both going UP and DOWN. It depends on which data point you use as a starting comparison -- and what point you might be trying to prove. What are those two facts "indicators" of?? What's the longer term trend??

As a Throwback Thursday, I'm sharing this webinar that I did back in 2012, as hosted by Karen Martin...

On this theme of “The Suggestion Box is Dead,” I thought to prompt ChatGPT to create an image of a burial scene and mournful employees...

There's a common misconception about Toyota's “Andon” system, often expressed as:

“When a team member pulls the cord, the line stops.”

But that's not entirely accurate, as this enlightening Toyota video demonstrates...

I'm very happy to be participating in Jared Thatcher‘s “Global Lean Summit” event this September in Indiana.

I'll be there to network and learn, which includes time visiting a Toyota Material Handling factory (an entire day!)

I'll be speaking and facilitating:

• A workshop on Psychological Safety as a Foundation for continuous improvement
• A learning session featuring Dr. Deming's “Red Bead Game“
• A fun keynote talk on warning signs and mistake-proofing

Learn more and register

Digital transformation is about rethinking and reinventing with digital tools. For over 13 years, KaiNexus has moved beyond the outdated suggestion box model.

Traditional suggestion boxes, whether paper or digital, often fail (or usually fail!–ideas get locked away, reviewed by a select few, and lead to frustration.

We believe in dynamic platforms that foster real-time communication and collaboration.

Don't digitize the old, broken way of doing things!

Mark Graban:
Don't digitize the old broken process. Whether that's a suggestion box or anything else, digital transformation is about rethinking reinventing the way we do things with digital tools. From the beginning, more than 13 years ago, KaiNexus has never been an electronic suggestion box because suggestion boxes don't work, whether it's in paper form or an online digital form. Why is that? Suggestion boxes in the paper model have a locked box.

Ideas sit. Some special person with a key opens up box maybe once a month, maybe once a quarter. Some far off team talks about those suggestions without coming back to talk to the person who filled out that suggestion box slip. People give up on suggestion boxes, and it's understandable. So we don't want an electronic or a digital version of that.

What we do want is a digital process with proven, continuous improvement methods. We often refer to this as Kaizen, engaging people in opportunity identification, not just jumping to solutions but bringing forward a problem so we can talk about it locally and then escalate it to management by exception. Don't digitize the old, broken way of doing things.

Psychological Safety means everybody gets their say, but it doesn't mean you get your way.

Psychological Safety is an individual's belief, feeling, or perception that it's safe for them to speak up in a situation.

When people are rewarded for speaking candidly, that leads to rigorous debate and better decisions.

Psychological Safety doesn't mean freedom from being challenged or disagreed with.

It doesn't turn the workplace into a democracy and it doesn't mean you need 100% agreement to move forward on anything.

Psychological Safety means you can disagree with your manager or a peer… and they have the safety to disagree in return.

Psychological Safety doesn't mean shutting down a discussion because you feel uncomfortable.

What practices and behaviors have you seen in a workplace that cultivate Psychological Safety? What are some examples of rewarding people for speaking up candidly?

To me, it comes down to three high-level countermeasures for leaders:

• Modeling candor, vulnerability, and the behaviors you want to see
• Encouraging candor
• Rewarding candor

In summary, Psychological Safety is the foundation of a healthy and productive workplace. It ensures that everyone has the opportunity to voice their thoughts and concerns without fear of retribution, even if it doesn't always mean getting their way.

Again, Psychological Safety means everybody gets their say, but it doesn't mean you get your way.

When leaders model, encourage, and reward candor, it fosters an environment where rigorous debate leads to better decision-making and continuous improvement. By adopting practices that promote Psychological Safety, such as open communication, constructive feedback, and a growth mindset, organizations can unlock the full potential of their teams.

If you're looking to cultivate Psychological Safety within your organization and drive better outcomes through open and candid dialogue, I can help. With extensive experience in fostering cultures of learning and innovation, I offer consulting, workshops, and coaching tailored to your specific needs.

Contact me today to learn how we can work together to build a safer, more effective workplace. I'm happy to do a free discovery call with you.

Or check out my book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. Or do both :-)

The LinkedIn event

My latest book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation, is turning one year old!

Join me, along with my co-host Elisabeth Swan, for what we hope will be an engaging, insightful, and fun discussion about learning from mistakes. We'll be joined by special surprise guests who will share their unique perspectives and experiences. This isn't just a one-way broadcast–it's an interactive session where we'll conduct live polls and open the virtual floor to your questions, ensuring a dynamic and participative environment.

View this page and click “Attend” to be reminded of this when it starts. A recording will also be available on LinkedIn and my YouTube channel.

Mistakes are a universal experience, and what truly matters is how we learn from them. Together, we will explore ways to improve our ability to learn from mistakes, both as individuals and as organizations. My goal is to uncover practical strategies that can be applied in various contexts to foster a culture of continuous learning and improvement.

We also have a special reason to celebrate. The Mistakes That Make Us is marking its first anniversary/birthday on June 30th. However, since that falls on a Sunday, and let's face it, who wants to be on LinkedIn on a Sunday? I've decided to move the celebration to Friday, June 28th. This will give us the perfect opportunity to not only discuss the themes of the book but also to celebrate its impact over the past year.

I'm excited to share my breakout session at the Michigan Lean Consortium Annual Conference!

In this session, I dive into the critical role of Psychological Safety as a Foundation for Continuous Improvement.

We explore how fostering an environment where team members feel safe to share ideas, take risks, and learn from mistakes can drive remarkable progress and innovation.

Oh, and did I mention that Traverse City is usually gorgeous in August?

When writing or speaking, I use the words “mistake” and “error” interchangeably. The definitions in some dictionaries are comically circular.

Dictionary.com defines an error as:

“a deviation from accuracy or correctness; a MISTAKE, as in action or speech.”

It also defines a mistake as:

“an ERROR in action, calculation, opinion, or judgment caused by poor reasoning, carelessness, insufficient knowledge, etc.”

So, a mistake is an error, and an error is a mistake.

I'm excited that the Shingo Institute asked me to present a webinar on June 18th.

Click here to register for the webinar

They've also published an article that I wrote:

Psychological Safety: The Key to Effective Andon Cord Pulls and Continuous Improvement

The webinar description:

Join us for an engaging webinar as we explore the transformative power of cultivating a culture that learns from mistakes, ultimately driving continuous improvement and innovation, leading to greater success! Renowned author Mark Graban will draw upon examples from a diverse array of companies, including industry titans like Toyota and agile software startups such as KaiNexus.

During this session, participants will gain valuable insights into the experiences of CEOs and other leaders, regardless of company size, who have adeptly turned mistakes into opportunities for growth and advancement. While these leaders remain vigilant in error prevention, they recognize the profound value of embracing mistakes as pivotal learning moments, particularly within environments fostering psychological safety and robust problem-solving capabilities.

Through compelling narratives, attendees will discover lessons that both educate and inspire, recognizing that in the dynamic landscape of business, mistakes are inevitable — yet it is the process of learning from them that propels us forward!

I was talking recently with a trusted friend in the Lean community. He told me a story. It's certainly believable, even if it's second or third-hand to me.

He had no reason to make up a story like this.

A relative of his works in a U.S. factory. Yes, we still have factories here.

I'll call this relative of my friend “Guy,” which is pronounced the American way, not the French way.

Guy's factory would claim to use Lean methods and might even claim a “Toyota Production System” label as its inspiration.

The Big Picture: In the Lean community and beyond, some people mistakenly equate “psychological safety” with being comfortable all the time. This misconception can undermine the true essence of psychological safety in the workplace.

Psychological safety is not about constant comfort or shielding managers from discomfort. Synthesizing a few definitions of psychological safety, I say it's a person's belief, feeling, or perception that it's safe enough to speak candidly about things including:

• Mistakes
• Problems
• Ideas
• Differing views

without fearing marginalization or punishment.

What Psychological Safety Really Means

IMAGE: A sign that reads "CAUTION: DON'T OPERATE ON THE WRONG SIDE"

It's silly, right? I've never seen a sign like this in an operating room. And I'm not advocating for them. It's not the right approach for quality and patient safety.

If warning signs actually prevented mistakes, and given that a vast majority of mistakes are caused by human factors (like fatigue) and systemic factors (like being behind schedule because instruments were delivered late to the O.R.)…
1) A sign like this would be posted in every operating room

and
2) Wrong-site, wrong-side, and wrong-patient surgeries would never occur
But, of course, it's not that simple.
What works?
Mistake-proofing works.

TODAY marks the centennial of one of the most significant innovations in quality management: the control chart. 🎂 🎉 🎆

In the early 1920s, Walter A. Shewhart, working at Bell Labs, recognized the need for a statistical method to monitor and control manufacturing processes.

On May 16, 1924, Shewhart created the first “control chart,” a tool that distinguished between common cause variation (inherent in the process) and special cause variation (due to specific, identifiable factors). This simple yet powerful distinction laid the foundation for modern statistical process control (SPC). Control charts were dubbed “Process Behavior Charts” by Donald J. Wheeler Ph.D.)

The latest and greatest of the control charts is the “XmR Chart” — as Wheeler wrote about in Understanding Variation and I wrote about in Measures of Success (a book that has a foreword written by Wheeler).

Research by Ethan Burris shows that the top two reasons employees choose to keep quiet in the workplace are:
1️⃣ Futility
2️⃣ Fear
Fear of getting in trouble is a big problem. But there are also many workplaces where people say, quite literally, “I'm not afraid to speak up, it just isn't worth the effort.”
That's the Futility Factor.
Please answer this poll question via LinkedIn. And I'd love to hear your thoughts in a comment here on the blog post or LinkedIn. Please check out people's comments and stories that they shared on Linkedin.

I'm very happy to announce the release of my new Mistake-Proofing course, available NOW through Karen Martin and TKMG Academy.

You can buy the course individually at TKMGAcademy.com for $129. Volume discounts are available for large teams or your entire workforce (for more information, email info@tkmgacademy.com).

The course is also part of the wonderful collection of courses in the all-access annual subscription. The annual price of $529 goes up significantly at 11:59 pm CDT on May 31st, so act now for the best value pricing.

Other TKMG Academy instructors in the series include Karen Martin, Elisabeth Swan, Mike Osterling, Tracy O'Rourke, Brent Loescher... and more.

And if you subscribe to TKMG Academy, you can participate in Karen's "Community of Practice" meeting with me on Wednesday, June 26th.

I love Steve Spear‘s emphasis on a Toyota-based Lean model of:

“See, Solve, Share”

See problems, solve problems, and share what worked as countermeasures. That's the ideal, and it's powerful where it exists.

At Toyota, and companies like it, there's an understanding that speaking up about problems leads to a constructive response from leaders. 

That's not always true at other companies that are starting or attempting their “Lean Journey.”

The Psychological Safety that might be taken for granted at Toyota must be actively cultivated in a company before continuous improvement can really take root, let alone take off.

I think the model could also be stated as:

“See, Share, Solve, Share”

Research by Ethan Burris shows that the top two reasons employees choose to keep quiet in the workplace are:
1️⃣ Futility
2️⃣ Fear
Fear of getting in trouble is a big problem. But there are also many workplaces where people say, quite literally, “I'm not afraid to speak up, it just isn't worth the effort.”
That's the Futility Factor.
Please answer this poll question via LinkedIn. And I'd love to hear your thoughts in a comment here on the blog post or on LinkedIn.

You don't find the root cause of a problem in a conference room.

OK, so we've gotten away from the whiteboard. Now what?

You might not even KNOW the root cause by thinking and talking out where the work is actually being done.

That's one of the most powerful lessons I've learned from former Toyota people I've been able to work with.

Professors Robert H. Hayes and William J. Abernathy have harsh words about a common, if not typical style of American management:

“…an overdependence on analytical detachment – what they call ”managerial remote control.”

They say it is an approach that exalts financial analysis, not line operations. It rewards executives who see their company primarily as a competing set of rates of return, who manage by numbers and computer printouts.

Further, they say, it is a seductive doctrine that promises the bright student a quick path to the top and that piles its rewards on executives who force through impressive short-term performance, at indeterminate cost to long-term health.

Fearing any dip in today's profits, American companies keep research and technology on short rations, skimping the investment critically needed to insure competitiveness tomorrow.”

These are warnings about:

• Prioritizing financial analysis over an operations focus
• Emphasized and rewarding short-term performance over long-term perspectives

Is that from a recent article that I've read? Yet another article about Boeing's troubles?

No. It's a 1982 article in the New York Times. Hat tip to Tom Ehrenfeld for sharing it with me.

It's interesting to observe a hospital process (or lack thereof) when a family member needs surgery. I had the opportunity to do so one day last week. I originally shared this on LinkedIn as a post and real-time updates.

Thankfully, the clinical care seemed to be good, and that family member is recovering well from the outpatient procedure.

But, the experience could have been better. I'm critiquing the process and the apparent culture, not the individuals involved. They are part of a system, which includes their job role design, training, and supervision.

The other day, I read about the passing of Donald E. Peterson, who was a key CEO for Ford Motor Company in the 1980s (from 1985 to 1990).

From the Detroit Free Press:

Former Ford CEO Don Petersen, who spent 41 years with automaker, dies at 97

How often do you hear executives blaming employees, including frontline workers, for different problems or poor performance?

I don't think that's a good look when leaders do that.

Leaders are responsible for the system, especially senior leaders. Even though they are part of a system, they have more freedom and more ability to change systems that ultimately drive most performance.

A blaming leader looks at low productivity numbers and blames “lazy workers.”

A blaming leader sees mistakes and blames “careless workers.”

A blaming leader sees employees choosing not to speak up about problems and blames “cowardly workers.”

I recently spoke and facilitated at a health system's quarterly leadership forum event on the topic of “Psychological Safety as a Pre-Condition for Continuous Improvement.” It was very well received, and I'm very passionate about the need for leaders to help every team member believe that it's both safe and effective to speak up in the workplace.

Psychological Safety plus Problem Solving is a very powerful combination.

Let me know if you'd be open to a brief conversation on collaborating for your next leadership forum or another executive event. I'm keen to share insights that can further empower your team and take your improvement journey to the next level.

Learn more here and let me know if this would help your healthcare organization (or any organization outside of healthcare):

Transforming Healthcare Leadership: Cultivate Psychological Safety for Unprecedented Continuous Improvement

I have been really enjoying this book, released in 2021, by Kiyoshi “Nate” Furuta, a retired Toyota executive: Welcome Problems, Find Success: Creating Toyota Cultures Around the World. I bought it a year ago and wish I had started reading it sooner!

Furuta is the retired former chair and CEO of Toyota Boshoku America, Inc. — an automotive parts supplier to companies including Toyota and General Motors. 

There was a fascinating article in Bloomberg BusinessWeek about GE doing its final spinoff of GE Vernova (ticker symbol: GEV) and the remaining business that Larry Culp remains CEO of, GE Aerospace (formerly GE Aviation, ticker symbol: GE).

The inside story of how GE CEO Larry Culp dismantled a 131-year-old American giant.

AN EMPIRE DIVIDED

Embracing Imperfections and Learning from Mistakes: A Leadership Insight from the 2022 AME Annual Conference...

In a riveting conversation between Larry Culp (at the time, CEO of GE and now CEO of GE Aerospace) and my good friend Katie Anderson at the 2022 Association for Manufacturing Excellence (AME) Annual Conference, valuable lessons on leadership, transparency, and fostering a culture where challenges and imperfections are openly shared were illuminated.

Come join AME at their 2024 Conference in Atlanta later this year.

Here's a short clip:

As we sit in seat 26A, mindlessly watching a movie, we take for granted that our cell phone (or the shirt off our back) won't be suddenly sucked out through a gaping hole in the side of a plane. That's because the odds of this happening are unimaginably low. Until now, that is. Are we entering a new era where shoddy manufacturing (or maintenance) exposes us to more risk, reversing a decades-old trend of greatly improved aviation safety?

On January 5th, an Alaska Airlines 737 MAX-9, designed and assembled by Boeing, safely executed an emergency landing after a “door plug” blew out of the plane's left side. Thankfully, the resulting hole and loss of pressure didn't suck out any passengers or crew. 

Now, the window and middle seats next to the door plug were thankfully empty. That raises questions about what Alaska knew and what chances they were taking by continuing to fly the plane after previous complaints about “whistling sound” and alerts about cabin pressures on previous flights that plane took.

The crew performed valiantly in these circumstances, and we should celebrate them. This incident creates an opportunity for the aviation industry (including regulators) to learn how to ensure this sort of door plug failure never happens again.

Instead of blaming human error, people should ask why the company didn't have better systems to prevent or detect the mistake or mistakes that led to this incident. Some leaders throw up their hands and lament,

“It's human error… we'll never be perfect… so what can we do?”

Instead of leaving that as an unanswered rhetorical question, we need to work at it seriously. What can we do to prevent mistakes and protect ourselves from human error?

Does it Feel Better to Be Vulnerable or Candid in a Workplace?

I've learned so much from Timothy R. Clark of the firm LeaderFactor, author of the excellent book, The 4 Stages of Psychological Safety. I can't recommend his work enough--including his free podcasts, webinars, and more. I was fortunate to go through a formal certification course with him on Psychological Safety.

He was a guest on my podcast, "My Favorite Mistake." He was kind enough to write a blurb about my book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation.

Clark defines "Psychological Safety" using language that's similar to Harvard Prof. Amy Edmondson's definition. To synthesize them, Psychological Safety means a person:

Feels or believes it is safe to speak "without fear of being embarrassed, marginalized, or punished in some way" in a given situation.

The part in quotes is from Clark's definition. Edmondson says it's a belief that "one will not be punished or humiliated" for speaking up about things like "ideas, questions, concerns, or mistakes."

Recently, I've heard an idea a few times that I'd like to share and discuss in this post. As I'm writing this, I can't remember who to cite. That's my mistake. I'll happily correct the post if I remember or somebody lets me know who to credit. Because I love this idea... but it's not my idea.

It's pretty common for a speaker to ask the audience, at the end of a talk:

"Do you have any questions?"

I'm quite certain I've done that. Sometimes, the answer is yes. But the framing of the question is closed-ended. And the question, whether at a talk or during a meeting, might be intimidating. People might wonder, "Is it OK to have questions? Should I be embarrassed if there was something I didn't quite understand?"

That's why it seems a better question is the open-ended version of that:

"What questions do you have?"

It’s 9 p.m. in an operating room, just before the last procedure of a long day that had been full of delays. A nurse sees that the surgeon is about to make an incision without first stopping for the expected “timeout,” a crucial step that helps the team confirm, among other things, that the correct surgery is about to be performed on the correct side of the correct patient. The nurse is also concerned they don’t have enough units of blood on hand for this type of procedure. 

The nurse pauses and wonders,

“Should I speak up or keep quiet?”

I'm currently working on a Mistake Proofing class for Karen Martin and TKMG Academy. Coming soon!!

In the process of writing the course and its script, I've gone back to some older source material that has been on my bookshelf for a long time. In this case, it's a book I not only own but read many years ago (20 years ago?): Zero Quality Control by Shigeo Shingo.

It was published by Norman Bodek during the heyday of Productivity Press when he still owned it.

A while back, I uploaded the entire PDF of my 2018 book, Measures of Success: React Less, Lead Better, Improve More, into the premium version of ChatGPT.

As an author and publisher, it's a really useful tool for generating marketing content — although maybe it's a mistake to upload my content that way. I'm sure a PDF of the book was already on the internet to be potentially scanned by ChatGPT. Please leave a comment if you think I made a big mistake there.

One use is what I'm sharing here: Asking ChatGPT to provide its summary of the book and each chapter. It did a really nice job:

We can all make mistakes, so I advocate for learning from mistakes through my book, podcast, and speaking. I do my best to learn from my mistakes, so I don't repeat them. I fail to meet that standard sometimes, and I try to learn from those moments (as I shared in this recent post).

A few times now, a friend has sent me a photo or tagged me on a LinkedIn post about a sign similar to the one below. They assume I'd love the sign and the sentiment.

"Mistakes are proof that you are trying."

My response?

It depends.

What do Boeing frontline mechanics and engineers think about this day? What did they expect going into it? How did the day turn out? I'd love to know.

“Quality is made in the boardroom.”

I rolled my eyes hard when I read this announcement from Boeing, as part of the aftermath of the January 5th door plug blowout incident on an Alaska Airlines flight:

In recent years, there have been many complaints about the Boeing culture. Culture starts with the executive suite. They're responsible for the culture, and they're responsible for the results of bad decisions made in the boardroom or the remote C-suite. Or they should be responsible.

W. Edwards DemingBoeing to hold Quality Stand Downs

I loved a recent New York Times article about Chef Gordon Ramsay, including this part:

“Ramsay said that when he makes a mistake, he owns up to it. He has been candid about the misjudgments that led to the closure of Amaryllis, his fine dining restaurant in Glasgow, and admits that he has opened restaurants that were “badly conceptualized” or opened in the wrong area. “You should never be embarrassed of failure,” he said. “But never make the same mistake twice.”

For a long time, I've heard the phrase “the hidden factory” used to describe various forms of waste in a factory, including rework operations and activity.

I was surprised to hear Boeing CEO Dave Calhoun refer to this in a news story using a similar phrase, “shadow factory.”

Boeing Wants to Close Its ‘Shadow Factories.' It Would Be a Positive Step.

As I recently shared on LinkedIn, I really appreciated the annual shareholder letter that was published and shared by Larry Culp, who has been CEO of General Electric for just over five years now (the first-ever outsider CEO in their 125+ year history).

Read the full letter here. I've also archived it here as a PDF.

First off, I can't help but notice that the photo shared at the end of the letter is not a corporate headshot of Larry in a power suit and tie. It's a photo from a "gemba" (or factory floor) with him wearing safety glasses, a casual shirt, and a high-visibility vest.

He certainly looks to be in his element and enjoying it. How rare is that amongst CEOs of manufacturing companies of any size? How much better off would other manufacturers (or healthcare organizations) be if they had CEOs who don't just sponsor or support Lean, but are instead leading and driving the culture change? How many hospital CEOs truly enjoy donning PPE to be at the frontlines of patient care?

This post is built around excerpts from the book The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. Read more about Toyota, including stories and key lessons learned in the book.

Download a free preview of the book

From the book:

Fear and punishment drive people to get better at hiding mistakes when they could channel that energy into preventing them. When they can't be hidden, repeated mistakes illustrate how punishment accomplishes nothing beyond deflecting blame from leaders.

One of my heroes, W. Edwards Deming, who also deeply influenced Toyota executives, shared what may be the most important recommendation in his famed “14 Points for Management”:

“Drive out fear, so that everyone may work effectively for the company.”[i]

Driving out fear means, in part, that everyone can feel safe to speak up about mistakes and improvement ideas, as discussed in Chapters Five and Six. Leaders can also alleviate the fear of making mistakes, to begin with, when they combine the right methods and mindsets.

Starting with mindset, as former Toyota leader Darril Wilburn says,

“It's a leader's responsibility to create a system in which people can be successful.”

Therefore, it's the leader's responsibility to drive out fear. This includes creating work systems where it's easier to do the right thing and more difficult to make a mistake. This responsibility doesn't fall solely on the shoulders of leaders. They also engage their team members in designing effective mistake-proofing methods.

Mistake-proofing, or “poka yoke” in Japanese, is a core method within the Toyota Production System. It's a mindset based on the idea that people want to do good work but are imperfect. So, leaders have an obligation to help.

You might not think of Toyota as an entrepreneurial company today, but it started small in 1926 as a manufacturer of weaving looms based on patents held by founder Sakichi Toyoda. One of his key innovations was a mechanism that would automatically stop a loom when a thread broke, preventing it from cranking out more defective cloth. This innovation also led to huge productivity increases. One worker could now oversee upward of 30 to 50 machines, walking over to respond to problems when they were detected instead of having to hover over a single machine continually.

Toyota originally used the phrase “baka yoke,” which means “idiot-proofing.” Many decades ago, that term upset a Japanese factory worker who, correctly, complained that they weren't an idiot. We should also avoid saying “fool-proofing” or “dummy-proofing,” regardless of how often we hear them spoken around us.

Professor John Grout, the former dean of the Campbell School of Business at Berry College, is an expert on mistakes, receiving some of his early education in the field from Toyota leaders. He thinks mistake-proofing should be called “slip-proofing,” as it's easier to prevent execution errors than bad decisions (planning mistakes). One common slip is closing a file without saving it. The “Are you sure?” dialogue box tries to protect us, but as John points out, we're likely to click “Yes” out of habit. That's a slip on top of a slip–one that's hard to prevent. Using software that continually autosaves your work eliminates that risk (to my benefit, as I write this book in Google Docs).

This post originally appeared at mistakesbook.com.

Psychological Safety is not some nice-to-have touchy-feely concept.

Psychological Safety means that you feel safe speaking up in the workplace. That could mean:

• Asking questions
• Pointing out problems
• Admitting mistakes
• Disagreeing with your manager
• Sharing ideas for improvement

It's been pretty well proven that organizations with a higher level of Psychological Safety perform better.

A lack of Psychological Safety in a factory can turn deadly. A lack of it has proven deadly in healthcare settings too, of course.

If workers and engineers are punished for speaking up about quality problems in aerospace factories, that puts customers (and passengers) at great risk.

When people are pressured into being silent, that's a management problem and a culture problem. I'm not blaming the individuals who keep quiet to save their jobs. I do admire those who take great professional and personal risk to speak up anyway.

This WSJ article (which should be a free-reading link) talks at length about workers being punished at Spirit Aerosystems (a key Boeing supplier, formerly part of Boeing) for speaking up about quality concerns and problems.

There's so much to potentially dig into regarding decisions made by past Boeing executives about spinning off factories or outsourcing work. But I'll keep this post focused on the psychological safety elements.

I saw the punchline of this one story coming a mile away. It's not a funny situation, but I did literally laugh out loud:

“At one point, Dean said, [Spirit] threw a pizza party for employees to celebrate a drop in the number of defects reported. Chatter at the party turned to how everyone knew that the defect numbers were down only because people were reporting fewer problems.”

It's so predictable. It's happened before, and it will happen again.

Dr. Deming wrote about this dynamic 40 years ago, with a story of a factory that offered an incentive for “zero injuries.” Guess what, people stopped reporting injuries, even though people could be seen walking around with arms in slings and such.

Remember, including in healthcare, that “reported incidents” are not the same as “incidents,” especially when Psychological Safety is sorely lacking. In a true Lean Manufacturing environment, people are REWARDED for raising concerns and pointing out problems. We need more of that good Lean culture. Lives are at stake.

More from the WSJ article about people being punished for putting quality first:

The result, some current and former employees say: a factory where workers rush to meet unrealistic quotas and where pointing out problems is discouraged if not punished. Increasingly, they say, planes have been leaving Wichita with so-called escapements, or undetected defects. 

“It is known at Spirit that if you make too much noise and cause too much trouble, you will be moved,” said Joshua Dean, a former Spirit quality auditor who says he was fired after flagging misdrilled holes in fuselages. “It doesn't mean you completely disregard stuff, but they don't want you to find everything and write it up.”

And also:

On the Spirit factory floor, some machinists building planes say their concerns about quality rarely get conveyed to more senior managers, and that quality inspectors fear retaliation if they point out too many problems. 

Union representatives complained to leaders last fall that the company removed inspectors from line jobs and replaced them with contract workers after they flagged multiple defects. “This is leaving them with great quality and safety concerns,” one of the representatives wrote in an email to union officials. “Also feeling retaliated against for doing their jobs.” 

That doesn't give me more confidence about flying on Boeing airplanes. I hope the culture at Airbus isn't as dysfunctional.

‘This Has Been Going on for Years.' Inside Boeing's Manufacturing Mess.

Congratulations to my podcast(s) guests who were named to the Thinkers50 list of influential management thinkers!

I am thrilled to extend my heartiest congratulations to a remarkable group of individuals who have recently graced the stages of my podcasts, “Lean Blog Interviews” and “My Favorite Mistake.” These brilliant minds have been recognized on the prestigious Thinkers50 list for their groundbreaking contributions to the field of management thinking. Each has shared their invaluable insights with us, and it's a true honor to see them receive this well-deserved accolade.
⭐ Amy Edmondson (both podcasts)
⭐ Erica Dhawan (MFM)
⭐ Daniel Pink (both podcasts)
⭐ Zeynep Ton (Lean podcast, twice)

I have a limited number of copies of my book Measures of Success: React Less, Lead Better, Improve More that are available for about half of the Amazon retail price — and this includes free shipping.

tl;dr summary: Karyn Ross enlightened me about World Kindness Day and provided invaluable feedback on my book, The Mistakes That Make Us. Her insights particularly helped me replace the term “grace” with “kindness,” enhancing the book's inclusivity. She also helped me better distinguish between being “nice” and “kind.”

A Question -- Email From a Listener:

But I was prompted to think about this recently when I received an email from a podcast listener:

"So I heard an interesting distinction between Gemba and Genba today.

The M version is a place of work

The N version is a place of investigation (used by Japanese police).

So you go to the place of work before you go to the place of investigation."

Hmmm. I had never heard that. So I thought I'd do a little research and check with friends who have varying levels of Japanese language skills.

Leaders and organizations have a choice:

1) cultivate a culture of fear and punishment or

2) a culture of learning and innovation.

That choice significantly affects happiness and performance at all levels within the organization.

A culture of fear and punishment drives mistakes underground. An organization with a culture of fear cannot learn from mistakes because people don't feel safe admitting them.

People who do admit mistakes to their manager aren't more virtuous or courageous; they likely are in circumstances where they are able to feel safe doing so. Instead of telling people to be brave, leaders must help people feel safer.

Those who fail to learn from mistakes are doomed to repeat them.

In this episode, Mark recounts an unexpected ordeal in an Italian hospital after his mother-in-law broke her arm while on vacation. Faced with difficult choices about surgery and travel, the family navigates a foreign healthcare system. Amid the stress, a seemingly small act of kindness by a hospital staff member leaves a lasting impression, exemplifying universal compassion.

It’s not unusual to see individuals get blamed for systemic errors and problems.

Case in point, this article:

Delta Air Flight Attendant Makes Expensive Mistake After Emergency Slide is Accidentally Deployed Shortly After Landing in Dublin

It seems like a fact that the flight attendant deployed the slide. But is the mistake their fault?

This is an article that I wrote, published on the Quality Digest website.

It begins: "I can’t count how many times during the past 20 years I’ve heard executives complain that their people aren’t enthusiastically participating in their lean program. Leaders lament that while the company has spent a small fortune to put everybody through continuous improvement training, hardly anybody submits ideas. The problem isn’t their employees; it’s a cultural problem and, therefore, a leadership problem."

I was very excited to learn about an event that is being produced by GE, next Wednesday, September 6th, in New York City. I'm thrilled to have been invited to attend in person, along with other "Lean Influencers," including my friends Katie Anderson and Jamie V. Parker. We will be fortunate to be there in person to share highlights from the event via social media, blog posts, podcasts, and more -- on Wednesday and beyond.

See the LinkedIn Event page:

The Lean Mindset: The Pursuit of Progress

From the post:

This is really hard to write, as I was stunned and saddened by the recent passing of a good friend and colleague, Chris Burnham. Word had started to spread on LinkedIn and I feel bad about having to share this news here.

You can read his obituary here:

There will be a celebration of life event on Sunday that I will be fortunate to attend. Chris was, most recently, the Senior Director of Lean Strategy at KaiNexus, a company I have been involved with since 2011. Many of his colleagues will also be there to pay our respects, to honor him, and to support his loved ones.

I say this with all sincerity that Chris was one of my favorite people in the Lean community. I appreciated his positive and thoughtful approach to Lean and to our work. We shared a love of discovering new Bourbons to share and discuss, which then lubricated the social fun and work discussions.

Christopher Burnham Obituary

When you do work related to processes, quality, improvement, and learning from mistakes… the universe has ways of testing you (or playing a prank on me). As I share at the end of the post, I failed that test in one way. A big way.

My wife and I had a 3-piece sectional couch that we've recently replaced, so we were looking to donate the old one to a good cause.

This is something from my book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation, that I shared on LinkedIn recently.

Here's something I figured out thanks to education in a combination of fields, including Lean management and psychological safety. I wish I had understood this much sooner:

“Speaking up isn't a matter of character or courage–it's driven by culture. People feel safe to share when their leaders and colleagues treat them with respect. Instead of asking people to be brave, leaders must create conditions where people can feel safe.”

This post shares a story I heard at the Michigan Lean Consortium annual conference earlier this week. They've been kind about sharing ideas and doing a book club discussion around my new book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation.

During a book signing session at the conference, an attendee, Cori, told me a story that's too good to not pass along. I'll do my best to be true to the details of the story.

Below is some material that I wrote, but didn't use, in my book The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. Maybe it was a mistake to cut it. But the material wasn't really related to my podcast. It was based on some interactions with some Veterans Administration Health Care leaders after giving a talk on learning from mistakes last November.

What is culture?

Some say it's simply how we do things in this organization.

The late Edgar Schein, a famed MIT professor, wrote that we can observe and describe culture through artifacts, espoused values, and assumptions.

One example of an artifact is a small card given to me by a U.S. Veterans Health Administration site leader who is building a culture of learning from mistakes.  

On one side, the card said the holder was “free to fail.” The card framed a “FAIL” as the:

“First Attempt In Learning.”

An Artifact from a Veteran's Administration Healthcare Site

I was saddened to learn today that Masaaki Imai passed away, as announced this week by the organization he founded, KAIZEN Institute. He was 92.

Mr. Imai was well known for his books, including KAIZEN, his follow up Gemba Kaizen, and his latest, Strategic KAIZEN™ (published in 2021). He traveled the world teaching people about continuous improvement.

I'd like to first express my deepest condolences to Mr. Imai's family, friends, and colleagues.

I had the fantastic opportunity to meet Mr. Imai a few times -- once in Seattle when he was visiting and speaking at a healthcare organization, and twice during Japan study tours organized by Kaizen Institute. Thank you for your contributions to the world, Mr. Imai!

My new book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation, is still only in a draft state before final proofreading (actually, the proofreading is taking place now).

Trying to get some proof copies printed by Amazon sure does open up the possibility of mistakenly hitting "Publish Your Paperback Book" instead of "Save as Draft."

The following material was found on the “cutting room floor” for my upcoming book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. And I've supplemented it with some new material to flesh it out into a post.

Come to the live book cover reveal event tomorrow (Tuesday, May 2) if you can!

I've asked more than 215 people the same question (releasing 208 episodes to date):

“What's your favorite mistake?“

You might wonder why I seem to be so obsessed with this question. It's not because I love embarrassing people or because I want to gloat about the mistakes of others. I ask this question to learn and improve myself as a person and leader. 

The book and the podcast series are meant to be reminders that we shouldn't mock people for their mistakes. We shouldn't be too hard on ourselves, even if that's easier said than done.

As we explore concepts like psychological safety and Diversity, Equity, Inclusion, and Accessibility (DEIA) in this blog post series, I’d like to kick things off with a look at some serious problem statements that we must address. I’m thankful for the organizations, including Value Capture clients, who aim to close these performance gaps in systematic and sustained ways.

If you're interested in my upcoming book (available June XX, date TBD), The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation, the Kindle edition is available to be pre-ordered now through Amazon!

The date is set as June 27th, but it will likely be available sooner. Amazon (and their KDP platform) make it easier to pull a date forward… and they punish you for pushing a date back.

The book will also be available at the same time in paperback and hardcover formats. I'm going to work on an audiobook version over the summer.

Amazon also makes it more difficult for me to make a paperback or hardcover book available for pre-order. But again, I think it will be on sale early- to mid-June.

You can also enter this contest to win a free signed copy of the paperback edition.

Here's another reader question, this one received from The Netherlands, a country I have loved visiting over the past eight years (see my blog posts about the country and Lean healthcare efforts there).

Here is the question, in part:

Your work has been an inspiration here, so I started to research the origin and dissemination of lean in healthcare in the USA. Your first book, can be considered a standard work in this field and won a number of awards. But what I couldn't found in my search, was your motivation to write it. Can you please answer that for me: what triggers made you decide to start practicing lean in healthcare?

In a nutshell, here's the answer...

I'm happy to announce that I've finished the manuscript for my upcoming book (a real one, not an April Fool's Joke).

The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation

It's taken about a year from saying, “I'm going to write a book based on the My Favorite Mistake podcast” to completing the book writing.

Tomorrow is the 4th anniversary of the paperback release of my book Measures of Success: React Less, Lead Better, Improve More.

Long story short, I'm running a limited-time sale to celebrate.

Looking back to the release, I took an odd approach, perhaps, in that the eBook and Kindle version were available first, in August 2018, I think.

I wanted to test my hypothesis about people being willing to buy the book. Once I saw eBook sales start coming in (and getting positive feedback), I made the investment in getting the paperback book created (a professional page design and layout process). By the way, the phrase “self-publishing” is a misnomer. My company is the publisher, but I didn't do it myself!

For my next book, The Mistakes That Make Us, my company will be the publisher again, but the plan is to launch Kindle and paperback versions together at the same time. Probably this summer. But I need to finish the manuscript first! I'm almost there. That's my main focus these days, finishing that up.

Amazon has sold over 5,000 copies to date (a total of both formats). A relatively small number of books have been sold through other channels, including direct sales through me. One advantage of being the publisher is that I can see real-time data from Amazon and IngramSpark. For previous books, I have to ask my former editor to run a report.

  This article caught my eye today, and it's a change of pace to think about and write about mistakes other than my own (and I made more today — but healthcare mistakes are more important).

Penn Medicine hospital cited over wrong-site surgery

It's a mistake to perform surgery on the wrong leg. Not an “unintended mistake” (which is redundant). All mistakes are unintentional. Intentional harm could be called sabotage or assault....

Following up on my blog post about GE CEO Larry Culp's AME keynote speech, I wanted to share some of the discussion from his "fireside chat, absent the fire" (as Larry called it) with Katie Anderson (as we discussed in our podcast episode).

It was a real treat to hear Larry Culp, the CEO of General Electric and CEO of GE Aerospace, speak at the AME 2022 annual conference in Dallas. He recently reached the four-year mark of his tenure as GE's first-ever outsider CEO (read the 4-year update that Larry posted on LinkedIn).

Below are some highlights and quotes from his 15-minute remarks, along with some of my commentary and thoughts.

A culture of learning makes the difference, not "low inventory"

Last year, I wrote a post that criticized those, including the Wall St Journal, who claimed that Toyota was "abandoning" the Toyota Production System or that strategically adding some inventory meant they were moving away from "Just in Time" approaches:

Toyota leaders, including my friend Jamie Bonini, were quoted in this new article by HBS professor Willy Shih in HBR:

What Really Makes Toyota's Production System Resilient

Did TPS hurt Toyota during the pandemic?

NO

Elon Musk tweeted this yesterday: "Please note that Twitter will do lots of dumb things in coming months. We will keep what works & change what doesn't."

Contact me to talk about psychological safety - measure, learn, improve

“Simply put, we cannot get to zero harm without psychological safety.”

I wrote that as part of this page on the Value Capture website:

Psychological Safety and its Essential Link to Continuous Improvement

I've come to understand that psychological safety is a precondition for “implementing #Lean” or however you might say. Toyota seems to strive for (if not have) a relatively high level of psychological safety.

A contractor unplugged my WiFi router.

Or was there more to it than that? Instead of blaming somebody else, what mistakes did I make that led to the Q&A section of my webinar being knocked offline?

In this episode, Mark Graban breaks down a rare moment in mainstream business journalism: a Wall Street Journal article that actually does a respectable job explaining Lean. Using GE and CEO Larry Culp as a case study, Mark explores why the story stands out—and what it reveals about leadership, culture, and the real work of continuous improvement.

Mark walks through examples highlighted in the article, from simple but powerful flow redesign at a GE factory to Culp’s hands-on participation in kaizen events. He reflects on the WSJ’s surprising accuracy in describing Lean as a culture—not just inventory reduction—and discusses why focusing only on “just-in-time” often distorts Toyota’s system.

You’ll hear commentary on:

• Why “rewiring” GE mattered more than the later corporate breakup

• How tracing a steel blade’s 3-mile journey exposed deep operational waste

• Why Lean is as much about psychology and management as tools and layouts

• The importance of CEOs modeling improvement—not just sponsoring it

• How standard work, kaizen, and even DEI efforts connect through the same principles

This episode is for anyone interested in understanding Lean beyond the clichés—and seeing what happens when journalism, leadership, and operational excellence (for once) all line up.

If you’ve ever wished major business media would reflect how Lean actually works, this conversation might feel refreshingly close.

See some of that poor WSJ track record, including recent pandemic supply chain articles.

You're normally better off reading about Lean from the source.

Oh, how I enjoyed this article a month ago when it was sent to me. It's from 2003, but it was new to me:

Why dolphins are deep thinkers

I received a question from a healthcare leader who had read about the “idea card” format and method that Joe Swartz and I shared in our Healthcare Kaizen books.

I read your post about the Idea Card. Amazing! Have a follow up question. What does Kaizen suggest about how to incentivize people to submit ideas?

She's asking about the “Kaizen” style and approach to continuous improvement.

I'll share some of my reply along with some relevant excerpts from the book.

I'm really excited to be hosting and moderating this webinar next week, the second in our new Value Capture Webinar series.

The title is "Applications of Lean Leadership Methods in Home-Based Care."

In this era of Covid--19 vaccination, I'm still pretty much sidelined and not on site with any clients, although I did get to visit two mass vaccination sites (in addition to the one that vaccinated me).

I have tried really hard to be a cheerleader for continuous improvement and, in particular, for sharing continuous improvement ideas through the free VacciNexus platform and through other channels.

I believe, of course, in the power of many, many small improvements being driven by front line staff and their managers. That's the focus of my Healthcare Kaizen books. I also realize there's a time and a place for process re-design and for being innovative (thinking of it as step-change improvement.

In this post, I share and discuss improvements large and small.

tl;dr summary: Lean isn't just efficiency... it's safety, quality, delivery, cost, and morale. People often misunderstand that -- they don't know or they were taught the wrong things

I often have the opportunity to teach a group of experienced healthcare professionals, from a wide range of disciplines, about Lean. My session is part of a longer professional development program that's framed as "clinical outcomes and patient safety."

Lean has a lot to contribute to those outcomes, and you can see a collection of results here or here.

Since my last session had to be virtual, due to the pandemic, I took advantage of the opportunity to use some interactive tools from Mentimeter.com. This is something I'll continue doing even when I have the chance to teach in person, as people can vote or give input from their phones, anonymously, while sitting in class.

One question I asked the group was:

What does "Lean" mean to you in terms of improvement?

In this post, I'm going to share some reflections from one of my workplaces, some things that occurred last week. I'm going to be vague, so forgive me for that. It feels right to be less specific in this case, or at least that's the cautious (and maybe respectful) thing to do.

When wearing one of my different "hats" with one of the organizations I work with, something went wrong. It wasn't something I did (or I would own up to that in specific ways). But the mistake affected me and the work I was doing.

When a preventable process problem occurs, the engineer in me finds it relatively easy to be logical and think through "what happened?" instead of "who messed up?" A few deep calming breaths help, as well.

I'm not a Buffalo Bills fan (a.k.a. "The Bills Mafia"), but I did attend one game at what was then called Rich Stadium in 1998 when I was a grad school intern at Kodak.

Even without being a fan, I wish I could have written a headline for this post that said "Buffalo Bills Kaizen Their Way to a Super Bowl." Readers of this blog, of course, know that "Kaizen" is a Japanese word meaning "good change" and it's framed as an approach to engaging everybody in small improvements to the way they do their work.

So what does this have to do with football? Football is a workplace, even if it's college. I blogged about my alma mater, Northwestern University, using the word "Kaizen" (and the mindset) within their football program.

This article about the Bills isn't new, but I recently discovered it on Twitter:

Sean McDermott, Bills use 'Kaizen' strategy to stress constant improvement

From the article...

During this "let's try to get people vaccinated" phase of the Covid-19 pandemic, almost every article that I've seen about the vaccine and its distribution mentions the need to not waste precious doses.

There are many opportunities for error with the different vaccines. If some of them aren't stored properly at the correct temperature, the vaccine degrades and gets wasted (or worse, gets injected and gives a false promise of effectiveness).

Good process design (lessons I learned as an engineer) means being proactive and thinking about what could go wrong -- and then designing the process in a way that prevents errors or mistakes. The ideal would be "error proofing" that makes it impossible to make a mistake.

Or, we could make it more apparent that a mistake has been made (for example, a temperature-sensitive label on a vaccine bottle that would let you know if it's been out of the correct storage temperature too long). A countermeasure like this might prevent the mistake of using expired vaccine.

But how can we prevent the storage problem (and the waste of the vaccine) to begin with?

I wasn't planning on blogging over the holidays, but this article caught my attention:

Wisconsin hospital tosses 500 doses of COVID-19 vaccine due to 'human error'

(See the full post at the link https://www.leanblog.org/audio310)

Subscribe now to "My Favorite Mistake"

You might have heard of a "social media takeover" where a brand with a large following gives control of their social media feed to somebody who is promoting a cause or a social message.

One person I've followed on LinkedIn is Deondra Wardelle. She is a Lean practitioner (like me) and she's a Black woman (unlike me).

So, thinking back to the idea of a "social media takeover." I was inspired by Deondra, so I asked her to accept a "blog handover" as I'm calling it. My initial thought was to give a platform for her to write and talk about anything she wanted, to give more exposure to her voice.

Today, I wanted to share an excellent article written by Dr. John Toussaint (of Catalysis) and Ken Segel (of Value Capture)...

I'm excited to announce that our book Practicing Lean is now available as an audiobook through Audible.

As we did with the paperback and Kindle versions of the book, 100% of royalties will be donated to the Louise Batz Patient Safety Foundation (it's been almost $5000 so far).

You can buy or subscribe through Audible.

It's possible that I could start traveling again for my healthcare consulting work next month... or maybe in July. My colleagues at Value Capture aren't sure yet how this will work out, but clients are sharing their current plans for starting to re-open -- to a new normal, not the old normal.

As I mentioned (if not buried) in a post last week, my wife and I relocated from Orlando to Los Angeles last week because she is starting a new job (we will still have our permanent home in Texas).

Anyway, as the consultants start to think about traveling again, I have compiled some thoughts from my own research and experience since I'm the only one who has flown or stayed in hotels over the past two months, due to the relocation.

It was a sad weekend, hearing about the passing of Paul H O'Neill, Sr. on Saturday. He was 84.

I had the good fortune to meet and spend time with Mr. O'Neill on a few occasions and I'll share some reflections in this post. My condolences go out to his family and friends, and especially to my Value Capture colleagues who worked with him at Alcoa or at the firm over the past 15 years.

Here are his obituaries from the WSJ, the New York Times, and the Pittsburgh Post-Gazette. You can also read more about his life on a memorial page that his family set up and people are sharing memories there.

This is from the 3rd edition of my book Lean Hospitals. I've copied and pasted from the book with no additional edits, although I'll bold italic some parts for emphasis. I'll some closing thoughts at the end.

For a more complete PDF excerpt, click here (requires Dropbox access).

Thanks to Elisabeth and the team at GoLeanSixSigma.com for inviting me to contribute some thoughts in this piece:

How Lean Six Sigma Can Help Fight the Coronavirus Pandemic

It's great to see examples of manufacturing companies being flexible and adaptive in these challenging times. Lean methods are often providing a huge boost in what can be life-saving efforts.

Lean often gets mislabeled as a “low inventory” system (or “zero inventories”) but that misses the point. We don't just lower inventory at all costs (anybody can make that mistake without Lean) — we have to create systems and supply chains that might possibly allow for low inventory.

.....

But back to the one manufacturing company that inspired this post. It was great to see this article (hat tip to Brad Miller):

How to pivot an entire company in a week–and remain profitable

See more in the blog post (link at top)

I had a phone conversation yesterday with an emergency medicine physician after her shift at an unnamed hospital in an undisclosed state.

She had a number of frustrations to share and she doesn't really have an outlet (and doesn't want her name out there for fear of retaliation). More importantly, this isn't about one institution. She works in a well respected system. So this lack of preparedness and leadership could be widespread. When I posted my concerns about hospital preparedness for Covid-19, I guess they weren't unfounded.

I'm sharing these concerns in a public way because I think it's important to try to inspire other healthcare professionals and improvement specialists who CAN be on site to drive improvements.

I also hope it serves as a reminder to the public to NOT GO to the hospital unless it's a life-or-death emergency right now.  "When should I go to the hospital?" and more questions were be covered in a webinar that was done on Wednesday. Listen, watch, or read a synopsis here.

I normally love the public radio program "Marketplace" and have listened to it (on radio or as a podcast) for 15 years or so.

But, I was very disappointed with this recent piece, which you can read here:

"Just-in-time" manufacturing model challenged by COVID-19

Yes, many factories have been shut down in China, which disrupts global supply chains. However, if you're a company that decided to move all of your production to China (to then ship out to customers around the world), that wasn't a "Lean" strategy.

It's really difficult to support "just in time" delivery over such long distances. If it were a "Lean" approach to move all of your production to China, then Toyota would have done that. But, Toyota didn't.

I've been thinking a lot about hospitals and how they're preparing for the expected tsunami of Covid-19 patients who will need ICU beds and ventilators (when it's expected that there won't be enough of either).

There have also been recent preparations (and ongoing actions) to screen patients who arrive at emergency rooms and outpatient clinics.

I was at one organization last week that was in the process of installing new protocols and procedures in an outpatient clinic setting and I was able to have a tiny amount of input into that. Now, I'm home and trying to help remotely with the situation.

I hope this blog post helps more broadly.

Looking back at a blog post and an article from 2012 and 2014...

Thanks to the Shingo Institute for inviting me to facilitate a half-day workshop at the Shingo Conference, being held this year in Orlando, April 16 and 17. The workshop covers concepts and methods from my book Measures of Success: React Less, Lead Better, Improve More.

I hope you can join us for the conference, as this is an event I have enjoyed in the past — and if you're going to be there, please say hi and, better yet, come to my session.

My workshop will be a concurrent session on Friday at 8:30 AM. Here is a video they asked me to make where I share a little bit about the workshop:

Here's an article from Bloomberg BusinessWeek:

GE's Larry Culp Faces Ultimate CEO Test in Trying to Save a Once-Great Company

Very early on, the article mentions Culp's advocacy for "Toyota-style lean manufacturing." Or is he pushing "Danaher-style lean manufacturing" and is that different? And does that matter?

Culp was "in his element" visiting a GE factory in Pensacola -- can that be said about most CEOs?

Today, I'm sharing a question from a reader who started their career at Toyota and now works at another company. See previous posts with reader questions.

The reader has given me permission to share this -- to get your input -- and there are no identifying details included:

I came across something interesting at work around goals that I wanted to share with you and perhaps get your thoughts.

At the beginning of the fiscal year, our manufacturing sites submitted their cost savings targets to me. I looked them over to make sure they both seem reasonable yet challenging and asked questions as needed. From there, I submitted them to the operations VP for final approval. The VP accepted them without question.

We're at the end of the first quarter, and 3 of the 9 sites are not meeting their run rate target...

We had an excellent English-speaking tour guide for our visit (she lived in Hawaii at one point). As we talked through the facility (up in a "catwalk" that gave good visibility down into the process), she would occasionally stop at pre-determined points to explain something about the process or about the Toyota Production System and its elements.

At each stop, there was a box with a microphone and other audio/visual equipment and speakers. She didn't have to carry a microphone with her.

The guide was carrying a bag, something between a briefcase and a large purse.

One of our sharp-eyed tour attendees, a Chief Medical Officer from a Canadian hospital, noticed a hook that she would hang her bag on while stopped and talking. He asked her about the hook.

Sure enough, it was a Kaizen improvement! And, it was her idea.

Dr. Iida talked about the connections between "Kaizen" (small improvements) and innovation (larger improvements) and how, together, they lead to breakthroughs. He also talked about how one is absolutely necessary for the other to occur.

Dr. Iida has been the CEO for just over 20 years and his hospital receives visitors from around the world, including Europe and Africa. They were on the verge of bankruptcy when he took the job in 1991 and they are now "in the black" and had the money to build a new hospital, while most Japanese hospitals are losing money today, he said.

Last week was our fifth annual KaiNexus User Conference (or "KaiNexicon" as we now call it).

One of our keynote speakers was Jess Orr, a former Toyota engineer who shared perspectives on what it was like to now lead continuous improvement in another company. Jess has previously presented three webinars for us at KaiNexus (see links at the end of the post) and she always has something insightful to say.

I took a lot of notes during her talk, so here are some of the highlights as I captured them.

So, upon some reflection, it seems like "Just Do It" isn't really the right phrase to use. A classic suggestion box system has cards that start with listing a suggestion. That's, in a way, jumping to solutions. Kaizen isn't a suggestion box model.

Maybe "Just PDSA It" is a more accurate phrase to use?

In the huddles, the manager and team talk about problems, issues, or opportunities for improvement.

In some huddles, the team might say, "We can't think of anything that came up yesterday."

But, then, as the huddle progressed, the team was asked if anybody should get recognition or kudos for something they did.

http://www.kainexus.com/webinars

Today, I'll be hosting and moderating the latest in our KaiNexus Continuous Improvement Webinar series.

I'm really excited that the presenter will be Mark Valenti -- he's been a bit of a mentor and coach for me on the topic of "Motivational Interviewing," something I've really found helpful these past few years.

Click here to register for the webinar, which is intended to provide tips for leaders and managers (and a transcript can be found at the end of this post):

From Ambivalence to Action: Leadership Lessons from Motivational Interviewing

The webinar is today at 1 pm ET. If you can't attend live, please register anyway and you'll be sent a link to the recording.

General Jim Mattis has been making the rounds to talk about his new book that is out today: Call Sign Chaos: Learning to Lead.

"Learning to Lead" sounds like it could be the title of a book about Lean management. We're learning how to lead people, to lead improvement, to lead organizations. You might say we're "practicing leadership," myself included.

A few things jumped out from an article and an NPR interview with Mattis that made me think about Lean and the challenges we face in various workplaces. 

This past weekend, an old friend came down from Michigan to spend two days in the Dallas area.

Amongst the activities and catching up, we went bowling -- something I did a lot of as a kid and something my friend and I usually do when we get together.

I ordered a drink -- not a Lean whiskey, perhaps surprisingly -- but this:

"An UN-sweetened iced tea, please"

This is a radio segment from the KOGO morning news on August 23rd, 2019.

LaDona Harvey: When it comes to your career path, your family’s financial future, or even a weight loss journey, focusing on little setbacks can throw a real wrench in your progress.

Ted Garcia: Joining us on the KOGO news live, the author of, “Measures of Success. React Less, Lead Better, Improve More,” Mark Graban. Good morning, Mark.

Mark Graban: Good morning.

Here is an article that caught my eye recently, from HBR:

"How One Health System Overcame Resistance to a Surgical Checklist"

Anyway, this article caught my eye the other day:

Top Chefs and Restaurateurs on the Best Lessons They Learned from Failures

Check out the article for the detail, but here are the five lessons and I think they apply to Lean and other things we practice, with my commentary…

Hat tip to Stan Feingold from StoreSMART (a Lean Blog sponsor) for sending me this article:

Bob Lutz Talks Panel Gaps, Tesla, and Why Every Detail Matters -- Getting it right starts at the top.

When we have really sticky, complicated problems (like the widespread healthcare patient safety and quality problems), I think it's interesting to think about problems in the following terms... for a particular problem, which is true?

• It can't be solved (in general)
• That organization can't solve it (don't know how?)
• They won't solve it
• They don't need to solve it

When we look at patient safety, there are many examples that show improvement is possible. So, it comes down to a question of "can't, won't, or don't need to?"

I guess I'm wired for improvement. Or, it's just become a habit. Or, it's both.

I celebrate moments when I can identify an opportunity for improvement in my work. I tend to be pretty transparent about problems and even mistakes (like forgetting my socks). 

The Toyota-ism of "No problems is a problem" resonates with me. Identifying a problem shouldn't bring blame and shame... it's the first step in improving the way work is done.

I'm fortunate that we've built a culture at KaiNexus where problems and opportunities are celebrated. It's safe for people to speak up and problems lead to improvement, not punishment.

Our book Healthcare Kaizen shares stories and examples from organizations that have built a strong and sustained culture of continuous improvement. I almost take it for granted that improvement is a positive thing.

Registration is open for "Kaizen Live!" -- the 2019 edition.

Joe Swartz and I are excited to announce that we are hosting the fourth site visit to his organization, Franciscan St. Francis Health, in Indianapolis. It's being held October 3 and 4, with an optional workshop on October 2nd. 

Click here to learn more. You'll find links to the registration page and be sure to check out the early registration and group rate discounts that are available.

Inside Toyota's Takaoka #2 Line: The Most Flexible Line In The World

I had a chance to visit the 'Takaoka #1" line in February 2018 as part of my tour with Kaizen Institute. This article makes me wish we had been able to see Takaoka #2, but that sounds like a somewhat rare and special opportunity (even more special than visiting Toyota is normally).

A principle that has been often discussed (and hopefully practiced) in the Lean community over the past few years is usually described as “respect for people.”

A certain British rabble rouser recently said the following at a Lean conference: “All this respect for people stuff is horse sh*t,” and it is a “conventional Western management interpretation.” He mocked the idea of “respect for people programs,” although I'm not sure where such a standalone program has ever been attempted. That sounds like a strawman, the idea that a company would have a “respect for people” program.

Let me explain why he's wrong — “respect for people” is not horse sh*t” — and we can explore some great links on “respect for people” in this post.

"Over the past year, I've heard about the “OKRs” methodology that is used in tech companies like Google. OKRs stands for Objectives & Key Results.  The approach (along with examples and case studies) are laid out in the book by venture capitalist John Doerr, Measure What Matters: How Google, Bono, and the Gates Foundation Rock the World with OKRs."  There are things I like about this model... and it reminds me of the Lean "Strategy deployment" practice... but I think it would be better with "Process Behavior Charts." #okrs #OKR #leanstartup #leanmanagement #business 

Last year, I gave a talk called “When Being Right is the Wrong Strategy for Change” and KaiNexus recently shared a nicely-shot video of that talk on YouTube. So. I'm sharing that here... and the blog post has a transcript I had done, annotated with some slides and links. You can also read a shorter summary via the KaiNexus blog.

http://www.leanblog.org/audio275

I find it really interesting when scientific facts and truth get superseded by new evidence. Science isn't supposed to be stubborn… it's OK to cast aside the old status quo when we learn something new (pay attention, “flat Earth” crowd).

There are a lot of these themes, also, in a book I've been reading, The Case Against Sugar, by Gary Taubes. Some of the established science about low-fat diets being good for us might not really be true.

How does this all apply in medicine and our practice of Lean?

I've seen some compare her process to the Lean practice of “5S.”

Kondo says you should only keep an item if it “sparks joy.”

I'm guessing he created the headline, since the phrase “give a damn” doesn't appear in the article:

"Michael Dowling: CEOs — Give a damn about your people"

Who are the CEOs he is speaking to who do NOT give a damn? What inspired him to write this?

In 1995, nobody claimed GM was Lean so the expectations were low. They were who they were and my new plant manager in 1996 started to change things. Boeing is a company that has been pointed at as a great example of Lean Manufacturing, so it's troubling to read reports that suggest otherwise.

From the New York Times:

Claims of Shoddy Production Draw Scrutiny to a Second Boeing Jet

Workers at a 787 Dreamliner plant in South Carolina have complained of defective manufacturing, debris left on planes and pressure to not report violations.

Ever since I started podcasting in 2006, I've been using a company called “Hipcast” to be the “hosting” company for the podcast audio files and feeds. For those of you not familiar with podcasting, that's the website where I upload podcast audio files… and they then serve those files when requested by services like Apple Podcasts or Spotify.

This has been an aggravating week or so, since Hipcast has been having a lot of technical issues going back to last Tuesday or so. Their website has been down, the podcast feeds (RSS feeds) have been broken. People haven't been able to listen to my podcasts unless they had already downloaded the episodes through their app.