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Lean Blog Audio

By Mark Graban

Mark Graban reads and expands upon selected posts from LeanBlog.org. Topics include Lean principles and leadership in healthcare, manufacturing, business, and the world around us.

Learn more at www.leanblog.org/audio
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Do Words Matter on a Kaizen Card?

Lean Blog AudioJun 04, 2017

00:00
06:43
The Problem (737 MAX and Beyond) at Boeing Isn't "Idiots." It's Far More Complex Than That... But Fixable

The Problem (737 MAX and Beyond) at Boeing Isn't "Idiots." It's Far More Complex Than That... But Fixable

The blog post

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?

Mar 19, 202416:56
Cultivating a Culture of Candor: Transforming Workplace Communication for Better Outcomes

Cultivating a Culture of Candor: Transforming Workplace Communication for Better Outcomes

The blog post

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."

Mar 07, 202407:36
A Better Question Than "Do You Have Any Questions?"

A Better Question Than "Do You Have Any Questions?"

The blog post

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?"

Mar 05, 202403:31
Instead of Urging Your Employees to Be Brave, Help Them Feel Safe Speaking Up

Instead of Urging Your Employees to Be Brave, Help Them Feel Safe Speaking Up

The blog post

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?”


Mar 04, 202408:06
Shigeo Shingo & Norman Bodek on Learning From Mistakes, Including Shingo’s

Shigeo Shingo & Norman Bodek on Learning From Mistakes, Including Shingo’s

The blog post

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.

Mar 01, 202407:57
ChatGPT Summarizes the Chapters in My Book, Measures of Success

ChatGPT Summarizes the Chapters in My Book, Measures of Success

The blog post

A while back, I uploaded the entire PDF of my 2018 book, Measures of Success: React Less, Lead Better, Improve Moreinto 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:


Feb 29, 202407:27
Come to Japan With Me and Katie Anderson in November to Study Lean!

Come to Japan With Me and Katie Anderson in November to Study Lean!

I'm excited to announce that I've registered for Katie Anderson‘s Japan Study Trip in November! Read the blog post.
Between 2012 and 2019, I visited Japan five times, and I learned something new each time. I've been really itching to go back. I'm excited to see and learn new things with Katie and her team!!
It's a great opportunity to deepen your understanding of Lean and the Toyota Production System. Visiting Japan helps one understand which of the broader cultural elements of the country contribute to a Lean workplace.
But it also helps you understand that not all Japanese companies are made in the Toyota mold. Toyota has worked very diligently to cultivate its culture and practices over time. And our organizations can do the same.

Feb 26, 202410:06
Mistakes are Proof that You’re Trying? A Situational Analysis

Mistakes are Proof that You’re Trying? A Situational Analysis

The blog post

We can all make mistakes, so I advocate for learning from mistakes through my bookpodcast, 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.

Feb 22, 202408:57
What Will a “Quality Stand Down” Day Accomplish at Boeing?

What Will a “Quality Stand Down” Day Accomplish at Boeing?

The blog post

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

Feb 16, 202411:16
Chef Gordon Ramsay on Never Making the Same Mistake Twice

Chef Gordon Ramsay on Never Making the Same Mistake Twice

Blog post link

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.”

Feb 13, 202403:22
Closing Boeing’s “Shadow Factory” is Harder Than it Sounds

Closing Boeing’s “Shadow Factory” is Harder Than it Sounds

Blog post

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.

Feb 07, 202404:21
Lean Leadership in Action: CEO Larry Culp's Journey to Revitalize GE at the Gemba

Lean Leadership in Action: CEO Larry Culp's Journey to Revitalize GE at the Gemba

Read the blog post

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?

Feb 05, 202406:23
Mastering Mistake-Proofing: Insights from Toyota's Poka Yoke Approach

Mastering Mistake-Proofing: Insights from Toyota's Poka Yoke Approach

Blog post

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.


Jan 16, 202405:30
Psychological Safety in Manufacturing: How Silence in Aerospace Factories Can Turn Deadly

Psychological Safety in Manufacturing: How Silence in Aerospace Factories Can Turn Deadly

Blog post link

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.

Jan 13, 202407:46
Congrats to Four Podcast Guests Who Were Named to the “Thinkers50” List

Congrats to Four Podcast Guests Who Were Named to the “Thinkers50” List

Blog post with more info and links

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)

Nov 28, 202305:35
Cyber Monday / Week Deal: “Measures of Success” Signed Copies

Cyber Monday / Week Deal: “Measures of Success” Signed Copies

Blog post with link to purchase and more

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.


Nov 27, 202301:18
World Kindness Day, The Mistakes That Make Us, and Help From Karyn Ross

World Kindness Day, The Mistakes That Make Us, and Help From Karyn Ross

Blog post

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.”


Nov 16, 202309:07
Gemba vs. Genba -- Different Spellings or Different Words and Meanings?

Gemba vs. Genba -- Different Spellings or Different Words and Meanings?

Blog post

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.


Nov 15, 202310:22
From Punishment to Improvement: Transforming Workplace Culture

From Punishment to Improvement: Transforming Workplace Culture

The episode's blog post

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.

Oct 02, 202303:04
The Power of Small Acts: How 60 Cents Became Something Priceless

The Power of Small Acts: How 60 Cents Became Something Priceless

Read the blog post

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.


Sep 30, 202305:55
Boeing 767 Emergency Slide Mistakenly Deployed — Is This the Flight Attendant’s Fault?

Boeing 767 Emergency Slide Mistakenly Deployed — Is This the Flight Attendant’s Fault?

Direct blog post link

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?

Sep 18, 202307:31
Stop Spending Money on Problem-Solving Training; Focus on psychological safety instead

Stop Spending Money on Problem-Solving Training; Focus on psychological safety instead

To read the article and comment, click here or leanblog.org/audio340.

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."

Sep 13, 202311:48
An Exciting Live-Streamed Event on September 6: The Lean Mindset with GE and Many Special Guests

An Exciting Live-Streamed Event on September 6: The Lean Mindset with GE and Many Special Guests

Blog Post

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

Aug 29, 202307:08
Remembering and Honoring Chris Burnham, a Colleague and Friend

Remembering and Honoring Chris Burnham, a Colleague and Friend

Blog post

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

Aug 22, 202314:60
When Life Tests You: My Attempt to Donate a Couch Was Blocked by Bureaucracy

When Life Tests You: My Attempt to Donate a Couch Was Blocked by Bureaucracy

Blog post

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.

Aug 17, 202309:25
Speaking Up Isn’t a Matter of Character or Courage–It’s Driven by Culture

Speaking Up Isn’t a Matter of Character or Courage–It’s Driven by Culture

Blog post

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.”


Aug 15, 202304:38
Lean Blog Audio: Trailer
Aug 14, 202300:53
Story: When Firing an Employee Doesn’t Prevent the Repeat of the Mistake

Story: When Firing an Employee Doesn’t Prevent the Repeat of the Mistake

Blog post

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.


Aug 14, 202304:09
A Workplace Culture Where "FAIL" Means First Attempt in Learning

A Workplace Culture Where "FAIL" Means First Attempt in Learning

Blog post page

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

Jun 26, 202307:13
In Memoriam: Masaaki Imai, "The Father of KAIZEN™" (1930⁠-⁠2023)

In Memoriam: Masaaki Imai, "The Father of KAIZEN™" (1930⁠-⁠2023)

Blog post with photos and more

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!

Jun 17, 202316:56
A Near Miss with Amazon's Publishing Platform - Save Draft or Publish

A Near Miss with Amazon's Publishing Platform - Save Draft or Publish

Read the blog post and get links

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."


Jun 12, 202305:38
Why Keep Asking, “What’s Your Favorite Mistake?”

Why Keep Asking, “What’s Your Favorite Mistake?”

Blog post link

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.


May 15, 202305:58
Organizations Cannot Solve Problems Unless Leaders Admit Them and Help Others Feel Safe Speaking Up

Organizations Cannot Solve Problems Unless Leaders Admit Them and Help Others Feel Safe Speaking Up

Link to the blog post at Value Capture's website

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.

May 12, 202312:14
Kindle Pre-Orders Open for “The Mistakes That Make Us” — Enter to Win Signed Paperback

Kindle Pre-Orders Open for “The Mistakes That Make Us” — Enter to Win Signed Paperback

Episode page and blog post

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.


May 07, 202303:24
Reader Question: Why Did I Get Into Lean Healthcare?

Reader Question: Why Did I Get Into Lean Healthcare?

Blog post for this episode

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...

Apr 11, 202310:21
“The Mistakes That Make Us” — My Manuscript is Done! Some Backstory and What Comes Next

“The Mistakes That Make Us” — My Manuscript is Done! Some Backstory and What Comes Next

Blog post for the episode

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.

Apr 05, 202314:28
Measures of Success (Paperback Version) Turns Four Years Old

Measures of Success (Paperback Version) Turns Four Years Old

Blog post including a link to buy the book

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.

Mar 31, 202305:56
Learning from Small Mistakes to Avoid Big Mistakes, Operating Rooms and Patient Harm

Learning from Small Mistakes to Avoid Big Mistakes, Operating Rooms and Patient Harm

Blog post

  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....


Feb 23, 202309:05
GE's Larry Culp on Making it Safe for Bad News to Flow to the CEO (or Other Leaders)

GE's Larry Culp on Making it Safe for Bad News to Flow to the CEO (or Other Leaders)

Read the post for this episode

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).

Dec 01, 202208:35
Highlights from GE CEO Larry Culp's Remarks at the AME Conference in Dallas

Highlights from GE CEO Larry Culp's Remarks at the AME Conference in Dallas

Blog post

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.

Nov 28, 202214:52
Toyota Was Helped, not Hampered, by TPS During the Pandemic

Toyota Was Helped, not Hampered, by TPS During the Pandemic

Blog post 

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

Nov 22, 202207:55
Does Learning From Mistakes Mean It's OK to Try Any "Dumb Thing" - For Elon Musk or Any of Us?

Does Learning From Mistakes Mean It's OK to Try Any "Dumb Thing" - For Elon Musk or Any of Us?

Blog post - https://leanblog.org/audio321

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."

Nov 10, 202204:03
Psychological Safety as a Pre-Condition for Lean

Psychological Safety as a Pre-Condition for Lean

Blog post: http://www.leanblog.org/audio320

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.

Nov 10, 202203:31
Isn't It Ironic? Mistakes That Interrupted My Webinar About Mistakes

Isn't It Ironic? Mistakes That Interrupted My Webinar About Mistakes

Episode #319 -- read the blog post that contains video of the webinar

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?

Jul 03, 202214:10
This WSJ Article About Lean Isn't Terrible (via GE and Larry Culp)

This WSJ Article About Lean Isn't Terrible (via GE and Larry Culp)

Blog post: https://www.leanblog.org/audio318

The Wall Street Journal has an epic track record when it comes to always getting it wrong when they write about Lean or the Toyota Production System. They always focus on just the “just in time” pillar, ignoring “jidoka” (built in quality) as the other pillar (per Toyota). They ignore many other aspects of TPS, like the culture and the management style.

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

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

But, they did better in this recent article about General Electric and CEO Larry Culp (who knows Lean very well from his time as CEO of Danaher):

Larry Culp Rewired GE. Then He Unwound It.
Jan 04, 202212:15
Dolphins Are Also Smart Enough to Game the System to Get More

Dolphins Are Also Smart Enough to Game the System to Get More

Blog post: https://www.leanblog.org/audio317

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
Oct 11, 202107:06
What Does Kaizen Suggest About How to Incentivize People to Submit Ideas?

What Does Kaizen Suggest About How to Incentivize People to Submit Ideas?

Blog post: https://www.leanblog.org/audio316

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.

Oct 08, 202112:08
Free Webinar: Applications of Lean Leadership Methods in Home-Based Care
Oct 07, 202103:15
Improvements to the Covid Vaccination Process -- Small and Large (and Hockey Hubs)

Improvements to the Covid Vaccination Process -- Small and Large (and Hockey Hubs)

Blog post: https://www.leanblog.org/audio314

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.


May 20, 202115:51
What Does Lean Mean to Healthcare Professionals? What Should it Mean?

What Does Lean Mean to Healthcare Professionals? What Should it Mean?

https://www.leanblog.org/audio313

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?
Mar 18, 202108:03