We Thought We Solved That: The Art and Judgment Calls in the PDSA Cycle

What does it really mean when a problem “comes back” after a team thought it had been solved?

In this episode, Mark Graban reads his article, “We Thought We Solved That: The Art and Judgment Calls in the PDSA Cycle.” He examines how a frustrated executive’s question—“Why did the problem come back?”—can either support learning or trigger blame, depending on how it is asked.

Mark explores five possible explanations for a recurring problem: the wrong countermeasure, poor implementation, failure to sustain the change, changed conditions, or the possibility that the problem never actually went away. He also explains why Toyota’s language of “countermeasures” is more useful than declaring a problem permanently “solved,” and why process behavior charts can help distinguish real change from routine variation.

The larger lesson: reaching the Study step of PDSA requires more than checking whether an action item was completed. Leaders must examine what actually happened, what the data show, and what the organization needs to adjust next.

Read and share the original article at leanblog.org/audio471.