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Stick with the problem a little bit. Understand the problem. Understand the process. Find root cause first.PDCA, which stands for Plan, Do, Check, Act/Adjust, has provided a structure for process improvement for decades. Originally created by Dr. W. Edwards Deming, PDCA is an easy-to-follow method that works in any industry and on any process.

Tune in to our 1-hour Introductory Webinar to get a primer on how this model can help you in your quest to explore root causes, improve processes and get results!


Webinar Level

  • Introductory


In this 1-hour Introductory webinar, we will cover:

  • What is PDCA?
  • The evolution of PDCA
  • The four steps of PDCA
  • PDCA and the A3
  • PDCA and DMAIC

Webinar Transcript

Elisabeth Swan: Welcome to another’s webinar. We are so happy to have you join us today. This webinar series is for you, our learner community. Lean and Six Sigma are worldwide go-to improvement methods and these webinars are part of our efforts to make it easy for you to use those tools and concepts.

My name is Elisabeth Swan. I’ll be your moderator. Today’s webinar is Introduction to PDCA. And our presenter is Tracy O’Rourke. Hello, Tracy.

Tracy O’Rourke: Hi. How are you Elisabeth?

Elisabeth Swan: I am good. And I’m psyched for this. Tracy is a Managing Partner and Executive Advisor here at

About Our Presenter

A little background on Tracy, she is co-host of the Just-In-Time Café Podcast. She teaches Lean Six Sigma at University of California at San Diego. She is a long-time Lean Six Sigma Consultant and Master Black Belt.

Besides from over 20 years in the business, Tracy speaks at Lean Six Sigma conferences around the world. Tracy lives in San Diego, California with her husband and two sons. Welcome, Tracy!

Tracy O’Rourke: Thank you so much. Happy to be here today.

How to Interact

Elisabeth Swan: During the presentation, you will all be in listen-only mode. There will be a question-and-answer session following the presentation. But please feel free to ask questions any time. You can just enter them into the question window.

We will ask you to participate in some polls. And if we don’t answer all of your questions during the webinar, we are definitely going to post all of the questions and the answers after the webinar. And you will be able to see answers to everyone’s questions and you will be able to download this webinar once it’s posted.

Once again, you will have access to downloading this webinar after it’s posted. And since you signed up, we’ll let you know when it’s posted.

Where Are You From?

So, our first interactive poll session is to find out where you are from. We have hundreds of attendees today. People are joining us from all over the world on this webinar and we’d like to find out where. So if you click on question and type in where you are from, I’m guessing some of you are up early and quite a few are up very late. So let’s see.

All right. So let’s take a look at where we see. And we’ve got John in Charlotte, North Carolina. We’ve got Christopher in the Bay Area. We’ve got Jessie in Minnesota. We’ve got Ray in Columbus, Ohio. Candice in Mississippi. We’ve got Josh in Pensacola. We have got – looks like Ogochukwu in Nigeria. Welcome.

Tracy O’Rourke: Wow!

Elisabeth Swan: Welcome. Welcome. We’ve got Cherie from Minot, North Dakota. Oh man, people are calling in from all over the place. We’ve got Valparaiso, Indiana, that’s Christine. Fredericton, New Brunswick, that’s Jane. Welcome, Jane.

Man, we’ve got folks calling in from all over. You have a wide range there, Tracy.

Tracy O’Rourke: Well, thank you. And thank you everybody for coming all over the world. That makes me feel great. And I really hope you see value in this webinar today on PDCA.

Who Is

So, I just want to let you know that I’ve been with Go Lean Six Sigma since its inception and we have a couple of guiding principles. We believe in simplifying complex concepts and we believe that complexity just confuses people.

So our goal really is to demystify complex concepts, make training effective, practical, accessible, oh, and fun! Wouldn’t that be good? So, that’s really our mission and if you’ve been to any of our trainings, our online trainings, you have probably seen the Bahama Bistro. And if not, you should go.

And ultimately, we created a dreamy and relaxing training facility that we could send you to training for. So, it’s a really nice place. It’s very enticing.

We’ve Helped People From…

Many organizations agree with our philosophy because here are some of the organizations that we’ve helped and you can see that we’ve got all different kinds of organizations from brick and mortar, online companies, diverse industries such as health care, manufacturing, financial services, and state government.

Why? Because Lean Six Sigma is about problem-solving. And every organization has problems to solve. They will always have problems to solve. And guess what? They need people that are good at problem-solving.

And so ultimately, that’s really what we’re doing is helping organizations and individuals build their problem-solving muscles.

Today’s Agenda

So, let’s talk about our agenda. Our agenda today is really about PDCA. And what I love about doing this webinar is we do webinars every month and most of the time, it’s pretty much stuff we’ve been doing all along. But for this particular webinar, I actually did a lot of research and guess what? I learned some stuff too. And that’s what I love about doing this is we’re always learning. We’re on the learning path. And I’m excited to share some of the things that I’ve learned too.

So ultimately, today’s agenda is about what is PDCA, the evolution of PDCA because I actually think that there’s a lot of strong opinions out there and that was going after fact because we need more facts in this world. And then we’re going to talk about the four steps of PDCA. PDCA and the A3 and PDCA and DMAIC and how they might fit together.

What Is PDCA?

So let’s talk about what is PDCA. So first of all, if you haven’t figured out yet, it’s an acronym. It stands for Plan-Do-Check-Act. And that’s original acronym. So what is it though? It’s an iterative 4-step method for solving problems related to processes, improving processes, improving products and services.

So for some people that may resist change, they might think that or they might want PDCA to stand for, please change don’t change anything. But in the world of process improvement, we wouldn’t have an acronym that really stands for that because we really are about trying to make things better and that does involve change.


So, let’s talk a little bit more about Plan-Do-Check-Act. So, it is a cyclical process. And at a high level, really what you’re doing in the plan phase is these are some of the steps you’re doing, identifying the issue and the root cause and you’re designing experiments to address the root cause. But there are a couple of other things you’re doing in plan that we’re going to talk about later, identifying a problem and goal, formulating a theory, and then trying to figure out what the root cause is. So we’re going to discuss that in a little bit.

So these are activities that are followed by the Do step. And in Do, ultimately what you’re doing is you’re implementing your running experiments or applying counter countermeasures to fix the root cause. And a lot of times, you’re saying, “Well, I think this might work, this countermeasure and let’s try it. Let’s run an experiment, see if it works.”

Now, some people go with the countermeasure. Sometimes the word “solution” indicates a permanent fix where countermeasure is really more speaking to a temporary solution if you will to address the root cause at hand. And so the idea is that it is cyclical. If you put a solution in, the thought is you don’t ever have to look at it again.

But really with countermeasures, you’re really addressing what you see at hand now and it doesn’t mean you would not revisit it later or try to make another improvement later in another cycle. So that’s ultimately why we use countermeasures versus solutions in this method.

Then we have the Check step. And ultimately what you’re doing here is you’re checking to see if it worked. You’re actually looking at the experiment and you’re really looking to see if it worked and if it didn’t, what could be done differently, what could we change? You compare results to the goal and then you’re doing sort of an assessment if you will of your experiment.

And then finally, the last step is that you’re going to be acting and a lot of people use adjust now because sometimes people say, “Well, what’s the difference between do and act?” Well ultimately, act is really saying you’re going to fine tune it. You’re going to make some adjustments to it and then continue the cycle of planning.

So ultimately, that is the four steps. It’s a never-ending cycle of continuous improvement. The idea is you’re always in this cycle and the idea is it’s really how you think. So I think that’s the cycle piece that we really want to speak to. It’s not a one and done. So a lot of times when we think about projects, a lot of organizations say, “OK, the project is complete. What’s the next thing?”

But with PDCA, it’s not just a cycle. It’s a way to think about something and it’s that continual process of thinking through experiments to make things better. So it becomes more culturally what’s happening.

Poll #1

So I have a poll for you all ready. And this is really more designed to see what you know so far about PDCA. Again, this is introductory. So if you don’t know the answer, that is OK. We have a poll for you. And we’re going to launch the poll and I’m going to have you actually tell us your thoughts here.

This is basically, what else is PDCA known as? And you’ve got a couple of examples. We’ve got Plan-Do-Check-Adjust, Plan-Do-Study, the Deming cycle, the Shewhart cycle, all of the above.

So what do you guys think? Go ahead and enter in your thoughts. What do you think, Elisabeth? Do you think that this is a trick question?

Elisabeth Swan: I think it’s easier to hear me if I’m not on mute. I think it could be a trick question, Tracy. I think it could be a trick question.

Tracy O’Rourke: It could be.

Elisabeth Swan: These guys are all familiar. I mean familiar to us of course, Dr. Deming and Shewhart. And they both came out of the Bell Labs with the Hawthorne Works. There’s a lot of big quality people that came out of that back when – back before they broke the labs up into what we know now as the million different phone companies we’ve got. But anyway, they have lots of good quality folks there.

Tracy O’Rourke: Good. And if you have any more insight to some of that when I talk about the evolution of PDCA, I’m sure our listeners would love to hear some of your thoughts on that too.

Elisabeth Swan: Cool.

Tracy O’Rourke: All right. Let me close the poll and see what we got.

Elisabeth Swan: So what you got was almost half the folks thinking it’s all of the above and then the next group of 31% thought it was Plan-Do-Check-Adjust. And then they thought it was the Deming cycle. And that’s 13%. And then 9% thought it was Plan-Do-Study-Act. And 2% thought it was the Shewhart cycle. So that’s the group they belong to.

Tracy O’Rourke: So the correct answer – the correct answer is E, all of the above. So it’s true. PDCA has been known for all of these things. So obviously, the acronyms standing for PDCA is obviously Plan-Do-Check-Adjust. But in terms of the methods, they have been called all of these other things by various people throughout the years.

So I think that’s what was interesting to me is when I started doing more historical research on PDCA. It was – a lot of people believe that PDCA came from Deming and it didn’t. It actually came from his mentor, Walter Shewhart. And a lot of people called it the Deming – the Shewhart Cycle.

Evolution of PDCA

The Deming Cycle is also there and also sometimes people call it the Deming Wheel. So we’re going to talk a little bit about the evolution of PDCA. And I think it’s very interesting. So a lot of people again think, “Well, Deming started it.” And then some people say, “Well, no. Walter Shewhart started it.”

And it’s true. He did coin the term. But really, PDCA started way before Walter Shewhart and that was with the scientific method. And that was in the 16th century. And if you look at the definition of scientific method which is basically saying it consists of systematic observation, measurement, experiment, formulation, testing and modification of a hypothesis. These are all elements of what we know of PDCA and even some of the more modern philosophies that are existing as well.

And so, this was really interesting to me. And they’ve even – there’s some recordings of Galileo Galilei‘s ways work consisting of some of these steps which I thought was really interesting. And if you have more than interest in learning about the historical elements of PDCA more and beyond this webinar, I would suggest an excellent white paper I came across in some of my research. It’s available with the Deming Institute and it’s on the website. It’s called Foundation and History of the PDSA Cycle by Ronald Moen and Cliff Norman.

And basically, this article provides a history of every Deming’s PDSA Cycle and it also shows some of the work by Galileo in 1600 most through Deming’s last version of PDSA Cycle of 1993 but it talks about Shewhart Cycle in 1939, the Deming Wheel in 1950, and then use for the Japanese between 1951 and 1985. So I think it was very interesting and we’re going to speak a little bit to it here. But if you really want to do some more reading, I thought it was great and I’m passing it along. And we’ll post that on our website as well.

So ultimately, Walter Shewhart did coin the term PDCA and he has been known as the Father of Modern Quality back then. And Edward Deming was his student and his spiritual son. So Shewhart really introduced those concepts. What he is really known for is SPC, which is Statistical Process Control. But ultimately, his really big contribution as well is PDCA.

So, he worked in as you had said, Elisabeth, at Bell Labs and he also worked with the Western Electric Company. And he was the mentor for Deming and also worked alongside Joseph Juran and had some influence with some of those other statisticians.

So he had later worked at Hawthorne until 1925. And then again, he worked at the Bell Telephone Research labs.

And so, there’s a lot of history here and it’s really interesting to see and hear and read about the relationships that some of these statisticians that are known as our Grand-daddies of Quality and how they’ve had interaction and have been working side by side.

Any interesting pieces of information you want to share about some this history, Elisabeth, since you’ve read about them?

…it’s a tool that we use widely to understand whether processes are performing normally or if there’s something new and different happening in the process.

Elisabeth Swan: I think also that Walter Shewhart was famous for creating the control chart as you say that comes under statistical process control. But it’s a tool that we use widely to understand whether processes are performing normally or if there’s something new and different happening in the process. He developed a way of staffing that out if there’s common cause variation or whether there’s special cause variation. So it’s another thing about Walter Shewhart that we appreciate.

Tracy O’Rourke: Yes, we do. And we talk about that every time we’re in Green Belt Training. Thanks, Elisabeth.

So let’s talk a little bit about Deming. So again, the evolution of PDCA came from his mentor, Walter Shewhart. And like any good student, Mr. Deming really started working with and practicing the PDCA elements and he is probably most well-known for his work in Japan. He helped the Japanese after World War II sort of rise from the ashes and helped them develop very good products, excellent products, excellent processes for quality products.

And I remember in ‘80s how Japanese products were absolutely the premium product. I’ll give you a little insight to say that I actually worked in – OK, I’m going to date myself here. I used to work at Circuit City in college and I worked in the audio department. And what I thought was really interesting is we’d have people come in all the time and they would want me to pull these receivers off the wall so they could see if it was made in Japan. And they wouldn’t buy it if it wasn’t made in Japan. And so, that’s a testament to the quality of Japanese that products were associated with back then.

And so, Deming really helped bring that along for them. And in relation to PDCA, he started to look at the cycle and he really made some changes to it. So he really felt strongly about changing PDCA to PDSA, and the S stood for Study, not Check.

And ultimately, it’s because he really wanted to focus on – he thought that check was more about implementation of a change with success or failure. And he really wanted to focus on studying the actual results and comparing them to possibly revising the theory and then trying the cycle again.

And he actually did some work and collaborated with Dr. Kaoru Ishikawa, most known for his fishbone diagram and evolving some of these PDSA steps. So that was also an interesting historical finding that I was like, “Uh! I didn’t know that.” He wrote some books. Deming had the 14 key principles for managers to transform business and he first presented those in his book, Out of the Crisis. If anyone is an avid reader, they can take a look at that book and see really how much of what is said in that book is prevalent today in some of our process improvement methods.

And then I think also there is an entire institute as I mentioned earlier on Edward Deming in Washington DC. There’s a collection at the Library of Congress. It includes extensive audiotapes and videotapes if you have an interest in doing some more historical research where I think can be a lot of fun.

Toyota Business Practice Within PDCA

So, let’s talk now a little bit about some of the detailed steps within PDCA because when you actually apply it, it’s a little – you need a little bit more guidance than just four steps. And so, I’m going to talk to you a little bit about what those detailed steps are so that you can for someone who might want to follow this practice and method. And so, I will also say that it was interesting that there are different schools of thought out there about what these more detailed steps would be.

So I have my own that I’ve been following. And when I did some more research just to look at what other people are doing, I found 8 steps. I found 10 steps. I found 12 steps.

So I think the point of it is everybody is trying to help people implement this and sometimes people have their own way of explaining what these specific steps are. But I have seen some variation. I’m not going to say that’s bad. I think if it’s effective and it works for that audience then that’s great.

So here are some of the general steps for practical problem-solving. I will say though that I think one of the most popular and prevalent steps is the Toyota’s business practice within the PDCA, the steps for practical problem-solving is what they call it.

And as you can see, there are 5 steps in the plan phase. And so, you can imagine that most of the work is frontloaded for PDCA. So you’re doing a lot of things like clarifying the problem and breaking down the problem, setting a target, analyzing root cause, developing countermeasures. You’re doing all of that before you actually do anything.

And I think what most people are familiar with is we have a problem, we jump to solution. And so, we kind of skip all these steps. Most people in corporate America will say – I can’t speak to all of you in other countries but in corporate America, we love jumping to solutions and we’re actually rewarded to jump to solutions. I think even there’s some sort of management sign you can buy that says, “Don’t bring me problems. Bring me solutions.”

Stick with the problem a little bit. Understand the problem. Understand the process. Find root cause first.

So we have constantly been rewarded to jump to solutions. And ultimately, what PDCA and many other forms of process improvement are saying is, “Hey, slow down a little bit.” Don’t just jump to solution. Stick with the problem a little bit. Understand the problem. Understand the process. Find root cause first. So ultimately, that’s what we’re doing in plan. There’s a lot of work that’s happening in there. But I think the natural intuitive thing for many people to do is just put in a solution.

So, plan has 5 steps. Do has one, you’re basically implementing the solution to address the root causes or I will say countermeasures here. You’re implementing those countermeasures and running an experiment to see if it’s actually working, if it’s going to actually resolve the root cause. And that’s an important step too because I think sometimes people want to implement the solution and then just walk away.

And I have actually seen that happened in real life where people implement a solution and they were still kinks that needed to be worked out but they basically said, “Well, we don’t have time to actually address it.” And that’s unfortunate because now the employees are in pain and they’re told they can’t make an improvement to or tweak to make the process better which is sort of flies in the face of this methodology unfortunately.

And then we have check, which is what I’ve just said, did it the actually work? Did the improvement, did the countermeasure actually work? How is it going? Are you going to change your hypotheses? And do you have a new hypothesis potentially that you’re going to test? And again, adjust it or act.

Learn from those failures. If the improvement worked, are you going to standardize some of that? Are you going to set another target? Those are some of the things that are happening in Act.


So we’re going to talk briefly about some of these and I’m just going to kind of take them one by one. And you’re probably going to notice as I walk through some of this that if you’ve done any process improvement before like Lean or Six Sigma or Lean Six Sigma or total quality management, you’re going to probably see some familiarity with this because guess what? They all came from the same broth basically. We just got different vegetables here.

Clarify the Problem

So ultimately, the first thing you’re doing is clarifying the problem. And I work with a lot of people on this step and I think what’s interesting is how often people don’t get it right unfortunately especially new people, and of course that’s why we’re there. We’re there to help people understand this step.

So ultimately, you start with a problem. You’re starting with a gap of some kind or a problem and it’s usually something with a process. It’s not something people related or some sort of solution you want to implement. And so I think that’s really important is, I always try to get people to write out what is the problem. And even though I tell people, don’t blame anybody. You can’t say the problem is the accounting department because they suck. That’s not appropriate.

And you don’t want to have a root cause in here because again, the whole point of this methodology is to really look and identify what the root cause is. You might have a theory on what the root cause is and you will find – we’ll show you where to put that but it doesn’t belong in the problem statement.

And finally, problem statement should not have a solution in it. And I think people confuse the three of them a lot, problems, root causes, and solutions. I think if people just generally knew what those – the definitions of those were and could speak appropriately to those, there will be a lot less confusion in this world.

I’ll give you an example. This is an example from the Bahama Bistro. The problem is we need to hire more people. I mean how often do you hear people say that? That’s not a problem. That’s a solution. What are you trying to resolve as a result of hiring people? And so, we really have to sometimes back into what it is, what is the problem we are trying to solve? Let’s not jump to solution. Let’s get agreement on the problem.

And so that’s really what your problem statement is going to answer for you is what the problem or the issue? What is the measurable thing you’re trying to impact? So usually, a problem statement is going to have a measure in there somewhere as well.

Break Down the Problem

So the next step will be to break down the problem. And that’s really about assessing and getting a grasp of the current condition. And so again, this is something often without process analysis and process improvement, people skip. How often have you seen people just slap on random solutions without really knowing what’s going on in the process today? Or let’s say you have a new person and they just want to bring in their solutions and then slap it on and that’s so frustrating for people that have been working in that process for a while because you don’t even know what our process is and you’re already slapping solutions on.

So the idea around this is let’s break down the problem. Let’s grasp the current condition of this situation. So let’s talk a little bit about that.

So a number of things you could do in this step in itself. One is again, getting clarity on the measure and really say, “OK. Here is where we are today.” But ultimately, walking the process could help a lot with getting – grasping the current condition. And so, a process walk, we have lots of resources on our website on how to do a process walk. I think we have two webinars on process walks for participants and for – we’ve got interview sheets. This is a great way to grasp the current situation.

So don’t focus on the people. Focus on the process.

And then ultimately, getting a sense of what’s happening in the process. So don’t focus on the people. Focus on the process. And what can we do? I always say, people that are in a bad process, they are victims. They are biggest victims of being in that process. And the sad part is, most of the time they are getting blamed for it.

And so, that’s unfortunate. If we’re blaming them, why would they want to help anybody learn about what their process is? Because they’re always on the defense. So get an idea of what the current situation is and do the process walk.

And then the other thing is sometimes you have to break down the bigger problems. Sometimes you have to really isolate a step in the process or reduce the scope so that it feels manageable because often what I also find is people are picking boil the ocean projects or solving world hunger. And it’s so monumental. People can’t even – they don’t even know where to get started. They are paralyzed.

And so, making it something achievable, manageable, and meaningful is really important in this part of the process because we wanted to be something that moves people forward but doesn’t feel like it’s solving world hunger that you’re not going to be able to get any traction for five years.

So ultimately, there are a lot of things you could be doing here in breaking down the problem. And again, building profound knowledge of the current state is one way to get an understanding of what’s happening and then figuring out what is within your scope. So it could be walking the process like we’ve said, mapping it, collecting data, interviewing people, all of these things are part of breaking down the problem.

Set a Target to Achieve

So then you are able to set a target to achieve. So this is again agreeing on a goal and an expected outcome. And so again, this is – I’m explaining this linearly but sometimes people set this earlier. Sometimes they set it a little later. But the point is, you’ve got it somewhere in plan.

I find that you have to set a target. You can set a target once you understand the problem. But when you get a better grasp of what’s happening, you might change the goal. And then when you discover root cause, you might change the goal again.

So again, this is very exploratory. And that’s going to be the nature of the progress when you do something like Plan-Do-Check-Adjust. It’s very different than project management where project management might have a charter and you’re tasked with implementing something and you don’t want to move the milestones and if the change is bad potentially.

Well, in this case, no. These things are going to be changing in the plan phase, in the plan step. It’s the nature of the beast. You don’t know what the problem is. You don’t know what the root causes are. And when you discover them, you’re going to have to look at what the target is. And you might have to make a change.

Ultimately, the goal statement or the goal does have some measurable target to make it concrete. I think that is something that I see process improvement teams struggle with a lot is they don’t really know what they are trying to achieve in a measurable form. And when you get clarity, ultimate clarity on what you’re trying to improve, you’re going to see really creative ideas and innovative ideas on how to go about doing that.

I think that is something that I see process improvement teams struggle with a lot is they don’t really know what they are trying to achieve in a measurable form.

So this is just an example of some data on the histogram. So basically you’re saying, for orders at the Bahama Bistro, it’s lunch orders, the average lead time is beyond 20 minutes so you could see here, this pink line, this is the target in this case. Sometimes that line is an average.

But in this case, I really like it when they use it as the expected. This is what we wanted to be and here’s what’s actually happening. So this histogram in green is saying here’s how the data is really performing right now. We’ve got an average of 28 minutes from 100 lunch orders that we’ve looked at and we really want it to be under 20. So we have to move this entire histogram to the left of 20 minutes.

And so that is great because it gives people the visual in one graph of what is expected and what is actually happening. And so, it’s a really nice visual. And then getting clarity around that can really help teams be very focused on what needs to happen and be very creative about how we can achieve that. So that’s a part of plan.

Analyze Root Cause

And one of the last steps of plan, analyze root cause. So again, this is when you’re really trying to figure out why is it taking so long? Why is it beyond these 20 minutes? What is causing the lunch orders to take 28 minutes on average?

So this is really when again, we don’t want to blame people. We say, “The chef doesn’t know what he is doing.” We don’t want to blame people. We really want to analyze the process and collect some data. We actually want to incorporate the chef’s ideas and involve him on trying to help to solve this problem and he needs to feel safe about being able to participate in a way that he is not going to get blamed because remember, a lot of people feel like they’re getting blamed, they are not going to help you.

So again, recruit, involve people really all along this process, and go ahead and participate in conducting some of this root cause analysis and this data analysis. And you might look at a lot of things. You might actually produce some graphs. You might look at a swim lane. You might do some Pareto charts in terms of where the biggest defects are occurring or you might say, “Here are the things that are taking the longest to cook or to prep.” And again, it’s related to the product, the food. It’s not, “I’m not going to time the chef and find out what’s wrong with him.”

So again, we need these people. We need people in the frontline to help us come up with a hypothesis and to find out if they’re true or not. Don’t make them your enemy. And so ultimately, that’s what you’re doing in the analyze root cause phase and then hopefully, you will find one. As a matter of fact, you can’t really leave this step until you find root cause because the next step is develop countermeasures.

Develop Countermeasures

So countermeasures again as I have said before, these are potential temporary solutions that we think might address the root cause. Well, you can’t come up with those if you don’t know the root cause. So you really can’t move forward on number 5 until you actually have root causes identified from step 4. So we really want to make sure that we brainstorm ideas for countermeasures and select the things that we want to implement as part of the do phase.

Do Tools

So ultimately, that’s what you’re doing. And these might be some of the things you end up planning to do. So workload balancing you might decide or standard work. You’re going to create standard work or let’s do some 5S or I notice there are a lot of movement by the chef or the prepper when they’re building salads, maybe we need to reorganize that space so that it works – it flows better.

And I also noticed that the chef was running back to get more stock items during our primetime season, time of the day. Maybe we need to make sure that he doesn’t have to do that. Maybe we need bigger bins so that there’s less running around and moving around.

So these are all things potentially that you might be deciding that you’re going to do. And again, you do this in plan but you actually implement them in the do phase, which is what it says here. So implement those countermeasures. You coordinated and launch a pilot test or an experiment and then document those things so that people know what they’re supposed to be doing. And also, you can observe and see if it’s working too.


So again, in Do, we’re moving out of Plan and into Do, you’re actually doing the ideas that you have, the countermeasures for the root causes that you found. So again, there’s a lot of excitement in this step. We see that people love this step because they’ve been spending a lot more time early – before this step, getting ready for exploration, what are the root causes.

Unfortunately I have to say, for people who are so used to being in solution mode, plan is hard for them. They feel like it’s unclear, it’s confusing, I feel a sense of urgency because I don’t know if we’re doing anything. I’ve heard all of these things. For people that are typically jumping to solution, they are very uncomfortable in plan. They want to get out of there as soon as possible. So we really have to sort of give them therapy or something. Talk to them. Talk through it. It’s going to be fine. This is normal. This is normal, how you’re supposed to feel. It’s exploratory. We don’t know while we’re implementing yet.


So, I’ve had these conversations many times with people that are new to process improvement and root cause analysis. So once you get to do, hopefully what ends up happening is now you can reflect on those results. You evaluate the process. You evaluate the results. And again, this is the part where Deming was really saying, “Well, let’s study this. Do we have a new hypothesis? What worked and what didn’t? What did the participants think of the pilot? What do they think needs to be changed? What do they really think worked?” And document those learnings.

So this is really a checking up against did we actually get the results we wanted based on the countermeasures that were implemented? And sometimes the answer is no. And sometimes we create a new theory and we start the PDCA cycle over because we’re not going to adjust it. We’re going to keep moving forward. And sometimes it’s because yes, it did work. We’re going to make a couple of tweaks here and ultimately see how that works. We might actually implement it to a broader group or something like that.


So it really depends. Act and adjust is really around what did you discover? I mean did it actually work? And there’s a set of steps that are going to happen if you actually decide you’re going to formalize it, you’re going to implement it to a broader group. And so, those steps are really around sustainability or expansion of what was learned and the solution or you might decide you’re going to make some adjustment. You’re going to do another cycle of PDCA before you make it broader to a broader group or you might just say, “You know what? That didn’t work at all. I think we have the wrong solution or wrong countermeasure for the root causes and maybe we even have the wrong root cause. And hopefully, that’s not the case.”

As a matter of fact, often I find that when we don’t get the results that we want, it’s often because the countermeasure wasn’t implemented as well as we thought or that we thought it was being implemented but only a small set of people implemented it. So often, we have to back up because it wasn’t the results we wanted. It’s because we found out something didn’t go perfectly or what we – during the implementation of the countermeasure. And so, that’s typically what I’ve seen.

And if you spend more time upfront in plan, you’re going to – it’s going to make all the other steps much more effective. But I find people sometimes want to just the box and get out of plan, so like we get to do. And guess what? You’re going to end up right back in there very soon, probably sooner than you expected because some of that work wasn’t done.

So it’s really important to really do a good job in plan and just pause with what you’re doing. Don’t just check the box. Really try to build that knowledge. Try to really be motivated and understanding the current process and what the root causes are.

Monitoring Plan

So again, if you did have some success with the study, you probably going to set up some sort of monitoring plan to make sure that things are actually being implemented. The natural tendency for humans is even if there’s a – if there’s a change, the natural tendency is to revert back to the old way because that is what people know. That is what they are comfortable with. Sometimes people have been doing those steps for 20 years and now, they’re going to do it different? They can do it in autopilot. They don’t actually have to think.

And so guess what? Sometimes people revert back to the old way even if the new way is more effective and more efficient and better for the customer. So that’s why we got to have monitoring. You just have to make sure that the new process is being followed and that is an important piece of that.

You just have to make sure that the new process is being followed and that is an important piece of that.

I always hear about people say, “Oh yeah, we did actually make an improvement but then it didn’t sustain because people stop doing it.” And so, that’s a concern. And so, the monitoring plan and monitoring how the process is working, the new process and that people are following it is great. So this is why I think process adherence comes into play. It can be really important.

PDCA Cycles

So again, I think the other idea around PDCA is that it is cyclical. It’s a wheel on purpose because it’s sort of never-ending and it sort of speak into this idea that, you know what? It’s OK. Experimenting is OK. Failure is OK. It has to be OK for an organization to share and learn their lessons in order to grow.

And I think this is sometimes very – it’s absent often in organizations. People don’t want to screw up. They don’t want to get in trouble. And experimentation is not OK in some places. And I get that. Like for example, I work a lot with government and they are very risk-averse as a whole. I’m not going to – this is a generic statement. I’m not saying everybody is risk-averse and every organization in government is risk-averse. But they don’t want to end up in the papers. They don’t want that kind of attention. And so, they have to be careful and it’s very hard sometimes to be innovative and experiment and be willing to take risks when you’ve got that looming over your head.

And so, the idea behind these cycles is that you are going through experimentation and it’s OK to fail. And I think what can you do about that?

So, I was working with an organization and they really were – we sort of – we’re observing people in the organization and made a discovery that it really wasn’t OK to fail in these organizations. And the leaders really were trying to figure out what they could be doing differently to help people feel that they could experiment and it’s OK that we’re not perfect.

And so, one of the things that they were doing in terms of strategy was they started admitting their failures as leaders. They started telling their organization where they were trying to learn and get better. And when people were putting up on their boards red dots, they were actually thanking people for admitting that there were problems to be worked on. They were promoting the fact that, “Hey, yellow and red on visual boards are OK. That means that you’ve identified a problem and that you’re working on it.” As opposed to having a visual board that has indicators green, yellow, red, and they’re all green, which there are many organizations that have boards and they’ve got indicators and everything on there is green. So that tells me that you are perfect. You don’t have to do anything to improve because everything is perfect.

And so, we sort of have to get away from – that is very telling to me when I see that in an organization. That means that it’s not OK to fail. It’s not OK to have yellows or reds on your boards. And I start to question some of the leaders about what are they doing when they see a red or a yellow dot on those things?

So here’s a quote from Thomas Edison and it’s, “I have not failed. I’ve just found 10,000 ways that it would not work.” Well hopefully, you don’t have 10,000 ways that it would not work. Hopefully, you have 4 or 5 ways that it didn’t work. So just get out there. Experiment.

If you’re a leader, make it OK for your people to experiment. It’s really important. And if they’re not doing these PDCA cycles, sometimes there’s a cultural element that we need to address as well. And that is an entirely new and different webinar.


So some of you have maybe heard about A3s, and A3s if you don’t know what they are, it’s actually the name of an international paper size actually. And it’s a summary of someone’s thinking through a problem. So it’s a way to help people go through this thinking process, this root cause analysis, this PDCA thinking. And it’s not about the paper. It’s about the thinking.

But I wanted to just point out that if you look at what a lot of A3s have on them, they are following Plan-Do-Check-Act or Plan-Do-Check-Adjust. And so, A3s, I think there’s a lot of mistaken understanding of the A3. People start to – they do the problem-solving and then when they feel like they got to fill this paper out and turn it in, and it feels very kind of Big Brother-ish.

And really, that’s not the point of A3. You should be using it while you’re problem-solving, while you’re thinking through a problem. It’s supposed to help you document your thinking in some of these steps. It’s not a check-the-box activity. And so as a leader, we have an entire series on how leaders can use A3s to help coach people through this thinking.

And so, I just wanted to point that out. If you really want to understand and apply PDCA, using A3s is a great way to do that, using A3s through the whole process, not just filling it out and turning it in later.

A3 Completed

So here’s just an example of an A3 and again, we’re not going to spend time explaining in A3 on this webinar. We actually have a webinar for A3 as leaders and I think we’ll be having an A3, how to use an A3 webinar coming out very soon as well. But ultimately, you could see that it is following some of the steps of PDCA.

Poll #2

All right. I got another poll for you. So true of false DMAIC and PDCA are both forms of the scientific method. True or false?

I’m going to go ahead and launch the pool. So go ahead and fill in the pool for us. And there are lots of other process improvement things out there too. Not just DMAIC, not just PDCA. But go ahead and vote and let’s see what you guys think.

Elisabeth, what do you think?

Elisabeth Swan: I think you know what I think. It’s interesting that we’ve kind of come down to these being the most prevalent improvement models, the 5-step and the 4-step. There are – I remember one that was based on the word process. So that was 7-step. I’ve seen 8-step.

I think the fewer steps, I think 4 or 5, it’s kind of like our theories on a team. You don’t want to get too far beyond 4 or 5-step. So even though when you break it down, there’s more going on in each of these steps. These are good high-level numbers of steps.

Tracy O’Rourke: Yup, I agree.

Elisabeth Swan: I’m interested to see what folks think.

Tracy O’Rourke: All right. Let’s close the poll and see.

Elisabeth Swan: Yeah. So most people, that’s 88%, believe that these are both forms of a scientific method, Tracy.

Tracy O’Rourke: Yup. Yup. And to this point, I think what’s interesting in some of this research that I’ve been doing lately on these particular subjects is there’s a lot of strong opinions out there about what’s better and who is wrong. To me, it’s an evolving thing. So look at PDCA. It has been around since Walter Shewhart and even his mentor, Deming, changed it. So now, this is what I like better.

And so, I think sometimes you’ll hear for those of you that are attending this webinar, you’re going to hear process wars. That’s what we call it. People fighting over which methodology is better. And has always said, “Hey, I don’t really care where it came from. If it solves the problem, that’s what’s important. If you’re actually applying a methodology that’s root cause analysis and you’re finding the root cause and then you’re actually solving for root cause, you’re doing the right thing.”

But when you’re learning it, I think it’s very – people want things a little bit more prescriptive. They want to be able to say, “Well, what exactly – how exactly do I learn this stuff and apply it?” And I think DMAIC does a good job of that. PDCA does a good job of that. There are a lot of people out there.

And so, they all come from this idea of the scientific method of understanding your problem, coming up with a hypothesis of what you think the root causes are, confirming that it is truly the root cause, and then coming up with these potential solutions.

So I just put PDCA and DMAIC side by side and you could see that plan is also part of define measure analyze and I guess developing an improvement solution is maybe where they differ a little bit because developing that kind of measure is in plan where in DMAIC, it’s under the Improve Phase. But very similar and ultimately it’s still following the scientific method.

So, I don’t – if it’s easier for you guys to learn PDCA and then the DMAIC differently by itself, that’s up to you. But ultimately, I feel like my learning and my experience has been enhanced by knowing both. And hopefully, you see the same thing. Hopefully, you see that any of these learnings aren’t wrong. They are different methods and approaches and all of them work. And so, how do you get really good at really the purpose of this, which is root cause analysis and solving through root cause?

OK. Just a couple of quotes to keep you motivated if you will. One of them is from Edward Deming. This is one of my favorite quotes. And I don’t – I think a natural thing is we do focus on people a lot. We blame people a lot. And the thing is, the truth is, if you put a good person in a bad system, the system will win every time. And I don’t think we do that enough. I think we tend to beat people up in processes. So just keep that in mind as you go through root cause analysis. They are the biggest victims of the process.

Well, in transactional environments, processes are invisible. You can’t see the process. And so what – we blame what we see, the people.

And why does this happen so much? Well, in transactional environments, processes are invisible. You can’t see the process. And so what – we blame what we see, the people. Processes are invisible. So make sure that you elevate the process. Make it visible and focus on the process when you do a process improvement. Don’t beat up the people. You need them. You need the people to help you solve the process.

And it’s funny because even if I say that, people send me a note and they go, “But if it is the person?”

All right. Focus on the process first. That’s what these tools are for. Use the tools. And you know what? If it is a person, that is not process improvement. That’s HR.

And then finally, “There’s a way to do it better – find it.” That’s by Thomas Edison. And you know what? He did it 10,000 times. He tried to find it. So we could try it 4 or 5 times and hopefully find a solution.

Today We Covered

All right. So guess what? That brings us to the end of the webinar. What we covered today is what is PDCA, the evolution of it, the 4 steps of it, we talked a little bit about A3s and how that incorporates PDCA and we did a little bit of comparison on PDCA and DMAIC briefly.


So, the next step is questions. If you have questions for me or Elisabeth, please type them in the chat window and we will get those answers for you. We’ve got about 6 minutes to answer any questions that you may have. And while we are waiting for you guys to put in your questions, I’ll just cover a few more slides based on some of the things that we can – that are other opportunities for you.

Getting Started

So look, if you haven’t had any training yet, we’ve got lots of training online. Our White Belt is free and we have Yellow Belt, Green Belt, Black Belt, and Lean. And you also can get a 20% discount on all courses because you’ve attended this webinar and you’ve got the coupon code. So go ahead and use that where appropriate.

Upcoming Webinar: May 24, 11am PDT

We also have another webinar coming up, May 24th at 11am and Elisabeth will be facilitating that. It’s called How to Make the Swim Lane Map Work for You. So Elisabeth, you want to give them any insight to that?

Elisabeth Swan: Sure. The swim lane map is also called a deployment map or a class functional map. We call it swim lane because that’s the structure. It comes lanes, and each lane represents a department or a group. So they’re really popular, these maps.

We’re going to talk about how to build it, how to analyze it, how to augment that analysis. And this is an intermediate webinar. Sign up. We’d love to have you.

Just-In-Time Café Podcast

Tracy O’Rourke: Thank you, Elisabeth. And we also have our latest podcast out. Elisabeth got to interview Chip Schaefer from the Chicago Bulls about boxing out injuries. Tell us a little bit about that interview.

Elisabeth Swan: So this is a great one. We noticed that Chip had been downloading single modules on root cause analysis, the fishbone, the 5 Whys, and also FMEA, which is risk assessment and mitigation and we wanted to know what’s he doing with it? He works for the NBA. He is Director of Sports Performance.

…[Chip Schaefer] tells us what he did with it, which is looked at why athletes got injured and how to resolve that and reduce injuries and keep athletes on the court.

And on this interview, he tells us what he did with it, which is looked at why athletes got injured and how to resolve that and reduce injuries and keep athletes on the court. He is a great guy. It was a really fun interview. I highly recommend tuning into that.

Success Stories

Tracy O’Rourke: Very nice. We also have a success story out this month from Kristin Kielich and she is from UC San Diego and she talks about how she actually saved, her team saved 2,000 hours a year in the employee onboarding process. And what organization does not have that process? We all made new employees. And if you want to do it in a better, faster way, you should really tune in to Kristin’s success story webinar.


All right. Let’s talk about questions.

Elisabeth Swan: So here’s a question for you, Tracy. And this one comes from Jenny and she wants to know, “If a countermeasure is a temporary solution, what’s considered a permanent solution? At what point does a countermeasure turn into a permanent solution? It is a temporary solution because it’s awaiting the evaluation and results?”

Tracy O’Rourke: Well, that’s a great question. And I really believe that the countermeasure is – the reason why they call it a countermeasure is because they want people to really be cognizant of the fact that installing permanent solutions may not always be what you’re trying to do at this step.

And so, yeah, I feel like once you’ve confirmed that something is working and that you’re going to sort of create more of a broad implementation, it could be a solution that is going to be permanent for a while. But again, I think in general, the use of the word “solution” sometimes feels like people never need to revisit it again.

And countermeasures just remind people that you know what, it’s OK. It’s OK if you make it better at some point. Processes should be looked at all the time, not every second of the day. But they should be looked at every year. And what worked two years ago may not be the best solution today.

And so, it’s the idea of knowing that countermeasures are going to be cyclical as opposed to solutions being permanent. And I think it’s just their way of saying, “Hey, just know that solutions aren’t always permanent especially in today’s world.

So, I hope that helps.

Elisabeth Swan: Yeah, that was great.

Tracy O’Rourke: Do you have any thoughts around that, Elisabeth?

Elisabeth Swan: No, I think you nailed it. The reality is just your attitude toward the changes you’re making that there is always a better way. You should always be looking for the better way.

You should always be looking for the better way.

OK. One more question and I think that will take us to the hour. You’ve got from Steven, “How do you explain why workers will revert back to the old way even when the new process is more efficient for them and better for the customer?”

Tracy O’Rourke: So I did mention that a little bit in the webinar and I just think it’s habit. Habits are hard to break. As a matter of fact, I’m reading a great book on habits, The Power of Building Habits. I can’t remember the author’s name right now. But I am so entrenched in it right now because it is really talking about this – that habits sometimes supersede everything else.

And so that’s really what you – what you need to do is recognize that it could be a habit. And if someone has been doing this process for 10, 5 years and now they’ve got to do it a different way, sometimes they’ll just come in and they’ll be on autopilot and they just start doing it the old way.

Elisabeth Swan: Yeah.

Tracy O’Rourke: And it really is – habits are sometimes stronger than new, better processes. I hope that helps.

Elisabeth Swan: It’s so true. And I just want to remark, the book that Tracy is talking about is The Power of Habit by Charles Duhigg. I think it’s D-U-H-I-G-G. It’s an odd-spelling last name. And yes, she is the – I totally agree with you, Tracy, that change is just uncomfortable especially if you’ve got an ingrained habit.

And one more thing, for your Tracy and then we’re going to sign off.

Tracy O’Rourke: Yes. OK.

Elisabeth Swan: Christopher says, “Awesome. Thanks so much.”

Tracy O’Rourke: Thank you. You’re welcome. All right. Well, thank you so much for joining this webinar. I really hope that you found some value in it. If you have any more questions, please come to our website or send us a note at [email protected]

As a reminder, yes, the slides will be available and the recording will be available on our website as well. Thank you so much. Have a great day.

Elisabeth Swan: Bye all.

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Tracy O'Rourke

Tracy is a Master Black Belt at, the co-author of The Problem-Solver’s Toolkit and co-host of the Just-in-Time Cafe. She is also a Lean Six Sigma Green Belt Instructor at UC San Diego and teaches in San Diego State University’s Lean Enterprise Program. For almost 20 years, she has helped leading organizations like Washington State, Charles Schwab and GE build problem-solving muscles.

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