The Challenge of PDSA: Feeling Like You’ve Fallen Short


Mark's note: Today's post is by Cristal Totterman, a pharmacist and Lean leader I have known for a couple of years now. She's written a post that made me think about and reflect on the never-ending journey of improvement, both as individuals and organizations. 

By Cristal Totterman

From the onset, it's easy to know that Lean is about continuous improvement, value delivery and waste elimination. Although I know that and I teach those concepts to others in my organization frequently, knowledge does not equal understanding.

I am coming to realize that the more I learn about Lean practice, the greater my gap in Lean seems to get. This concept was reinforced for me when I had a simple, yet profound ah-ha moment not too long ago.

This discovery that came to me was the product of not just this single moment in time, but from a multitude of moments culminating into something bigger, like a snowball rolling downhill, growing and accelerating until it crashes into the ground.

For me, this snowball was the understanding of the continuous improvement cycle, the iterative process towards ideal state or what many call “true north.” I have seen and explained the well-known visual many times; the person climbing up towards target state and, ultimately, ideal state through PDSA, only seeing ahead of them as far as the flashlight reaches.

The relationship of PDSA iterations and ideal state never really dawned on me while I was working through PDSA cycles in problem solving. The visual depicts the learner stair-stepping up through PDSA cycles, each step up the flashlight seeing further, learning more and getting closer to ideal.

In my mind the model depicted “continuous improvement” as the multiple iterations it takes to get to ideal state, showing the culmination of multiple improvement cycles over time. This is how I viewed the world. We are getting closer to ideal state with every iteration and eventually, voila! We will be there!

What I recently discovered, is that problem solving that happens every day is no different than what I experience in my personal journey in lean thinking and practice. What the stair step visual was missing was showing how with each PDSA iteration forward ideal state also moves forward.

Ideal state is not stagnant, firm in its place waiting for you to get there, it moves forward as you move forward. I'm fascinated by how I felt the reality of this concept with my personal lean journey, but how it did not connect it with problem solving gaps I saw external to myself?

It's interesting in the simplicity of it all, really. It only makes sense that for continuous improvement to exist, ideal state needs to move forward as well.

This left me with some questions:

  • What am I going to do differently because of this new learning?
  • How will that impact how I approach closing gaps moving forward?

When thinking about this deeply, it dawned on me, maybe frustration lies in my own expectation that I will get to ideal state at some point. That I must arrive there eventually.

Maybe this is my next ah-ha moment in the making.

In absence of a clearly defined Target state, satisfaction with progress, pace, and incremental improvements may more times than not, leave you feeling as if you have fallen short.

Bio (see full bio as PDF): Cristal Totterman, PharmD., is a clinician passionate about changing the paradigms of how healthcare is delivered to patients and communities today. Cristal has worked in healthcare for 7 years as a clinician and lean practitioner. In her current role as Manager of Performance Excellence at Martin Health System (MHS) she develops and helps implement MHS'  management system anchored in Lean thinking and practice. She serves as a senior internal coach for Lean principles and practice to leadership, front line associates, and novice Performance Excellence team members.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Iteration and continual improvement are key. Understanding that “target state” is a temporary target is important. If a “ideal state” is too specific it can hamper innovation. This usually isn’t so critical on fairly short term PDSA (except in those cases when we should look at innovation instead of improving the current process).

    PDSA process doesn’t hamper innovation. But, when people set in their minds ideal states or targets that they move toward and don’t see those as flexible based on new learning they can stunt innovation.

    Related post:

  2. Dave Snowden (Cynefin and complexity, not leaks guy) has taken it a step further: he has abandoned the idea of ideal state altogether. Our current notion of ideal state becomes simply another input to our decision of where do you take your next step from where we are. The improvement process becomes a never-ending set of assessments of where am I now, and what is my best available step of improvement.

    My only disagreement with this view is, if you truly follow the notion faithfully, you can end up in a local optima from which you cannot get to a better optima. But I do find the notion that ideal state is actually a fiction and we cannot know it, to be a helpful thought.

  3. I guess I should have taken the absolute value of that function:


    No pun intended on the use of the words “absolute” and “value” in relation to Lean :-)

  4. Thanks for the comments! I find the perspectives on the topic fascinating. Like how literal an individual may (or may not) look at the Target or Ideal state.

  5. I agree with the insight that ideal state will move in time with improvements. Making something better can open our eyes to greater possibilities. But I think it shouldn’t move as much as our future states, because in my experience “ideal” implies something close to a perfect world, it’s purpose to inspire and free our minds from limitations. I saw someone recently present using a quote supposedly from a past CEO of Toyota on Toyota’s vision. I don’t have it verbatim but it was something like:

    “We will build cars that can travel around the globe on a single tank of fuel and have zero possibility of harming human beings”. I was inspired by that, and it translates well to zero harm in healthcare.


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