PDSA, or Doing it Well, Starts With Psychological Safety


The core of Lean and the Toyota Production System is the Plan-Do-Check-Act (PDCA) or Plan-Do-Study-Adjust (PDSA) mindset. It's a structured approach for problem-solving and improvement.

However, as with many Lean methods, it's easy for people to go through the motions. Or, they might be pressured into doing so because of their workplace culture and the behavior of their leaders.

What some might call “Fake PDSA” might be described as “Plan-Do-Rationalize-Justify” where people feel pressured to “prove” that every attempt at improvement is a success. PDSA is an experimental approach and, as my friend Rich Sheridan (CEO of Menlo Innovations) said in his upcoming episode of the “My Favorite Mistake” podcast, if you always get the outcome you expect from your experiments… they aren't really experiments!

Being a scientific problem solver, using the PDSA approach (and the version of it called “A3 problem-solving”) requires a high degree of “psychological safety.”

That's part of what I talked about in this recent webinar:

Psychological Safety as a Foundation for Continuous Improvement

Without this feeling of psychological safety, the PDSA process breaks down (or we end up just going through the motions instead of realizing the full potential of this approach).


In the Plan stage of PDSA, we identify the problem or opportunity for improvement and we start to understand the situation. Doing so honestly and candidly requires a feeling of psychological safety.

Do we feel safe to point out a problem? Do we feel safe discussing it with others?

If we cannot point out a problem or admit a mistake, we won't have any chance of problem-solving or improving.


In the “Do” stage, we start by testing our idea in practice. I've long thought this phase should be “T” for “Test.” Testing an idea requires psychological safety.

Do we feel safe to try something? Do we feel safe to try something that might not work out, even if we have a reasonable hypothesis or assumption that it will work?

Study and Adjust

These are the key phases of a PDSA approach. Back to Rich Sheridan's thought, if we feel pressured to always be right, there are a few dysfunctions that we'd see:

  • People fudging the numbers (or ignoring the data) so they can declare it to be a success
  • Being super cautious and only trying things that are “guaranteed to work” (which means we'll be less innovative if we don't feel safe to take reasonable risks)

Do we feel safe to admit something didn't work out as expected? Do we feel safe to go back and iterate — to go back and try again?

It's a Matter of Leadership

Leaders create conditions in which people can decide they feel psychologically safe. They do so through two key actions:

  • Modeling vulnerable acts (such as pointing out problems or saying “I could be wrong, so let's test that”)
  • Rewarding vulnerable acts when employees follow their lead and do the same

You can read more about psychological safety here and I'd love to talk with you about how I can help assess, educate, and coach your organization in ways that help boost the general level of psychological safety that's felt by your people. You can use this form to contact me today.

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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.


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