Posted by: JC Gatlin | March 24, 2010

Where do PDCAs go when they die?

Have you ever heard of the “elephant graveyard?” 

It’s a mythical location where elephants go to die. However, no one has ever found its precise location, nor can any evidence of the elephant be found once they disappear into the elephant graveyard. Their remains just vanish. 

Believe it or not, we have a surprisingly large number of PDCAs that seem to vanish into this elephant graveyard.  Some were PDCAs that started strong, then for one reason or another fizzled out and never made it to counter measures. Some were counter measures that were implemented then forgotten about. In both cases, the PDCA just vanished. 

Here are some steps to take to ensure your PDCA doesn’t fizzle out and disappear into the elephant graveyard… never to be heard from again.  

Step 1. – Before starting the PDCA, pre-plan 2 or more group meetings
Depending on the complexity of the problem, schedule two or more PDCA group meetings in your calendar. Create meeting requests in Outlook. Pre-plan the number of times you’ll need to meet and locations before even analyzing the problem. (You should always start in the Gemba, as close to where the Point of Cause is occurring as possible, but subsequent meetings can vary.) 

Step 2. – Plan the follow-up, THEN FOLLOW-UP,  FOLLOW-UP,  FOLLOW-up
Once the counter measures have been implemented, plan the follow-up actions. Schedule the date to check on the success of each counter measure right then. Make sure your standardization has actually taken hold.

Step 3. Archive the PDCA
Keep a 3-ring binder on hand to archive every PDCA that has your name on it. Also, make sure the PDCA is added in a company-wide problem solving archive so that it can be referred to and found in the future.

© March 2010 Homebuilding Partners, Inc.   twitter-logo



  1. So that’s where the back charge PDCA went!

  2. […] Where do PDCAs go when they die? dal blog Lean Homebuilding di J. C. Gatlin: Come prevenire che le azioni di miglioramento vengano dimenticate (traduzione automatica) […]

  3. That cartoon is a great portrayal of a profound problem and is horrifyingly hilarious. I like the idea of setting a precedence upfront of how meetings will go, and laying the process overall with the group. The new procedure of “retiring” a PDCA if the group is just incapable of following through is a terriffic way of keeping the hard work put into something in plain view should that problem arise again. Hopefully it is more easily found than digging through the remnants of a graveyard!

  4. Hello JC,

    PDCAs that are forgotten and not running are problem of 99% of the companies.

    In my opinion PDCA is a process not a piece of paper. Many companies approach that from a To-Do List perspective. They just substitute their traditional To-Do lists with PDCA paper and then wonder why that does not work. In fact more appropriate question would be “why should it work?”

    As I mentioned earlier, PDCA is a process. That means We plan a task, we do it, than we check it, if it is properly done and finally if needed we do some more actions.

    In my department, I do it as follows:
    We plan the tasks together with my team during weekly meeting(60 mins) and place the tasks onto a Post-It Board so that everyone is aware of the tasks at all times. Then each day we check and modify the tasks during the morning meeting (10 mins).

    As you can see above we put the highest effort on Planning and checking, because “people need to be reminded more than they need to be instructed”.

    Now you may ask the question if these follow-ups are time consuming. The trick here is that the documentation of “planning and checking” is so easy and done realtime during the meeting, it is not a burden anymore for people.

    FInally, yes we throw away the post-its when they are done, but our PDCA process never dies.


    • Kivanc,
      Wiser words have never been spoken:
      “People need to be reminded more than they need to be instructed.”

      • Hello JC,

        I agree.

        Unfortunately, I am not that wise guy. This is a quote from “Samuel Jackson”. Frequently used by the Business Guru “Patrick Lencioni”. That is where I heard it.


  5. I think It is all about scale. perhaps you are only applying your PLAN-DO-CHECK-ACT strategy to the overall schedule or larger assignments, but not to the smaller decisions and activities that build the foundation of your overall work product. Keep is small, apply PDCA to your everyday tasks & assignments within the project, especially when you are “in a hurry,” dont be reactionary, stick to the PLAN, ask what the plan should be if you dont have a new plan to react to the changing circumstance. Are your PDCA Strategies adaptable to change?

  6. I think we have forgotten a few – and after the effort and discovery put into the problem solving – this should not occur. The process works and we know it – it’s up to us to continue to implement the “best as we know today” changes.

  7. I like Kivanc’s distinction. I was thinking the exact same thing – PDCA is a process but even more importantly, a mindset. When a company has truly embraced the concept, people operate from the smallest tasks to the largest change programs with PDCA as a reference point. I think documentation is a manifestation of the process, but certainly not proof that the “thinking” has actually taken place during the process.

  8. If that is the case, then they were just Plan-Do with no Check-Act. And at that, the Plan was incomplete since it did not include Check and Act, or the DO was incomplete since the Check and Act were not carried out as planned.

    The Check and Act is what keeps them from dying out vs. a discrete, purposeful decision to stay the course or try something else.

    • Thanks Mark… I was thinking exactly the same thing. And I may have even said it once or twice.

  9. I’m not sure what a ‘PDCA’ is. Is it the A3 ‘QC Story’ ‘kaizen Story’ …or just plain ‘A3’?
    When I first saw these in Japan many years ago, they tended to be completed in pencil on that thin Japanese paper …almost like tracing paper. These were simply punched and kept in an A3 ring binder in the team meeting/rest room (not to be confused with lavatory!!). I don’t even recall them being indexed, yet the zone supervisors seemed to know where to refer back to how they’d resolved particular problems and assured me the lessons learned had been engrained into procedures etc. (I don’t read Japanese, so had to take their word for it!)
    Regrettably, in cultures where people are always seeking the ‘next big thing’, QC Stories become passé, and taking ownership of such things might be regarded as a bit reactionary….

    • Hey Steve… I was technically talking about the A3 form or the PDCA process as a whole for a problem. One of the big differences in our company versus a manufacturer or hospital is that our Teammates are spread out miles apart. Where a manufacturer, warehouse or hospital has most of the employees working together within a single building, we generally have a couple of Sales Professionals and one superintendent in a community. Then we have communities spread out across three counties.

      • Maybe do some kaizen on the process? I’m sure loads of people can speculate on why they might be fading away …and on potential ways of addressing this – but better your own people do it.


    D-O (IT)
    A-GAIN !!!


  11. If PDCAs are dying then there could be one of the two problems. One either your management is not 100% dedicated anbd they are just doing it to write some thing in their review. Two, shop floor people are not involved, meaning their inputs are not included.

    What my company does is to make sure the team that works on it are from that specific area and management is 100% involved. They are evaluated in how many PDCAs are completed and how they impact th ebottom line.

    • I agree Syed. Management needs to be more involved – or at least have a person assigned to a certain area for PDCA if the Manager is spread too thin. Another area we struggle is reviewing how PDCA’s impact the bottom line. We know they do, but we don’t measure it or discuss it. How does your company discuss that?

  12. I’m still not sure what a “PDCA” is in your company. If it is problem-solving, then are you saying that you stop in the middle of solving the problem? Or are you saying that you stop before documenting what you are doing?

    We say, “PDCA everything,” meaning always act with a hypothesis (plan) and proceed through the scientific method when the hypothesis is disproved. The basis of a hypothesis in most environments is standard work. I’d say you need to check that you have standard work in place if PDCA is failing.

  13. All good points, in my personal experience I hold a 10-15 minute briefing every day with the front line employees at the beginning of every shift and use a dry erase board (issue board) to bring back the attention to certain issues that arise.

    I strongly agree with one of the previous statements
    “People need to be reminded more than they need to be instructed”

  14. Hello,
    in my opinion, as also already mentioned above PDCA, in general quality should be between, as we Dutch say, between the ears.

    It should be between the ears of the whole company, starting with the MD.
    If so, than priority stays at improvements and thus at the last two steps of the PDCA circle.

    A possibility to get it between the ears is to address the subjects not only to quality people but also to the problem holder, the department where the most probable root cause lays. These departments should have besides other goals also quality goals.
    Another possiblity is to make the problem financial, goals are to be reported financially; that the problem stays on the agenda.
    One more, please set SMART targets, so it’s easy to reach the Check and Act step.

    Lots of success,


  15. I find the PDCA board a useful tool. This is segmented: the start area is for ideas / problems written on formatted papers or Post-It notes. The P area for when an idea has ‘passed go’ and the 5W +1H framework agreed; D when investigations are under way etc.

    The value of this is that it keeps stuff visible – it’s not buried in a PC or a folder in someone’s drawer.

    If issues are simple – e.g. ‘Paint the scrap skips red’ then we can see who’s supposed to be doing it and how long it takes; we can avoid burdening individuals with too many tasks. Once it’s done, we can add another number to the tally of tasks accomplished.

    If issues are more complex, then write out a sheet – ‘kaizen story’ / PDCA / A3 / whatever – to summarise the activity, capture the learning points and retain for future reference or maybe share more widely.

    The board can be audited – how many tickets are in each section each week, etc. – to see how well this improvement engine is sucking in the problems and spitting them out. The engine runs well when there is a routine of meeting regularly round the board to assess progress, consider new ideas arising etc. …and when the boss is seen to show interest.

    The engine stalls when …just for this week, we cancel the meeting because we’re busy …and it’s Good Friday the following week, so we’re off work. And the boss has been away on a lot of sales trips, or something. I’m sure you get my drift! Then the ideas stop coming; ones on the board curl up, yellow and fall like Autumn leaves etc.

    Drop me an email if you’d like details of variations on the theme, etc.

    PS The cynic’s version of PDCA:

    • I think where the PDCA or Issue Boards trip us up is that in home building we’re so spread out. Our communities are cities apart, so there really isn’t a central location where that kind of board is accessible to everyone. I can see how it would work for a lot of companies though. Maybe someone will come up with a way for it to work for us as well.

      Our company has a problem solving web conference every two weeks where we go over kaizens and PDCAs that teammates put on the agenda. That’s helped keep PDCAs infront of everyone and from “dying” out.

  16. I like Mike’s tip of keeping an “issue” board in front of everyone so they can see the status of ongoing projects. This is a practice that can be replicated at all levels of the organization. For example, I’ve seen senior leaders start quarterly business meetings and strategic planning sessions with PDCA in mind. They will keep a list of ongoing initiatives or their strategic goals in front of them, and work their way through discussion and reflection on the status of each one. They use some basic action learning questions to guide the discussion:

    – What did we say we were going to do? (If it is not started, is it still a priority?)
    – What did we do? What is the status?
    – What are we learning from this?
    – What do we do next?

    These questions are particularly helpful at the “C” stage. At Honda, they refer to this as a “CAP-Do,” or reinvigorating the process with the “Check” and keeping the momentum going and rotating PDCA.

    What other practices are you all using or seeing in your organizations?

  17. At the California Prison Healthcare project, during the prototype design phase (2008-09) and during the project delivery design phase (2009), we posted A3’s on the walls (both “in process” and “actionable”) and also kept a binder of A3’s so the record would be fully accessible to all.

    We experimented with an oversight group to which A3 champions would propose and check-in with progress for those A3’s that had system-wide implications. Mixed success there.

    Some collaborator groups would keep commitment logs to guide the details of countermeasure implementation and facilitate monitoring. Still we didn’t quite get to the John Shook “Managing to Learn” model, but were headed that direction.

    We also used “PDCA” to revise and organize our standing meeting schedule, identifying from a 1,000′ view what meetings served what function (and that each part of PDCA was included), so that the overall program was PDCA’d.

  18. I regret I don’t know the answer to the problem of dispersed locations, or the latest arisings ‘trumping’ what is already underway. Some vaguely relevant experiences:
    – There was a Production Manager who kept dumping jobs on Andy, one of his Dept. Managers, because Andy couldn’t say ‘no’. Then he moaned he didn’t get chance to see things through because he kept getting more work given to him. Other Dept Mgrs said ‘no’ regardless of workload because Andy would always say ‘yes’.
    – A supplier actually started making improvements (rather than running a campaign and having meetings) when they learned the difference between good intentions (when they always said ‘yes’) and commitment (when they’d thought through the task, other priorities and the resources available). They too learned to say ‘no’; when they said ‘yes’ they meant it, and would give conditional ‘maybes’.
    – If arisings should trump current tasks, set the rules for this beforehand. Urgency / importance / FMEA-type factors etc. Then the boss (hopefully) won’t feel too upset if his latest whim is sent to the back of the queue by the rules, rather than an apparently awkward underling. Include such rules on the PDCA board, as with the ‘we meet every Friday 10:00 am to review’ etc.
    – Part of the A section is to review the process. If the process is flimsy, it needs to be strengthened. (Maybe some Catch-22 in here?!)

    The remoteness issue is tricky. In theory all can tap into the hub, learn from each other, avoid re-inventing wheels, etc. Maybe have an owner who indexes the completed PDCAs centrally? Having people update progress sheets and RAG colour code to indicate progress might work …but it’s another job. How about boards at remote locations with web cams – maybe (relatively) costly to set up, but once done, no extra work required. Maybe 3rd parties can join in remotely at reviews? Maybe knowing this is a regular fixture will help to ensure things get done?

    I worked as an Associate in a consultancy which had some central knowledge bank, and the facility to bounce ideas / ask questions from around the globe. It was all explained to me, but when I logged in, no-one had touched it for a long while. I asked why …but nobody answered!

    I personally find conference calls (everyone sat round a desk etc.) stilted, although it’s not something I do often. Maybe webcam on the board would be better? Leaders at each location might be encouraged to keep things tidy, give actions some forethought etc.

    Chad’s company certainly sounds as though they can make conference calls work for them.

  19. My experience of the PDCA cycle failing is that, in the main, we tend to get it wrong in the “P” stage.
    If we get that bit right I find that they don’t fail. I find that we don’t spend enough time getting that stage right before we move on.

  20. As others have stated the Plan Do part gets done, but the Check Act part doesn’t or doesn’t on an ongoing basis.

    The Plan Do is where all the resources are focused getting that great solution to whatever the issue was. Fun problem solving work.
    Check Act on the other hand is the routine everyday process of checking on it and making the tweaks to it to make sure it really works and continues to work.

    It’s usually not that hard to get Plan Do work done, everybody wants to do it, but getting an ongoing routine Check Act process takes real ongoing commitment to everyday mechanisms that build communication, involvement and ownership.

  21. Hello JC,

    2 pieces of advice, that actually helped to keep my PDCA’s alive as well as their impact on efficiency.

    1- Every head of department has to follow the number of PDCA’s in his / her team, and report as an indicator how many PDCA’s in P stage, D stage, C stage, A stage ; that’s an exception, here you don’t need any target : the indicator is used to show whether the PDCA process runs correctly, without dying phenomenon, and stays at a level under control (Im mean : not too many, to remain active). Then this indicator, monthly and quickly checked within the Management Committe, enables right decisions to keep PDCA alive

    2- Alive is not enough, it has to remain profitable !! You just have to build internal audit points linked to every new standard from A stage. Internal audits points are part of the Quality System of the firm, so they can’t vanish. Either the positive impact remains, or a decision is taken to suppress an audited point or a whole audit. But this time it’s no longer a surprise, it’s a decision under control.

    I hope this help many of you.
    Best Regards.
    Patrice FOULON
    Industrial Performance Manager

    • Great suggestion, Patrice. A fixed calendar appointment a couple times during the week by Management or Area/Department/Measurement Leader who is accountable for a certain number of PDCA’s in the cycle could function. Especially in an organization being discussed with multiple remote locations. Maybe the twice monthly company-wide conference call could shift funtions to discuss status?

  22. Hi
    Working at a Toyota dealer, I have found two tools very useful in kaizen work

    One: Evaluation as standard point on the agenda at team meetings
    Two: keep a strict log over team / kaizen activiites.

    Both help keeping things alive

  23. PDCA is “the heart” of KAIZEN. I you don’t Check, then how do you know if you have made an improvement or just a change? If you plan and do only, then you are “managing in the seventies” and all of your Quality Initiatives will be reactive and never be proactive. Our customers should not be the “major source” of failure information when we are updating PFMEA’s.

  24. Deb, I’m delighted to see you post about CAP-Do, as I’ve always found this a refreshing way to approach PDCA — to start with Check in examining the “current situation.” Starting with Check asks us to look first, then Adjust, and THEN Plan. Then our plans are informed by our observations of the current state.

  25. Hi JC

    As a Plant Manager I have broken down the cycle of “firefighting” or recurring PDCA’s and corrective actions by

    a. championing Daily “Hot Issues” meetings and implementing dry erase boards with posted PDCA’s and visual reminders that set priorities, improve communications, and increase awareness.

    b. improving team problem solving techniques and execution – why repeat, why not sustained, why inadequate execution, why ineffective solution, …

    c. implementing PDCA Management Audits to validate effectiveness

    d. adding a Lessons Learned program to capture PDCA’s that meet an established criterion

    e. implementing a simple database to capture our lessons learned for future reference and feedback loop to Engineering, HR, Quality, Finance,…

    f. by requiring PDCA training and signoff by all effected resources.

    It sounds like allot of work and it is however your team can in a relatively short amount of time begin to experience fewer repeat situations and many fewer fires.

    I have a process flow examples for lessons learned if you are interested and email me a request.


    • Interesting. Sounds like you’ve crossed our bridge before…

      d. adding a Lessons Learned program to capture PDCA’s that meet an established criterion

      e. implementing a simple database to capture our lessons learned for future reference and feedback loop to Engineering, HR, Quality, Finance,…

      What’s your Lessons Learned Program? Is it a reward & recognition program? We’ve also been working on a database. Any suggestions or pitfalls to avoid?

      I’ve often heard that “Lost Knowledge” is the 8th waste. Has this helped your company avoid that?

      • I’d like to also learn more about Craig’s PDCA Management Audits for validation? I feel this is a potential avenue to overcome our remote locations problem.

      • Hi JC and all other visitors,

        I didn’t want to hog this page so I pasted a link to my website where on the Management Tools page, I have a posting related to PDCA’s and the Visual Management approach I’ve had many successes deploying. Your readers may gain something from these Lessons Learned.

        I also have an ongoing poll related to 5S Sustainability that I invite you as well as all of your readers to participate with. I will share the results and a paper I’m preparing on the topic with you and the readers, as soon as I have an adequate number of responses.

        Lastly, I have a funny cartoon that I’ve drawn based upon my experience in home construction. The theme is 5S specific to a framing site. Let me know and I’ll be happy to provide this to you if you wish to post. email sent.

        “Like Motel 6 – The Lights are always on”

        Craig Lester
        Lean Operations Consultant

  26. I have done research on the relation between professionals and quality management. Important is in what quality paradigm your PDCA’s function (or rather do not function). Soon an article by me will be published on quality paradigms in Quality Progress (ASQ).

    Professionals prefer the commitment paradigm. They are – in general -committed to their profession, to the content of their job, to customers they have direct contact with. Another question for you could be: WHAT IS THE SUBJECT OF YOUR PDCA’s, DOES THAT MOTIVATE THE PROFESSIONAL?

    Maybe even more important. For professionals it is crucial that quality management is not considered to be a means of control. They do not like the control paradigm. Professionals do not mind to be accountable, but to peers, to people who really know what their job is. They do not like to be controlled especially not by nit-wits. So an important question in your case could be:

    Succes, Everard

    • I’m interested in the use of the term ‘professional’, and wonder what you mean by it? There are several aspects to the definition of the word implying that as a ‘professional’, one has ‘some degree of learning / some expertise in / some strong belief or affiliation in a subject’ as well as ‘undertaking as a means of subsistence’. In contrast, the amateur might engage in the subject for ‘sport or amusement’, has lesser expertise and lower belief or affiliation, and might also make a living through ‘art or craft’.

      I believe that the vast majority of people want to go to work and do a good job. They would prefer to be engaged in a successful organisation, as their its success will reflect positively on their remuneration and career prospects. A common feature amongst successful people is that ‘they get things done’.

      I have encountered people who have fine written qualifications, but little experience in getting things done. People who get things done but have no recognised trade, craft or professional qualifications. Supervisors and Managers with all the right ‘tickets’, and leaders with nothing but the respect of their people. I’ve seen individual workers of Olympic standard making widgets, and work teams as well choreographed as the Bolshoi Ballet …but unfortunately not in the same pay league as the likes of Elton John or David Beckham who make their living from ‘art or craft’.

      In industry, I find that there is usually respect for those who are good at their job in –say- making widgets. There is usually encouragement for the widget-maker to use processes & tools such as PDCA to improve the widget-making process, although using PDCA is not expected to be a core competency. I believe it is a Management (capital M!) responsibility to ensure that PDCA is used; Management own the PDCA process; any individuals might own individual projects or tasks within projects.

  27. […] All those projects (and there’s a bunch of them) that disappear into the blackness of the Elephant Graveyard are irrelevant. They were a waste of […]

  28. […] PDCA of the Month – “Dirt Piles” – February 2011 This problem has plagued our communities for years, and every year it seemed like someone would attempt to adress it. But each attempt fizzled out and disappeared somewhere in the elephant graveyard. […]

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