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

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

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

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

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

A construction worker named Sean Dow was working on the 22nd floor of Pfizer’s former Manhattan headquarters, a massive office building now being converted into residential apartments with additional floors being added.

Dow noticed cracks in a concrete slab. When he investigated further, he found a structural column visibly bending. But when he raised the concern, the initial response from the general contractor was reportedly, “Don’t worry, you’ll work on the floor below.”

Dow kept pushing. Workers were evacuated, and investigators later found floors sagging by as much as four inches.

The story illustrates an important distinction in psychological safety. People remain silent not only because they fear punishment, but also because they believe speaking up will accomplish nothing.

A genuine speak-up culture requires concerns to feel both safe to raise and worthwhile to raise. The real test is not whether leaders say they welcome concerns. It is what they do in the first minute after someone brings one forward.

Do they dismiss the concern and offer reassurance without investigating? Or do they respond with curiosity and say, “Show me”?

An organization that depends on unusually persistent workers to overcome a dismissive first response is not operating a strong safety culture. It is operating on luck.

A title change is not a culture change. In this episode, Mark Graban draws on his early experience at GM in the mid-1990s — where "foreman" became "team coordinator" overnight without anything else changing — to explore why renaming supervisors with Lean-sounding titles so often fails to deliver Lean results.

Read the blog post

The discussion centers on Ford's Process Coach role: what it's supposed to be, what it often is in practice, and why the gap between those two things is a leadership system problem, not a training problem. Mark also looks at why Toyota's Group Leader model works where Ford's equivalent often doesn't — and why a senior UAW worker has rational, concrete reasons to turn down a promotion to Process Coach even if they're the most qualified person on the floor.

If your organization has rebranded its supervisors without redesigning the conditions those supervisors work in, this episode is worth your time.