A breath of fresh air for ailing healthcare
Since the year 2000 we have applied in research  and in practical experience with healthcare providers principles and methods borrowed from the Toyota Production System (TPS). We have been rewarded with positive results in our efforts to reduce waste and errors in our industry and improve worker appreciation of healthcare careers.
The A3 Problem Solving Method and Document (A3) in combination with the Value Stream Map (VSM), both borrowed in concept from the Toyota Motor Company and adapted to manufacturing in the US and elsewhere, has now been demonstrated to be of value in healthcare in every department that wishes to reduce waste and errors and retain good employees.
Bolded below are specific features unique to the A3 process and A3 thinking.
The objective nature of the A3 creates safe and acceptable problem solving; it is never critical of an individual’s work. The VSM gives the user a “10,000 foot level” view of the steps in a process as they currently occur from the point of request to the point of delivery of that request. Data collected in each of the steps or “process boxes” shows statistically (thus, objectively) where there is variation in each step and indicates where we should observe the activities within that step to recognize opportunities to remove barriers around which the worker must work to produce the step. It is these “work-arounds” and “rework” that we attempt to remove with the A3 process, to ultimately contribute to improving the Value Stream.
The A3 is a way to look with “new eyes” at a specific problem identified by direct observation or experience. It offers a structure that begins by always defining an issue through the eyes of the customer. In itself this way of stating the problem makes resolution of the problem indisputable. After all, why are we all here if not to produce an Ideal service or product for the customer or patient?
Figure 1. IDEAL
Objectivity is further reinforced by deeply understanding the current condition before jumping to a solution. When we observe and draw the current condition, we realize that this is the way the current process works; not to assign blame to anyone but to acknowledge that this is the way the work happens now, with or without flaws. Once that first view of the issue is created, we can move on to ask ourselves, “What about the way this work is happening is not Ideal?”
There is so much power in deeply understanding the way the work is currently being done, and we have not always taken the time to observe and understand this essential information before creating a fix. In this alone, there is a tremendous opportunity to look at work differently and really see the opportunities for improvement. Even the very popular PDSA (or PDCA) process, which resembles the right side of the A3, does not begin with deeply understanding the current condition. The A3 first creates a new way to look at work.
The graphic nature of the A3 contributes to deep understanding of the current condition and the target condition. With the simple graphic representation of a system problem in the current condition drawing, the problem solver is able to recognize redundant work quickly and clearly and share the realization with whomever he/she involves in the resolution of the issue. Simple stick figure drawings and lines and arrows demonstrate loops in work that create work-arounds and rework. By drawing storm clouds on the graphic it is clear where the problems reside in the current condition. Also, because A3s, and in particular the drawings, are done in pencil, it is safe for a problem solver to take the drawing to other affected workers or departments and say, “Here is my understanding of how this work happens now…did I get it right, are there steps I may have left out?” This offers all of the involved problem solvers the chance to erase, redraw and correct any wrong assumptions that may have been made about the work. Because everyone knows how to use a pencil and it can be done immediately, problem-solving progress is rapid and accurate, and the affected workers are able to participate in creating the essential understanding, even in a busy work environment.
Root cause analysis is not new to problem solving, but the A3 offers a simple and consistent way to achieve and document it. Toyota’s “5 Why?” approach to getting to the root cause of the problems identified as storm clouds is easy to remember and easy to execute. When the final Why? reveals the root cause, we have concluded what must be addressed to remove the storm cloud and move the process closer to Ideal. The final Why? in the analysis of each storm cloud/problem creates a checklist for what we need to do later in the Implementation Plan.
Creating the Target Condition is easy because we so deeply understand the Current Condition.
The right side of the page is the creative and fun half of the A3. Because we enter it with such a deep understanding of the current work, identifying a better way to work comes easily. The right side is also drawn in pencil and we should see the simpler, cleaner process appear on paper, with fewer or no loops of rework or work-arounds. Because we’ve done the work on the first half of the A3, we can compare the target condition to the current condition and ask the essential question, “Does this new proposed way to work move us closer to Ideal?” If the answer is yes, then we can move forward to clearly defining Countermeasures, or changes that we need to make in the process to move from the current to the target condition.
Building accountability with a specific Implementation Plan occurs naturally as we outline the specifics of what needs to be done to make the countermeasures a reality. By defining what needs to happen, by whom, by when and with what expected outcome, we very clearly and realistically specify the work for the problem solvers involved. This is our work list; this is how the author or the team of the A3 can check progress. Again, it specifies the work and everyone involved knows exactly what’s expected of him/her. We can refer back to the root causes identified on the left side of the page and ask ourselves, “Have we removed each of the causes that are keeping us from achieving the target condition?”
The Test allows us to try out the proposed better way to work with a safe, experimental attitude and environment. Simulating the situation or creating a test environment to challenge and experience the proposed way to work, with a defined test timeline, makes it safe for problem-solvers to be creative and to try out their ideas. Because of the deep understanding of the process that has been achieved on the left side of the page, the risk is minimal and the ability to tweak the system before implementation is built in. Once the test is done and the authorization to implement is granted, full initiation of the newly designed work can occur.
The responsibility for Follow-up to assess the new process over time is assigned to one or more individuals with specific dates for re-evaluation noted on the A3. The follow-up report becomes the new current condition. If it’s not perfect, that’s OK! We initiate another A3 and ask again, “What about our new current condition isn’t Ideal?”, hence generating ongoing adaptation to the inevitable changes in our work. This again demonstrates the “safety” of the A3 process.
An A3 would be deemed successful if the efforts moved us closer to Ideal, even if there was yet more opportunity to improve that we could continue to achieve. No one is chastised for not making it perfect on the first round.
OTHER VALUABLE FEATURES OF THE A3
There is tremendous power in having one problem solving method in which management and staff members develop confidence. When staff and management have been involved with the A3 process and an issue arises for which the A3 approach is suggested, everyone knows the steps that will be employed, believes that they will be either involved or represented in the work redesign and that there will be a timeline and accountability for completion developed. They believe that the experimental environment will be safe. They know that when problem solving is reported, it will be easy to understand and consistently presented. When management says, “I think we should do an A3 on this,” everyone knows what that means.
The A3 is done on the front side only of an 11″ x 17″ (thus the name, A3) sheet of paper. With only a small area for problem analysis, the A3 forces the problem solver to choose issues that are specific enough to complete on one sheet. This assures that the work is of a scope that can be realistically completed, quickly demonstrating successful change and motivating workers to do even more problem solving.
A3 problem solving occurs in the course of work. Large numbers of staff do not have to be gathered for extended times to do speculative problem solving. Coaches can be recognized and easily trained to help staff validate and participate in the A3 process without leaving their work site.
A3 problem solving is intuitive and easy to learn and remember. Healthcare workers did not enter the profession to become management engineers or spend all their time improving processes; they came to this work to take care of people. The A3 process is logical thinking based on the familiar scientific method of problem solving that is easy to learn and teach and requires no technical training.
A3 thinking can be used to create better and fewer meetings. Conducting a lean meeting using the A3 process can greatly reduce the time and numbers of meetings required to achieve the work of the agenda. A3s are ideally done by a focus group of 2-3 people who represent the affected parties and can procure validation of the current condition and the target condition from their peers, in the course of work.
Measurement of the cost of implementation and the cost benefit is documented on each A3. The cost of the implementation plan is documented on every A3 and can be compared to the benefit, which may be measured in hard or soft dollars saved, or in a measure of quality of service. This information creates objective information for leadership to use in authorizing the implementation plan presented on the A3 document.
The A3 form is both a template for problem solving and documentation of the efforts. When the A3 document is stored in a 3-ring binder on the work unit and logged on the Improvement Marquee©, real activities can be reviewed by regulatory groups (JCAHO, CAP,etc.), governing board members, physicians and senior leaders, as well as staff from other departments. This allows cross departmental sharing of process changes and generates even more problem solving ideas.
Last, but certainly not least, the A3 process is satisfying to everyone who uses it, particularly
frontline workers. The A3 is an easy to learn and easy to teach method that staff can use to remove the frustrations of their daily work that are created by weak and un-supportive processes. This ability to be involved with creating a better way to work has been exceptionally well received by frontline workers, who Toyota recognizes as the resident experts in any industry. It involves the workers in improving work that is meaningful to them, at a level at which they can see and appreciate the changes they have participated in creating. In this era of current and impending healthcare worker shortage, this satisfaction is essential to retaining good workers.
Lean Healthcare West, Missoula, Montana
 National Science Foundation Grant coe.montana.edu/ie/faculty/sobek/IOC_Grant/people.htm