Managing with A3 Thinking
Building Consensus and Generating Authority
Jack Billi, M.D.
jbilli@umich.edu
sitemaker.umich.edu/jbilli
Michigan Quality
System:
• Quality
• Safety
Michigan Quality System:
med.umich.edu/mqs
• Efficiency
Adapted from John Shook, Dave LaHote,
Margie Hagene, with permission
• Service
• Appropriateness
1
A Question For You
What makes projects fail?
• Think of a specific project…
• Why did it not succeed?
2
What makes lean projects
(or any project) fail?
•lack of knowledge?
•lack of a plan?
•lack of leadership?
•lack of discipline?
•lack of commitment?
•lack of a champion?
•lack of resources?
•lack of focus?
•lack of…AGREEMENT!
3
So Many Solutions!
• “We need to implement
lean to reduce waste and
improve efficiency”
• “We need white boards
in patient rooms so
patients know who their
doctors are”
• “We need a new EMR to consolidate and organize
patient information”
• “We need more exam rooms, more nurses, more
ORs, more instruments, …”
4
Is the Issue Agreement?
Do we really agree on the where we
want to go? On what the gap in
performance is?
Future State
Do we really agree on
how we will get
there?
Current State
5
Do we really agree on the
where we are? On the current
condition?
How do you get agreement?
Sample answers:
Pro’s / Con’s
•
•
•
•
•
•
•
•
•
Persuade with logic
Appeal to emotion
Overwhelm with data
Dictate
Threaten
Manipulate
Trade favors
Compromise
Others?
6
How Do We Get Agreement?
State your
case more
strongly than
others
Force your
perspective
Meeting people into
submission
I’ve got
the data
Do the Hard Sell
7
Where is Disagreement?
“You won’t believe what
they want us to do”
8
“Yea, like I’m going to
do that”
How do you get agreement?
• Most effective is to tell a persuasive
story,
 if so,
• Would it not be best to tell it
concisely, preferably visually and in a
standard format?
9
“A3 Thinking”
A Template for Structured Problem-Solving
Background:
• “A3” is just a paper size (~11” x 17”)
• 1960s: Quality Circles problem-solving format
• At Toyota, it evolved to standard format:
–
–
–
–
Problem-solving
Proposals
Plans
Status reviews
• “A problem clearly defined is half solved”
10
Adapted from John Shook
“A3 Thinking”
A Template for Structured Problem-Solving
Traits:
• An A3 lays out an entire plan, large or small,
on one sheet of paper.
• It should tell a story, laid out from upper left to
lower right, which anyone can understand.
• It should be visual and extremely concise.
• What is important is not the format, but the
process and thinking behind it, and the
conversations it facilitates.
Adapted from John Shook
11
A3 Discipline
• State the issue and why it is important
• Provide background to facilitate
understanding
• Current performance and future goals
• Analysis and root causes
• Countermeasures and action plans
• Measurement and adjustment methods
12
Scientific Method (PDCA Cycle)
Grasp the
Situation
Plan
(Hypothesis)
Act
Do
(Adjust)
(Try)
Check
(Reflect)
13
Countermeasures
implemented as
Experiments
Scientific Method (PDCA Cycle)
Plan
(Hypothesis)
Act
(Adjust)
Grasp the
Situation
Check
(Reflect)
14
Do
(Try)
Countermeasures
implemented as
Experiments
An A3 Template
Date:
Owner:
Title: What we are talking about.
Background
Recommendations
Of all our problems, why this one?
The “ugly story”…
Current Situation
What are your proposed
countermeasures, strategies,
alternatives?
Where do we stand?
Problem Statement:
Goal
What is the specific change we want to
accomplish now?
Plan
What activities will be required?
What , Who, When?
Analysis
-What are the root causes, requirements,
constraints?
Follow - up
How we will know?
What remaining issues?
Modified -Verble/Shook
A3 Benefits
Purpose: A standard communication tool to
make it easier to understand each other:
• It fosters effective and efficient dialogue within
the organization.
• It develops thinking problem-solvers.
• It encourages front-line initiative.
• It cascades responsibility.
• It clarifies who is responsible for problems or
steps.
• It exposes lack of agreement that can undermine
plans.
Adapted from John Shook
16
A3 Benefits
• Builds consensus and gives the authority to take
action – pull-based authority
• Encourages PDCA (Plan, Do, Check, Adjust)
– scientific problem solving.
• Forces “5S for information.”
• Clarifies the link (or lack) among problems, root
causes, countermeasures.
• It leads to effective countermeasures and
solutions based on facts and data.
17
Adapted from John Shook
A3 - A Template For Structured Problem Solving…
…Does this sound familiar??
What we are talking about.
Background
Title:
Of all our problems, why this one?
The “ugly story”…
Current Situation
Date:
Owner:
Recommendations
What are your proposed
countermeasures, strategies,
alternatives?
Where do we stand?
Problem Statement:
Goal
What is the specific change we want to
accomplish now?
Plan
What activities will be required?
What , Who, When?
Analysis
-What are the root causes ,requirements,
constraints?
Follow - up
How we will know?
What remaining issues?
Modified -Verble/Shook
Name of Patient:
New Patient H&P
History
Date:
Clinician:
Impression - Diagnoses
Chief Complaint
1.
History of Present Illness
2.
Past Medical & Surgical History
3.
Medications and Allergies
Family and Social History
Plans
Review of Systems
Diagnostic:
1, 2, 3,
Physical Exam
General Appearance, Vital Signs
HEENT
Treatment:
1, 2, 3,
Heart & Lungs
Abdomen
Follow - up
Extremities
Neuro
Monitor x, y, z
Return visit:
A3 Outline (Boxes)
Create about five to seven boxes, combining the appropriate items to
make your story as simple and clear as possible.
1. Title (theme), owner, draft date
2.
3.
4.
5.
6.
7.
8.
9.
10.
Background
Current situation, Current State Map
Goal or target
Investigation of facts, analysis, root cause analysis
Recommendations, countermeasures, strategies,
alternatives
Action Plan – what, who, when
Verification of countermeasures
Review/Critique
Possible next steps, further action, follow up
20
Adapted from John Shook
Which Tool Could Be Used …
• Each item (box) should contain a graph, chart, or sketch.
• Use words only when a graph, chart, or sketch cannot show the details
of the contents, or it is impossible to explain the contents with them.
BACKGROUND
INVESTIGATION
CURRENT STATE
TARGET, OUTCOMES
ACTION PLAN
ANALYSIS
COUNTERMEASURES
VERIFICATION OF
COUNTERMEASURES
PREVENTIONS
REVIEW/CRITIQUE
Graph
Tally-sheet
Pareto Diagram
Scatter Diagram
Control Chart
Chart
Gantt Chart
Cause-and-Effect Fishbone
Relation Diagram
Tree Diagram
Pareto Diagram
Scatter Diagram
Graph
Sketch
Pareto Diagram
Histogram
Scatter Diagram
Sketch
Sketch
Histogram
Graph
Sketch
CS Map
Sketch
Control Chart
Histogram
Graph
Sketch
Chart
FS Map
Graph
Sketch
Chart
Chart
Adapted from John Shook
A3 Roles
3 Roles:
• Creating the A3 encourages systematic problem
solving, using “go see, ask why, respect people”
• Presenting the A3 fosters consensus, commitment
to move forward
• Discussing the A3 fosters critical analytic skills,
communication, respect
22
A3 Thinking is about
Reaching Consensus
Consensus on:
• What is the problem?
• Who owns the problem?
• Why is this problem important?
- ‘The ugly story’.
• What are our goals?
• What are the root causes?
• What strategies/options will we try to
overcome the root causes?
• What plan will we use to try the strategies?
- Who will do what, when?
• When/where will we follow up?
23
Evolving Uses of A3 at UMHS
To Build Consensus on Tough Problems:
•
•
•
•
UMHS annual operating budget
10 year Strategic Financial Plan
Planning the Lean Transformation in Ambulatory Care
Why we’re having problems creating the Ideal Patient
Care Experience
• Redesign of a Regional Health Coalition:
Employers/Payers/Providers: purpose, process, people
• University’s 5 Year Health Benefits Strategy:
“Healthy and Solvent University Community”
• IT strategy – from “best-of-breed” to “prime vendor”
24
Evolving Uses of A3 at UMHS
To Build Consensus Around Proposals
•
•
•
•
•
•
•
•
Improving Acute Medical and Surgical Streams
Advanced Medical Home
Single county-wide ACO
Major clinical expansion in a geographic region
IT capital project review ($50M in requests v. $13M)
Annual PDCA and plan for Michigan Quality System
Requests for central lean coach resources
Creation of a claims data warehouse for Michigan
physician organizations, with Blue Cross
• Fourth year medical student projects (1 mo. elective)
To Provide Status Reports
25
– Track progress on top objectives (Children’s OR flow)
Early Mobilization of ICU Ventilator Patients
Physical
Therapist
Nurse
Grandson
Pull-Based Authority
A3
26
27
28
IHI Open School – student organized QI learning –
MD, RN, Pharm, Soc Work, Engineer, MPH, MBA
A3 workshop: multidisciplinary problem solving
29
Practice in A3 problem-solving,
presenting, critiquing
30
A3 Group Learning Exercise
Work in teams
• Imagine clearly the story: the proposal you want to
make or the problem you want to solve.
• Focus on the left hand side:
–
–
–
–
–
–
What is the problem? Who owns the problem?
Why is it important to the organization?
How does it punch through to hurt a customer?
What is the current state?
What are our goals?
(What are the root causes? Not today!
No why before its time - David Verble)
• Before filling in the right:
– Recommendations, countermeasures, plans…
31
An A3 Template
Date:
Owner:
Title: What we are talking about.
Background
Recommendations
Of all our problems, why are we talking
about this one?
The “ugly story”…
Historical/organizational/business context…
Current Situation
What are your proposed
countermeasures, strategies,
alternatives?
Where do we stand?
Include options (some needing no
resources)
Trend chart, current state value stream map,
current gap…
Plan
Problem Statement:
Goal
Goal
What is the target
condition or performance improvement
you want now? Measurable, by when?
What , Who, When?
What activities will be required for
implementation and who will be
responsible for what and when?
Analysis
-What are the root causes of the
problem? Fishbone, 5 Whys, Pareto
-What requirements, constraints need to
be considered?
Follow - up
How we will know if the actions have
the impact needed? What remaining
issues can be anticipated? When/how
will we follow up?
Modified -Verble/Shook
A3 Presentation Etiquette
• Model respect: in presentation and feedback
• Presenter gives everyone an 11”x17” copy, for
notes
• Present straight through from the A3, not slides or
memory
– If you have a “better story”, use it in the A3
• Listeners don’t interrupt: only clarifying questions
• Plenty of time for feedback: time for mentoring
– Open ended questions, not answers
– Ask questions you don’t know the answer to
• Presenter modifies A3 right now, based on the
33
feedback/questions
A3 References
Books with Focus on A3 Use:
• Shook. Managing to Learn. (Best book on leadership in a lean organization and A3 use)
•
Sobek, Smalley. Understanding A3 Thinking. (Problem solving and A3 use)
•
Dennis. Getting the Right Things Done. (Strategy deployment or hoshin kanri)
•
Liker, Meier. Toyota Way Fieldbook. (Practical lean tools)
•
Baker, Taylor. Making Hospitals Work. (Workbook from Lean Enterprise Academy, UK)
•
Graban. Lean Hospitals. (General lean healthcare reference)
Lean Web Resources:
• Michigan Quality System at UMHS: med.umich.edu/mqs
•
Lean Enterprise Institute: www.lean.org webinars, books, meetings…
•
Lean Healthcare Leaders Network www.healthcarevalueleaders.org
•
Lean Enterprise Academy (UK): www.leanuk.org
05.17.10