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Managing with A3 Thinking . Building Consensus and Generating Authority. Jack Billi, M.D. [email protected] sitemaker.umich.edu/jbilli Michigan Quality System: med.umich.edu/mqs Adapted from John Shook, Dave LaHote , Margie Hagene , with permission. Michigan Quality System : Quality

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Building consensus and generating authority

Managing with A3 Thinking

Building Consensus and Generating Authority

Jack Billi, M.D.

[email protected]

sitemaker.umich.edu/jbilli

Michigan Quality System:

med.umich.edu/mqs

Adapted from John Shook, Dave LaHote, Margie Hagene, with permission

  • Michigan Quality System:

  • Quality

  • Safety

  • Efficiency

  • Appropriateness

  • Service


A question for you

A Question For You

What makes projects fail?

  • Think of a specific project…

  • Why did it not succeed?


What makes lean projects or any project fail

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!


So many solutions

So Many Solutions!

  • “We need to implementlean to reduce waste andimprove 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, …”


Is the issue agreement

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?

Transition Plan

Do we really agree on the where we are? On the current condition?

Current State


How do you get agreement

How do you get agreement?

Sample answers:

  • Persuade with logic

  • Appeal to emotion

  • Overwhelm with data

  • Dictate

  • Threaten

  • Manipulate

  • Trade favors

  • Compromise

  • Others?

Pro’s / Con’s


How do we get agreement

$495

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


Where is disagreement

Where is Disagreement?

Your Idea

“You won’t believe what they want us to do”

“Yea, like I’m going to do that”


How do you get agreement1

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?


A3 thinking a template for structured problem solving

“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”

Adapted from John Shook


A3 thinking a template for structured problem solving1

“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


A3 discipline

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


Scientific method pdca cycle

Grasp the Situation

Plan(Hypothesis)

Act(Adjust)

Do(Try)

Check(Reflect)

Scientific Method (PDCA Cycle)

Countermeasures implemented as Experiments


Scientific method pdca cycle1

Grasp the Situation

Plan(Hypothesis)

Act(Adjust)

Do(Try)

Check(Reflect)

Scientific Method (PDCA Cycle)

Countermeasures implemented as Experiments


Building consensus and generating authority

An A3 Template

Title: What we are talking about.

Date: Owner:

Background

Recommendations

Of all our problems, why this one? The “ugly story”…

What are your proposed countermeasures, strategies, alternatives?

Current Situation

Where do we stand?

Problem Statement:

Plan

What activities will be required?

What , Who, When?

Goal

What is the specific change we want to accomplish now?

Analysis

-What are the root causes, requirements, constraints?

Follow - up

How we will know?

What remaining issues?

Modified -Verble/Shook


A3 benefits

A3 Benefits

Purpose: A standard communication tool to make it easier to understand each other:

  • Fosters effective and efficient dialogue.

  • Develops thinking problem-solvers.

  • Encourages front-line initiative.

  • Cascades responsibility.

  • Clarifies who is responsible for problems or steps.

  • Exposes lack of agreement that can undermine plans.

Adapted from John Shook


A3 benefits1

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.

Adapted from John Shook


Building consensus and generating authority

A3 - A Template For Structured Problem Solving…

…Does this sound familiar??

Title: What we are talking about.

Date: Owner:

Background

Recommendations

Of all our problems, why this one? The “ugly story”…

What are your proposed countermeasures, strategies, alternatives?

Current Situation

Where do we stand?

Problem Statement:

Plan

Goal

What activities will be required?

What , Who, When?

What is the specific change we want to accomplish now?

Analysis

Follow - up

-What are the root causes ,requirements, constraints?

How we will know?

What remaining issues?

Modified -Verble/Shook


Building consensus and generating authority

New Patient H&P

Name of Patient:

Date: Clinician:

History

Impression - Diagnoses

Chief Complaint

History of Present Illness

Past Medical & Surgical History

Medications and Allergies

Family and Social History

Review of Systems

1.

2.

3.

Plans

Diagnostic:

1, 2, 3,

Treatment:

1, 2, 3,

Physical Exam

General Appearance, Vital Signs

HEENT

Heart & Lungs

Abdomen

Extremities

Neuro

Follow - up

Monitor x, y, z

Return visit:


A3 outline boxes

A3Outline (Boxes)

Create about five to seven boxes, combining the appropriate items to make your story as simple and clear as possible.

  • Title (theme), owner, draft date

  • 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

Adapted from John Shook


Which tool could be used

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.

BACKGROUNDGraphSketch

INVESTIGATIONTally-sheetHistogram

CURRENT STATEPareto DiagramGraph

Scatter DiagramSketch

Control ChartCS Map

TARGET, OUTCOMESChartSketch

ACTION PLANGantt Chart

ANALYSISCause-and-Effect FishboneControl Chart

Relation DiagramHistogram

Tree DiagramGraph

Pareto DiagramSketch

Scatter Diagram

COUNTERMEASURESGraphChart

SketchFS Map

VERIFICATION OFPareto DiagramGraph

COUNTERMEASURESHistogramSketch

Scatter DiagramChart

PREVENTIONSSketchChart

REVIEW/CRITIQUE

Adapted from John Shook


Building consensus and generating authority

An A3 Template

Title: What we are talking about.

Date: Owner:

Background

Recommendations

Of all our problems, why are we talking about this one? The “ugly story”…Historical/organizational/business context…

What are your proposed countermeasures, strategies, alternatives? Do they link directly to the root cause?Include options (some needingno resources)Future State Value Stream Map?

Current Situation

Where do we stand? What is our current performance?Trend chart, current state value stream map

Plan

What , Who, When? What activities will be required for implementation and who will be responsible for what and when?

Clear Problem Statement

Goal

Goal

What is the target condition or performance improvement you want now? Measurable, by when?

Analysis

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?

What are the root causes of the problem? (Fishbone, 5 Whys, Pareto)

What requirements, constraints and alternatives need to be considered?

Reviewed By: Date:

Modified from Verble, Shook, LaHote, Billi


A3 roles

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


A3 thinking is about reaching consensus

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?


Evolving uses of a3 at umhs

Evolving Uses of A3 at UMHS

To Build Consensus on Tough Problems:

  • Planning the Lean Transformation in Ambulatory Care

  • 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”


Evolving uses of a3 at umhs1

Evolving Uses of A3 at UMHS

To Build Consensus Around Proposals (plan)

  • Improving Acute Medical and Surgical Streams

  • 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)


Evolving uses of a3 at umhs2

Evolving Uses of A3 at UMHS

To Provide Status Reports – (check and adjust)

  • Creating the Ideal Patient Care Experience

    • Tracking each of 7 planks

  • Improvements to Children’s OR flow

  • Acute Medical Stream improvements

  • Progress on Strategic Plan “strategies”


Building consensus and generating authority

Early Mobilization of ICU Ventilator Patients

Physical Therapist

Nurse

Grandson

Pull-Based Authority

A3


Building consensus and generating authority

IHI Open School – student organized QI learning –

MD, RN, Pharm, Soc Work, Engineer, MPH, MBA

A3 workshop: multidisciplinary problem solving


Building consensus and generating authority

Practice in A3 problem-solving, presenting, critiquing


A3 references

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


A3 presentation etiquette

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 feedback/questions


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