A3 Thinking For All Seasons - Michigan Lean...

A3 Thinking For All Seasons

Michigan Lean Consortium Annual Conference

August 12, 2015

Brian Vander Weele

Senior Process Excellence Consultant

Mercy Health Muskegon

• Introductions

• Various A3 Formats

• Types of A3’s (case studies)

• Creative Use of A3’s (case studies)

• Hands-On Application

Agenda

Mercy Health Muskegon

Mercy Sherman Campus

Hackley Campus

Lakeshore Campus

Our Mission and Values

Reflection –

A young man approached the foreman of a logging crew and asked for a job. "That depends," replied the foreman. "Let's see you fell this tree." The young man stepped forward, and skillfully felled a great tree. Impressed, the foreman exclaimed, "You can start Monday.“

Monday, Tuesday, Wednesday, Thursday rolled by -- and Thursday afternoon the foreman approached the young man and said, "You can pick up your paycheck on the way out today." Startled, the young man replied, "I thought you paid on Friday.“

"Normally we do," said the foreman. "But we're letting you go today because you've fallen behind. Our daily felling charts show that you've dropped from first place on Monday to last place today.“

"But I'm a hard worker," the young man objected. "I arrive first, leave last, and even have worked through my coffee breaks!“ The foreman, sensing the young man's integrity, thought for a minute and then asked, "Have you been sharpening your ax?“ The young man replied, "No sir, I've been working too hard to take time for that!“

Our lives are like that. We sometimes get so busy that we don't take time to "sharpen the ax." In today's world, it seems that everyone is busier than ever, but not necessarily more productive. Often, a little time spent being proactive can save a lot of time in the long run.

Strategy deployment

Leader standardized work

Visual management

Improvement teams

Structured/scientific problem solving

Standardized work

Visual management

Pull systems

Customer first

People = most valuable resource

Gemba focused

Daily continuous improvement

Process Excellence Is…

A3 – Review of the Basics

What?

• 11 inches by 17 inches

(largest size for fax machine)

• A single page-that

summarizes the problem, it’s

causes, countermeasures

tried, results, and further

actions required

• Tells the story of the project

Why?

• Develops people &

creates a shared method

for problem-solving

• Provides common format

& understanding

• Communicates how you

got from point A to point B

• Visual / Concise

A3 should become the default way of making improvements

A3 - A Single Page Summary (cover sheet)

Infinite number of Tools & Documents that support the A3:

• SWOT Analysis

• Current State and Future State Process Maps

• Material & Information Flow Diagram / Value Stream Map

• Spaghetti Diagram / Communication Circle

• Cause & Effect Diagram / 5 Whys / Root Cause Analysis

• Direct Observations / Waste Walk

• Gantt Chart / Project Plan / Action Plan

Numerous A3 Formats

Oh - Which A3 Format Should I Do?

4 Box,

6 Box,

9 Box too,

A3 Report – 4 Box

Example – Patient Flow at Urgent Care Center

A3 – 6 Box

A3 – 9 Box

What would you do differently

Example – 9 Box A3

Site/Location: Project #

Who When Status

Linda /

Dawn

6/30/2015

5. HYPOTHESIS 8. CONFIRMED STATE STUDY

Metrics Current Future RIE 30 days 60 days 90 days

6. EXPERIMENTS DO

* Pharmacy / Informatics flexibility

* Having a physician champion

What did we learn… What would you do differently...

TRU

E NO

RTH

METR

ICS

Future State Metrics Goal UOM

* All areas properly documenting moderate sedation cases, in a consistent manner

* Proper documentation and data available to the Quality Department to fulfil its

analysis and reporting responsibilities

- Capture all moderate sedation cases regardless of outcomes

- Documentation meets CMS & Policy guidelines

- Provide appropriate feeback on metrics generated from documentation and data

submitted to Quality Dept.

Pe

op

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tere

d, Q

uality &

Safety,

Co

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e, P

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ealth

, Finan

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Stew

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Linda,

etc.

1) Revise current forms into one simple format for all areas to submit the

sedation information to the Quality Department.

What went well…

* Great Plans - leading to success * Include Informatics on team

* Followed the (A3) process - it works!

* Participation and representation

9. LESSONS LEARNED ACT

6/1

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* Updated policy - changes to procedure / * Good quality overall

* No change to documentation of quality & safety

* Great variability in how documented today (Providers, Nursing)

* Adverse Events - not reported officially but found for other reasons

* Confusion of policy - providers & ̂staff / Confusion of adverse events to capture

* Hackley ED (Leete) documents well / * Endo Lab (Sue) excellent job for tracking

* Specific roles for documentation in policy

* Heealthstream module for Nursing assigned to nursing in areas

Current State Metrics

What could be improved…

6/15/20154) Identify point person for each are to

submit sedation information to Quality Dept

5) Investigate other hospitals on how they

document and submit sedation data

6) Pilot new data forms in all areas

Sarah

Linda,

etc.

3. FUTURE STATE PLAN

TEAM

Out of Scope

ASCHeart & Vascular (MH) / ED (MH, HH, LS) / ICU (MH, HH) /

GI (MH / HH) / Radiology (MH, HH) / Specia ls (HH) / Pa in

Cl inic / Cancer Treatement Centers (educ. Only)

In Scope

The Sedation policy has recently been updated and now the process of

documentation and submission or availability of data to the Quality

Department needs to be improved and revised to meet the requirements

of the policy, and to be in compliance with CMS requirements. Currently

there is variation in how the documentation is completed, among the

various areas that perform moderate sedation and not all the

documentation or data is being made available to the Quality Department

to perform its required analysis and reporting.

2. CURRENT STATE PLAN

Current UOM

Physician Order for

procedural /

moderate sedation

Trigger Completed* Patient meets D/C criteria * Audits

* Adverse? ==> Voice report * Pharmacy Med Mine Info

* Monthly Report sent to Quality * Quality reports to

Quality Committee * Provider info. to DPPE

6/15/2015

If We…

1) Determine ALL patients who have received moderate & deep sedation.

2) Universal documentation process for all moderate & deep sedation

procedural information (nursing & physician)

3) Create a standard process for moderate sedation cases (triggered) - data to

be submitted or available to the Quality Dept.

4) Identify a point person in each area for collecting and submitting sedation

information to Quality Dept.

Then we . . .

will meet the items listed in Future State (box 3)

7) Review new forms, etc. with area

managers in preparation for Pilot

A3 Description: Moderate Sedation Physician Champion

1) Determine if Reports can be run out of EMR

to identify moderate/deep sedation

6/15/2015

Action Item-What

204

Exec. Sponsor(s): A3 Owner(s): PEx: Brian Vander WeeleTeam Leader:

Connie /

Linda

3/1

8/2

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5

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Date

:

1. BUSINESS CASE PLAN

6/15/2015

each

area

6/20/2015

6/30/2015

2) Determine Power Plan availability to all

areas

3) Revise current forms for monthly

submission form of sedation data to Quality

PLAN

Connie /

Linda

4. GAP ANALYSIS PLAN 7. COMPLETION PLAN DO

A3 – Toyota (5 Box)

Numerous

Variations

A3 - Others

In Summary

• Completing the A3 form doesn’t solve the

problem, or improve your process.

It’s not about the number of boxes

or the format your chose –

It’s all about the A3 thinking you use . . .

•Current Condition –

grasp the problem and

collect the facts

•Plan – choose a solution

•Do – try your idea

•Check – evaluate your

results

•Act – standardize and

communicate

Goal: Scientific Approach = Sustained Improvement

Current

Condition

It all goes back to the basic PDCA Cycle

• Makes problem solving visible – providing both the

A3 thinking template and the documentation form

• Go to the Gemba, observe and include the subject

matter experts who live the process every day

• Encourages Experimentation, not Perfection

A3 Thinking

The form itself is not the solution- it’s the thinking

and the process that makes A3 a powerful tool!

• A simple, structured methodology for improvement

• Reinforces understanding of the problem before

jumping to solutions

A 50% solution today, is better than a 95% solution 6 months from now.

There are no right answers or everlasting

solutions, only incremental improvements

to be tested and implemented as

employees get closer to the goal of

identifying what is of value to the patient,

then delivering it reliably.

From- On the Mend by John Toussaint, MD

Continuous Improvement

• Strategy Deployment

• Problem Solving

• Value Stream Analysis

• Kaizen (Rapid Improvement) Events

Types of A3’s

Strategy Deployment A3s

•Strategy

• Communicates Strategy with targets and action plans for the year

• Tells the strategy “story”

•Status

• Update on strategic objective (plan vs. actual)

• Should be able to tell the story in 5 to 10 minutes

Strategy A3 - Format

Example from Pascal Dennis’ book Getting the Right Things Done

Example – Strategy A3

See Additional Action Plan

• Work as a team at your table.

• Develop a Strategic A3 for addressing the quality of

roads in Michigan.

• Use either of the A3 formats available at your table.

• 10 Minutes, 5 Minute Debrief.

Group Exercise – Strategic A3

Problem Solving A3s

• Problem Solving

• Follows PDCA

• Documents your problem as you go…living document

Problem Solving Approaches – using A3 methodology

• Large area needing attention – Value Stream

approach

• Focused process step in a larger value stream –

Rapid Improvement Event approach (1-4 days)

• Smaller, problem or part of a process step –

Facilitated A3 Problem Solving workshop (4-8 hours)

• Very small problems, issues, wastes to address –

Individual A3 approaches

Facilitated A3 Problem Solving - 9 Box A3

A3 – 9 Box

Preparation Phase

Box 1: Business Case • Problem (“Punch in the Gut”) Statement

• Reason for action at this time

• Include Scope (In & Out) Process start & end

points

Box 2: Current State • Describe the process or situation right now

• Visually and Graphically represent the current

situation

Box 3: Future State • Graphically present the future state (desired)

process/situation

• Should be achievable targets within 30 – 90 days

• Include patients (customers) in defining the future

state

A3 – 9 Box

Problem Solving Phase

Box 4: Gap Analysis • Describe the difference between current and future

state

• Identify all possible (root) causes for the gap

• Use Cause & Effect, 5 Whys, Affinity Diagrams

Box 5: Hypothesis • Use the “If we do this . . . Then we expect this . . .”

approach to possible solutions for the gaps

identified

Box 6: Experiments • Run Experiments to validate Hypothesis from Box 5

• Describe the experiment(s), the plan for running the

experiments, and how they will be measured and

the results

A3 – 9 Box

Sustainment Phase

Box 7: Completion Plan

• List activities that still need to be completed

• Target completion should be within 30 days / 90 days

max.

• Include What, Who and When and track the progress

Box 8: Confirmed State

• Used to determine if team has achieved & closed the

gap

• Continue to monitor 30-60-90 day results on metrics

• Goal is for Box 8 to meet or exceed the Box 3 metrics

Box 9: Lessons Learned

• Document what the team has learned . . .

• What Went Well? / What Could be Improved? /

What Did We Learn? / What would you do differently?

Completion Plan

Confirmed State

Lessons Learned

Facilitated A3 Workshop


Who When Status

6/30/15



6. EXPERIMENTS DO

Oncology

* Splash of color

* Takt Time perspective

* Outside perspective (Px)

6 mos. / 3 mos.

* Stayed focused

TRU

E NO

RTH

METR

ICS


Abstracting (all sites / Breast & Lung)

Overtime costs

*Eliminate backlog within 9 months

* Eliminate the Quality Check within 12-18 months

* Appropriate staffing to meet demand (roughly 100 cases/month + growth)

* Electronic transfer of information (ie. Demographics, etc.) into Registry

* Continued improvements in efficiency with learning curve experience

* Specialization by Registrar and tumor site

* Registry requirements may include additional information in the future

* Be able to meet the RQRS requirements in the future

Pe

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Safety,

Co

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, Finan

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Stew

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* Summary after each step

(repetition)

In Scope Out of Scope

Suspense system and

abstracting

Cancer conferences, case finding, and follow-ups


Current UOM

1) Customize Pages (screens) for Emily to help improve efficiency

2) Review Quality Check feedback at beginning of day - not interrupt in real

time

3) Create Process Control Board to tracking cases abstracted each day to

determine if keeping up with demand, problem solving the barriers, and

determine overtime needed to keep up, etc.

4) Ongoing improvement in learning curve and better utilization of dual

screens instead of printing out all reports

What went well…

* A3 structure & charts on the wall

Abstracting (all sites / Breast & Lung) x months

Overtime costs

* Had fun


5/1

8/2

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* 2.8 FTE's cover a multitude of responsibilities, including abstracting and

entering cases into the Cancer Registry

* Currently, cases are being entered that are over

* Demand is currently about 100 cases / month that must be entered

* Each case takes roughly an 90 -120 min. to abstract w/ quality check

Trigger



CompletedCase finding and Suspense List Report to State Registry

5/23/154) Create tracking sheet for Production

Control Board

5) Develop a Plan to address the backlog -

eliminate it within 9 months

6) Investigate electronic method to populate

the Registry (demographic info., etc.)


TEAM

A3 Description: Oncology Tumor Registry Backlog Physician Champion

1) Customize pages (screens) for Emily 5/23/15

Action Item-What

209

Exec. Sponsor(s): A3 Owner(s): PEx: Team Leader:

N/A

5/1

1/2

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5

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:

1. BUSINESS CASE PLAN 4. GAP ANALYSIS PLAN 7. COMPLETION PLAN DO

Due to a variety of causes, there currently is an month back-log in

entering new cases in the Cancer/Tumor Registry. This could have

potential ACOS accreditation implications in the future. There have been

some changes in staff certifications, which has created an opportunity for

streamlining the process for: 1) keeping up with the demand for entering

new cases into the registry in a timely manner; 2) developing a plan for

eliminating the backlog.

5/23/15

6/30/15

6/30/15

2) Review Quality Check feedback at start of

day instead of interrupting throughout day

3) Order white board for Production Control

Board (tracking cases completed per day)

PLAN

1) Current Backlog:

684 cases x 2 hrs/case to abstract/quality check = 1368 hours (total)

1368 hours / 40 hrs per week = 34 weeks with 1 FTE to complete backlog

2) Current Demand and Capability (Takt Time): (see separate worksheet)

Takt Time = Total Time Available / Total Customer Demand

Available Time = 288 minutes / day Total Demand = 5 cases / day

TT = 288 / 5 = 58; A case must be abstracted every 58 minutes

However, it takes roughly 120 minutes/case (including Quality Review)

THEREFORE, the current capacity is about half the demand

Additionally, roughly 15 hrs of overtime is used each week to "keep" up

3) Additional "Gaps" are included in the Hypothesis box below

If We… Then We Expect…

* Develop Production Control Board for: 1) Daily Cases completed

2) Backlog Cases completed

5/23/15

7) Investigate best practices for abstracting

within Mercy Health network

Gap If we . . . Then We Expect . . .

Time consuming to get records

from outside sources

Interface technology

* ADT, electa

* Great Lakes health connect

Less time to input demographics -

improved efficiency in

abstracting

Printing vs. utilizing dual screens

to complete abstraction

Practice using dual screens to

get used to it

Improved efficiency in

abstracting (time savings in

printing and highlighting reports)

Some are more detailed wi info.

In the fields than others / some

less abbreviations

(No Standard) Different order for

how info. Is entered in registry

by each registrar

Interruptions during current case,

when given feedback on past

cases (quality check)

Schedule time at beginning

of each day to review quality

checks / use :) stickers for

good work

Less interruptions - Improved

efficiency in abstracting

Customize each page in

Registry for user preference

Improved efficiency in

abstracting

A3 – CAH Registration RIE Site/Location: Event #: Revision:

Who When Status

Barb /

Deidre

5. HYPOTHESIS 8. CONFIRMED STATE


6. EXPERIMENTS

36 min.---36 min.92 min.

$19,872 ---$19,872 $50,784

Good prep work / kept team focused

Gave it "our best shot"


Estimated annual cost of "rework" process $0 We can solve more problems w/ more time Have video conf. for last day report-Following PI process made issues

transpar.

BA

LAN

CED

MEA

SUR

ES

3. FUTURE STATE

Future State Metrics

* Create QDA encounter during the

event to experiment w/ technology

9. LESSONS LEARNED

What went well…

Good collaboration / Fresh Eyes More IS support

Having rework chart plotted out prior Consistent representation - all days

Open communication / no blaming

Goal VALUE Very complex process / many More physician attendance

Extra time for "rework" process (minutes/patient) 0 min. Future state doable but with many have legal representative

Have legal questions answered

What could be improved…* Desire an automated process that supports a seamless sharing of clinical data for

entire encounter (IP and OP) AND allows for proper separation of charges required

to meet CAH billing requirements.

Considerations/Options:

* Keep one clinical encounter (FIN #) and separate out charges on back end

* 2 separate processes to split in real time (FINS) - make cerner pull-over seamless

* QDA while patient stil l in ED? Carry over orders?

* Keep all clinical documentation on one FIN # but have A/B designation that

indicates there is second FIN for charges

Cost of Rework - Annual

1) Significant rework has to be performed after the patient is discharged (includes:

Util ization Review, PAS/registration, Revenue Management, HIM, Coding,

transcription, ECS Physicians)

2) Currently 2 "lists" are created to ensure no CAH patient is missed for "rework"

3) Potential confusion when requesting HIM records (two FINS - same encounter)

4) Must separate clinical information into 2 Fins (HIM)

5) Rework which separates everything out at the back end (after D/C)

Current State Metrics Current VALUE

Extra time for "rework" process (minutes/patient) 92 min.

Estimated annual cost of "rework" process $50,784

2. CURRENT STATE

Trigger CompletedDecision to admit patient Bill(s) submitted to Payor

Gerber Hospital, Primary

Medicare/MC-Advantage pts.ED ==> IP OP SURG ==> IP

OBS ==> IP ED ==> OBS ==> IP

Reed City / Kelsy Hospitals, All other payors or

Secondary Medicare/Adv.

Gift of Life / Hospice patients

12

/30

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8/2

6/2

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1. BUSINESS CASE 4. GAP ANALYSIS 7. COMPLETION PLAN The implementation of Critical Access Hospital (CAH) designation on July 1, 2014

has resulted in significant rework processes to assure patient safety and meet the

CAH requirements of two separate bil ls (in-patient and out-patient) for the

Medicare/Medicare Advantage patients.

The initial "go live" plan presented potential risk and safety issues for patients

transfering from OP status to IP status and the decision was made to create a

second FIN, after patient discharge, so that the IP services and OP services could

be bil led separately, until a better solution/process could be developed.

Action Item-What

1. Each group listed on Rework Flow Diagram

to develop their own standard work

11/1/2014

Adam

Clifford, Barb W

ainright, Brandy Carrier, Chris Johnson, D

an Powell,

Deidre W

eller, Jan Stone, Janna Varner, Jessica Shea

rer, Kim B

arricklow, Kristi

Hew

itt, Laura Schreiber, Mary D

eLaat (Lil), Maryann Juss, M

eleah M

ariani,

Paula Fitzgerald, Peg M

uckey, Nicki R

eed

TEAM


If We…

A3 Description: Gerber CAH Registration RIE Exec. Sponsor(s): Gerber Hospital 2

Steering

Committee:N/A

A3 Owner(s):Brian Vander Weele / Jenna Varner

Sensei:n/a

PI Facilitator(s):

Deidre Weller

Barb Wainright; Deidre Weller

Each

subgrouBrandy

Deidre

Deidre /

Chris

Barb /

Deidre

Barb /

Deidre

Then We Expect… * The hope that splitting the CAH patient's bil l into 2 FINs in real time, to eliminate

the current 92 min. of rework after patient discharge, resulted in shifting the rework

from support staff to the physicians and clinical staff. It also resulted in

unacceptable risk for patient safety, because the 2 FINs could not be linked together

as one encounter, and therefore some critical information might be missed or double

charges would be dropped for carry over products such as IV's, blood, etc. The team

then focused on improving the rework and resulted in significant reduction of time

and cost.

12/1/2014

1/31/2015

2/1/2015

2. Create and get approval on "special note:

See FIN # for ED/outpatient related

3. CreateCAH policy (based on using 2 FINs

and all documentation Located in IP FIN w/

4. Create Decision Document and

communicat to other CAH hospitals the

5. Schedule RIE workgroup follow-up meeting

to finalize Std. Work and spread to other CAH

hosp.6. Continue to pursue system and technology

solutions to identified barriers to implement

7. Share RIE work with CMS and Cerner

Extra time for "rework"

(Minutes/patient case)

Quality,

Safety, Cost, Delivery, G

rowth, Peo

ple

No. If We . . . Then We Expect . . .

1Use the QDA model Future State process to split

the inpatient from outpatient charges for CAH

to eliminate the current rework on the back

end

2

Can determine that Medicare (CAH) patient is

now an inpatient after ED discharge and on the

unit

to minimize documentation confusion- creates a clean break and handoff in time

- minimize other identified issues (pink stickies)

3Have attending physician write orders when

patient is on the unit

to eliminate planned state orders and

eliminate need for ED to chart on an IP FIN #

4Create second tab for patients chart to pull into

after admit orders are entered

better opportunity for previous clinicians to

access the old FIN #

5Can modify I-View for CAH hosptials to include

(link to) previous encounter

to eliminate the need to leave current view

and search for previous encounter

6Can create a seamless process for carry over

products (blood, etc.) and med ordersto eliminate or reduce opportunity for errors

7Can modify MAR screen for CAH hospitals to

include previous encounter

to eliminate the need to leave current view

and search for previous encounter

8Have a process for non-onsite admitting

physicians to write orders when patient on unit

to be able to complete the implementation of

the QDA future state process

9

10

Split the encounter at the back end, BUT

keep all documentation with the inpatient FIN

using the "special referral note"

Significantly reduce and streamline the current

CAH rework process of splitting the encounter

• Engage front line staff in problem solving skills and actions

• Develop an “army of problem solvers”

• Structured and supported by training and network of “coaches”

• Focused on small problems and improvement opportunities

requiring about 1 hr/week and completing 1 A3 per month

• Elimination of labor waste to be reallocated for value-added work

• Eliminate the “pebbles in the shoe” type, annoying problems

• Support moving the departmental (value stream) and organizational

metrics, as displayed on visual management boards

• Develop Pareto Charts, Standard Work, data collection forms, etc.

Overview of Mercy Health’s A3 Deployment Plan

Generate simple A3s from Waste Walks / Observations

Perform a waste walk and

develop A3 for the most

prevalent of the 8 wastes

found (single A3s for each

waste type).

• Serves as excellent learning for

beginning A3 problem solvers

• Builds skills and confidence by

completing these types of A3s

• Builds teamwork with co-workers

by removing waste and daily

“frustrations”

Problem Solving – “Simple” A3

• Choose opportunities from Visual Management boards to

help move the organizational (or value stream) “dots.”

Focus on a metric that is not meeting

the goals or trending in the wrong

direction.

Drill down to understand why (ie.

Pareto, 5 Why’s, etc.).

Develop A3 to address the cause and

improve the metric.

Generate simple A3s from Rules in Use Analysis

• Where is standard work

missing?

• Where is standard work not

being followed or is

ineffective?

• Where are hand-offs

(connections) not working

well?

• How can these hand-offs be

improved?

• Where is flow being

interrupted?


TITLE: What to look for - Specific problem / theme What to ask - What is the problem being addressed? PROBLEM SOLVER: END DATE:

A3 Type:Have you engaged other s takeholders? Have you gone to gemba, observed and ta lked to the people doing the

work? How can your A3 coach help? COACH: START DATE:

What to look for - Factors causing the problem. Drill down on each fact. Ask why until addressing the cause which will prevent

the problem from reoccurring.

ISSUE: FUTURE STATE / TARGET CONDITION

BACKGROUND/MEASUREMENTWhat to look for - How often, how long, how big, how costly? Data, Data, Data. Statements of fact instead of assumption

What to ask - How big or important is this problem? What criteria are you using? How do you know? How can you measure the

extent of the problem?

CURRENT STATE CONDITION

COUNTERMEASURESWhat to look for - Set of countermeasures vs. a single solution. Linkage between countermeasures & root causes. Thoughtful

prioritization of countermeasures. Narrowed scope of countermeasures to test.

Possible Tools - Gap analysis, standard work, leader standard work, visual management, checklists.

WHY

WHY

What to ask - What patterns are present in the problem? What is the gap between where we are now and where we want to be? What

prevents us from achieving our "Future State" or "Target Condition"? Make it safe to say I don't know, then explore answers at the gemba.

What to look for - Actual or projected measures of A3 benefits. Dollars or hours

saved per year. Hard dollar savings or hard dollar revenue enhancement

FOLLOWUP

Is the analysis deep enough? Did you Identify the root cause? What is the logic between symptoms and root cause?

COST COST BENEFIT / WASTE RECOGNITION

What to look for - Compelling statement from the customer perspective. Narrow and focused descriptions. What to ask - What

customer is impacted by the problem and how? What is the process under investigation? What is the waste? Where is it

happening?

What to look for - Process description. "Reality check" what is happening not what is suppose to be happening. Look to define

the process as it is currently being performed, do not try to solve the problem. Facts to support problem identification. Narrowed

scope of problems to investigate.

What to ask - How do you know? Do you know how the process actually works? How do you know how well the process

is working? What is the standard? Is the standard being met? How have you engaged others? What, where, when is the problem?

Possible Tools - Process map, flow chart, sketch, spaghetti map, floor plan, bar graph, pareto chart.

What to look for - Metrics of success. Copy of completed A3 submitted to process excellence for final review and reporting.

What to ask - How do you know the plan will be successful? What visual management is in place to monitor the success?

Who are you coaching to solve the additional problems you encountered? Can this A3 be translated in another work area?

Possible Tools - 5 Whys, fishbone diagram, pareto chart What to look for - Identify any costs of

countermeasures.

What to look for - Which problem will be addressed? Clear target with timeline.

What to ask - What does the Future State / Target Condition look like?

Possible Tools - Process map, flow chart, spaghetti map, floor plan, bar graph, line graph.

Possible Tools - Action plan w/ single point accountability, Gantt chart, checklists

TEST

WHY

WHY

WHY

PROBLEM ANALYSIS

What to look for - Deliverables to implement the countermeasures. Timelines which align with goals. Responsibility assigned for

What to look for - Small test of change. In a controlled environment. Process Measures

What to ask - Where are you testing your countermeasures? How are you measuring the success of your countermeasures?

ACTION / IMPLEMENTATION PLAN

What to ask - How did you arrive at your countermeasure? How did you engage others (front line staff) in developing

countermeasures? How did you prioritize the most important countermeasures? What is your plan for testing these

countermeasures? How much of the gap will be removed by the countermeasure?

each deliverable. Outcome for each deliverable.

What to ask - What is going well? What is your biggest problem? How have you addressed barriers? What could go wrong?

what who when outcome


COACH:

PROBLEM SOLVER:

A3 Type:

TITLE:

COST BENEFIT / WASTE RECOGNITION

WHY

WHY


ISSUE:

BACKGROUND/MEASUREMENT


FUTURE STATE / TARGET CONDITION

PROBLEM ANALYSIS


COUNTERMEASURES

TEST

COST

FOLLOWUP

WHY

START DATE:

END DATE:

WHY

WHY

Left Side of A3 Form

Issue

• What is not working, how does it affect the

patient?

Background

• What’s the history / how is it broken?

• Include data

Current Condition

• Use graphics to tell the story of the issue

• Highlight a few wastes or problem areas

with storm clouds

• Observe the process first hand

Problem Analysis

• Why is this happening?

• Use 5 Whys, Cause & Effect Diagram

• Solve the root cause, not the symptom


COACH:

PROBLEM SOLVER:

A3 Type:

TITLE:


WHY

WHY


ISSUE:




PROBLEM ANALYSIS


COUNTERMEASURES

TEST

COST

FOLLOWUP

WHY

START DATE:

END DATE:

WHY

WHY

Right Side of A3 Form

Target Condition

• Graphically depict the improved situation

• Highlight improved elements with clouds

Countermeasures

• What changes can be made to address the

root causes, move closer to the ideal state?

Test

• How will you test and prove the results?

Implementation Plan

• How will countermeasures be implemented?

• Include how improvements can be spread

Follow Up

• How has the improvement been sustained?

• Summarize results 30-60-90 day post impl.

Problem Solving – “Simple” A3 COACH:

PROBLEM SOLVER:

A3 Type:

TITLE:


WHY

WHY


ISSUE:




PROBLEM ANALYSIS


COUNTERMEASURES

TEST

COST

FOLLOWUP

WHY

START DATE:

END DATE:

WHY

WHY

Reference Manual missing at critical moments delaying response

to customers.

Identify all manuals Tom Smith 7/30/15

Place tape across Tom 7/30/15

Manuals as shown above

Create check sheet Susan 8/1/15

To track missing manuals

Review Results Team 9/1/15 Why? Reference Manual not at Nurses Station

Why? Manual not returned after being used

Why? Staff didn’t realize they hadn’t returned it

Why? No visual indicator it was missing from the desk

Identify all critical Reference Manuals

that should stay at the Nurses Station

with visual indicator when manuals

are missing, so that they can be

located prior to being needed.

3-4 times each week, during the past month, the list of on-call providers

has not been available at the Nurses Station, resulting in call-backs or

waiting to find the Reference Manual.

Track the number of times the Manual is missing when needed for

the next month

Problem Solving – Characterization A3

• When there are multiple problems noted in Current State, or

multiple causes detected in the Problem Analysis, this A3 can

become the “parent A3” and generate multiple “child A3s”.

• These A3s typically will not result in any actions or implementation

plan, except to identify and prioritize a strategic set of integrated

A3s. (Pareto Analysis, multiple causes, etc.).

Initial

A3

A3-1 A3-2 A3-3

A3 thinking is scalable – break

problems down into component

parts – but don’t go too far - sub-

optimization of the whole (system).

Cascading A3s

Problem Solving – Characterization A3

COUNTERMEASURES


What is not working? - Compelling statement from the patients perspective

* Include the customer affected, the process under study and the waste being created.

* Be factual.

* Do not point fingers or blame. Focus on PROCESS not PEOPLE


What is the history and how broken is it?

* Data, Data, Data - How Often? How long? How costly? How big?

* State how the issue is connected to strategy. Department and organizational ex. HCAPS

* Indicate who discovered the situation and when.


How does it look now?

* Graphical or Pictorial representation

* Process map or Flow Chart

COUNTERMEASURES

WHY ETC

Problem #1 - State problem

A3 - 3

A3 - 4

* At the end of the root cause analysis, ask if the root cause is clear and actionable.

FOLLOWUP

TIP: By working backwards from the last "why" to the first, inserting the word "caused" between each why, this should

create a "logical" progression. Good rule of thumb is you have a legitimate root cause analysis if the statement makes

sense is clear and actionable.

WHY

Identify any substantial costs of countermeasure. Are strategic benefits documented? (e.g. patient satisfaction, worker

engagement, safety, LOS etc.)

* Use the 5-Whys technique to find root cause of problems or wastes identified above. Ask "why" or "what caused that" as

you move down the chain.

* If the problem analysis will not fit in the space provided, the issue is bigger than an A3. Multiple A3s may need to be

performed on pieces of the problem.

WHY

WHY ETC

WHY ETC

outcome


* Floor Plan

* Graphic Data

* Use graphics to tell the story of the current condition: Process maps, data graphs, spaghetti diagrams etc. TEST

PROBLEM ANALYSIS - A Characterization A3 will typically include a rigorous analysis /

assessment of the various problems and A3s that will be needed to impact strategic

ACTION / IMPLEMENTATION PLAN - List the prioritized set of A3s to be completed to impact

strategic performance

Do NOT use this area with a Characterization A3

A3 - 2

* Give complete view of the condition and not a high level summary

* Highlight significant wastes or rules in use breakdowns (1 Activities, 2 Connections, 3 Pathways, 4 Improvement) with storm clouds.

* Label graphics so that anyone with some knowledge of the area under study can understand.

A3 - 1

what who when

Note: The standard, simple A3 form is not ideal for

characterization, but can be used if necessary.

Not meeting our Patient’s expectations as we had planned for 2015

A3-1 Call Light Response Jill 8/12/15

A3-2 Physician Response John 8/15/15

A3-3 Family Welcomed Bill 8/30/15 A review of the entire Patient Satisfaction Report indicated the following

opportunities that make up the Overall Satisfaction Score. The hospital

scored the lowest in the following categories/specific questions on the

survey:

1. Call lights answered in a timely manner = 3.8 (out of 5.0)

2. Physician answering questions or concerns = 4.1

3. Family members felt welcomed and part of the process = 4.1

Patient Satisfaction score is below 90, and the 2015 goal is 95 or

above.

Patient Satisfaction overall score does not meet the 2015 goal .

Problem Solving – Compliance A3

• Targets problems where the solution is known, there is often

standard work defined, but compliance with standard work is poor.

• It can also address prior improvement efforts where gains were

realized, but not sustained.

• The compliance A3 often applies one of these tools: Change

Management, Stakeholder Analysis, Barrier Analysis, auditing tools

and strategies, etc.

• Examples include: Standard work implemented to improve ED

throughput, but not sustained; staff roles modified to improve

efficiency but no accountability led to a deterioration in the

improvements.

Problem Solving – Compliance A3

FOLLOWUP

Metrics of success. Copy of completed A3 submitted to process excellence for final review and reporting.

COST COST BENEFIT / WASTE RECOGNITIONIdentify any substantial costs of countermeasure. Are strategic benefits documented? (e.g. patient satisfaction, worker


Deliverables to implement the countermeasures. Timelines which align with goals. Responsibility assigned for


What is going well? What is your biggest problem? How have you addressed barriers? What could go wrong?

How do you know the plan will be successful? What visual management is in place to monitor the success?


ETC

1) Stakeholder Analysis 2) Control System Tools

Action #3

Action #4

PROBLEM ANALYSIS - Change Management Action #1

Action #2

* Highlight significant wastes or rules in use breakdowns (1 Activities, 2 Connections, 3 Pathways, 4 Improvement) with storm clouds.

* Label graphics so that anyone with some knowledge of the area under study can understand. ACTION / IMPLEMENTATION PLAN - May consist mainly of actions to remove barriers to staff

compliance* Give complete view of the condition and not a high level summary


* Use graphics to tell the story of the current condition: Process maps, data graphs, spaghetti diagrams etc. TEST


* Floor Plan

* Graphic Data 2) Reporting and feedback of individual worker performance may facilitate coaching.

1) Facilitate leadership coaching to task leadership with further removing barriers to compliance and coaching staff toward

compliance.





* Graphical or Pictorial representation COUNTERMEASURES - 1) Integrating with lean management system 2) Control System Tools



* Include the customer affected, the process under study and the waste being created.

* Be factual.

* Do not point fingers or blame. Focus on PROCESS not PEOPLE


What is the history and how broken is it?

* Data, Data, Data - How Often? How long? How costly? How big?

Elevator hydraulic fluid mistaken for surgical cleaning detergent.

In Nov-Dec, elevator hydraulic fluid was used as detergent in one step of

a multi-step cleaning & sterilization process of surgical tools.

Investigation revealed the following:

Contract elevator maintenance employees drained the fluid from

elevators into containers that had held surgical detergent. The

containers were not properly re-labeled or stored securely. The

containers were restocked and shipped as detergent back to the

hospital.

Why? Surgical containers at hospital contained hydraulic fluid

Why? Containers not properly labeled with what they contained

Why? Maint. Workers did not follow procedure in re-labeling

the containers with hydraulic fluid since they used

detergent containers instead.

1. Revise procedure to never use an empty container that is meant for

another product when servicing the elevators

2. Provide empty containers with appropriate labels for all elevator

service calls

3. Perform Stakeholder Analysis to determine other potential safety

issues regarding elevator maintenance and put measures in place

to address any issues discovered

Implement an

Audit process

for Surgical

detergent

products.

Problem Solving – Prototype A3

• These A3s address a problem in one work area, typically a

strategic problem, that is occurring in numerous work areas.

• It is among the highest impact A3s because it will serve as a

springboard for multiple similar A3s that will have a high likelihood

of success.

• The Prototype A3 requires additional problem solving time due to

required extra rigor needed because it will be repeated multiple

times, with slight modifications, in different work areas.

• The “repeating” A3s are Translation A3s – as described in the next

section.

• Examples include: Noise issues on one inpatient unit; delay

issues in one urgent care location.

Problem Solving – Prototype A3

ISSUE: FUTURE STATE / TARGET CONDITION - Sketch, graph, process map, floor plan


* Include the customer affected, the process under study and the waste being created. - What customer is impacted by the problem & how?

* Be factual. What is the waste?

* Do not point fingers or blame. Focus on PROCESS not PEOPLE. - What is the process under investigation?


What is the history and how broken is it? How big is the problem? What criteria are you using? How do you know?

* Data, Data, Data - How Often? How long? How costly? How big? - How can you measure the extent of the problem

Set of countermeasures vs. a single solution. Linkage between countermeasures & root causes. Thoughtful

Is the standard being met?

prioritization of countermeasures. Narrowed scope of countermeasures to test.


* Floor Plan

* Graphic DataDo you know how the process actually works?





* Bar Graph, Pie Chart, Sketch COUNTERMEASURES - Standard work, leadership standard work, checklists

* Use graphics to tell the story of the current condition: Process maps, data graphs, spaghetti diagrams etc. TEST* Highlight significant wastes or rules in use breakdowns (1 Activities, 2 Connections, 3 Pathways, 4 Improvement) with storm clouds.Small test of change. In a controlled environment. Measuring process

* Label graphics so that anyone with some knowledge of the area under study can understand.

* Give complete view of the condition and not a high level summary ACTION / IMPLEMENTATION PLAN

How have you engaged others?

How did you arrive at your countermeasure? How did you engage others (front line staff) in developing

What Where When is the problem?

countermeasures? How did you prioritize the most important countermeasures? What is your plan for testing these

countermeasures? How much of the gap will be removed by the countermeasure?Do you know how wel l the process i s working?

What is the standard?



PROBLEM ANALYSIS - A Prototype A3 requires additional problem solving time due to the

required extra rigor. Deliverables to implement the countermeasures. Timelines which align with goals. Responsibility assigned for


What is going well? What is your biggest problem? How have you addressed barriers? What could go wrong?

* At the end of the root cause analysis, ask if the root cause is clear and actionable. FOLLOWUP Can this A3 be translated in another work area with a similar problem? If so note in fallow up section.

* If the problem analysis will not fit in the space provided, the issue is bigger than an A3. Multiple A3s may need to be

performed on pieces of the problem.


TIP: By working backwards from the last "why" to the first, inserting the word "caused" between each why, this should

create a "logical" progression. Good rule of thumb is you have a legitimate root cause analysis if the statement makes

sense is clear and actionable.

Where are you testing your countermeasures? How are you measuring the success of your countermeasures?

WHY

WHY

* Use the 5-Whys technique to find root cause of problems or wastes identified above. Ask "why" or "what caused that" as you move down

the chain. - What is the gap between where we are now and where we want to be (target)? - What prevents us from achieving our target?




WHY

WHY

WHY

Identify any substantial costs of countermeasure. Are strategic benefits documented? (e.g. patient satisfaction, worker

engagement, safety, LOS etc.)* Make it safe to say I don't know, then how to find out back at the Gemba. Did you identify the root cause? What is the logic between symptom and root cause?

FishbonePareto

Problem Solving – Translation A3

• These A3s are an adaption of a highly successful, rigorously

documented Prototype A3.

• The Translation A3s typically require comparatively little problem

solver time.

• Use the Prototype A3 as a blueprint for the Translation A3.

• If a section of the Translation A3 is identical to the Prototype A3, enter

“see Prototype A3” in the section on the form.

• If there are slight modifications, then only enter those on the form.

• If the Translation A3 root causes are validated to be the same, then

countermeasures will likely be the same. If different, then

countermeasures will probably be different as well.

Problem Solving – Translation A3

A3 Type:Translation A3 - These A3s are an adaption of a highly successful, rigorously documented prototype A3. The

Translation A3 is typically high impact and high feasibil ity, with a high success rate. Translation A3s typically

require comparatively l ittle problem solver time.

COACH: Coaches Name Here START DATE:

If there are slight modifications in the Translation A3 enter only those modifications on the Translation A3


COUNTERMEASURES - Standard work, leadership standard work, checklists


If a section of the translation A3 is identical to the Prototype A3, simply enter…

Est. Start Date

TITLE: PROBLEM SOLVER: Problem Solvers Name Here END DATE: Est. Complete Date




"See Prototype A3 (Name of Prototype A3)"



TEST

"See Prototype A3 (Name of Prototype A3)"If there are slight modifications in the Translation A3 enter only those modifications on the Translation A3




WHY


PROBLEM ANALYSIS - Pay special attention to customizing the Root Cause Analysis of the

Translation A3 If a section of the translation A3 is identical to the Prototype A3, simply enter…

WHY

WHY

FOLLOWUP Can this A3 be translated in another work area with a similar problem? If so note in fallow up section.



If the Translation A3 Root Causes are different from the Prototype

A3, then the countermeasures (solutions) will probably be

different than the Prototype A3

COST COST BENEFIT / WASTE RECOGNITIONIdentify any substantial costs of countermeasure. Are strategic benefits documented? (e.g. patient satisfaction, worker








WHY

WHY

Problem Solving – Best Practice A3

• These A3s are applied to assess a practice that has been

successful in another setting and is under consideration for this

setting.

• The practice may come from literature, IHI or other websites, or

similar departments or A3s within the organization.

• The key to success is to complete the left side of the A3

independent of the best practice countermeasure and without

prejudice toward the best practice.

• If best practice addresses the root cause for your setting complete

the right side of the A3 using the best practice, if not complete the

right side independent of the best practice.

Problem Solving – Best Practice A3

Est. Start Date


A3 Type:Best Practice A3 - These A3s are applied to assess a practice that has been successful in another setting and is

under consideration for this setting. The practice may come from literature, IHI or other websites, or similar

departments or A3s within the organization.



COUNTERMEASURES - Standard work, leadership standard work, checklists


If best practice addresses the root cause for your setting complete the right side of the A3 using the best practice, if not

complete the right side independent of the best practice.


The key to success is to complete the left side of the A3 independent of the best practice countermeasure and

without prejudice toward the best practice

TEST

PROBLEM ANALYSIS -



By completing a non-prejudice left hand side, the root cause of your problem in your setting is identified and validated

as feasible, with worker collaboration

WHY

WHY

WHY

WHY

WHY

if the best practice addresses the identified root cause for your setting, this indicates that the best practice may be an

effective countermeasure. If the best practice does not address the identified root cause for your setting, this indicates

that the best practice is not indicated as a countermeasure in your setting.

FOLLOWUP


Problem Solving – Design A3

• The Design A3 is applied to design a new process or service

capability.

• The Design A3 applies the A3 process to apply the scientific

method, Plan-Do-Check-Act, to design a new process or service

capability.

• The desired outcome is commencement of a new product or

service capability.

• Process or standard work are designed instead of being improved.

• Examples include: Designing a new method of meal delivery to

post cath lab patients; creating a process control board to monitor

and improve OR turn-around times, etc.

Problem Solving – Design A3

Est. Start Date


A3 Type:Design A3 - The Design A3 is applied to design a new process or service capability.


COUNTERMEASURES - Gap AnalysisGap Analysis


The Design A3 applies the A3 process to apply the scientific method, Plan-Do-Check-Act, to design a new process or

service capability. The desired outcome is commencement of a new product or service capability. Process or

standard work are designed instead of being improved.

Future State being designed.



Determine improvement strategy - RIE, Multiple A3s (Characterization A3)

Test new process


TEST


PROBLEM ANALYSIS -

WHY

WHY

WHY

WHY

WHY

FOLLOWUP


Note: The standard, simple A3 form is not ideal for

Design A3, but can be used if no other option available.

A3 - Example

• Watch the video.

• Take note of the wastes

involved in making simple

toast.

• We’ll develop a problem

solving A3 from what you

observe in this process.

Classroom Exercise – Problem Solving A3

• Used to develop a 12-18 month plan for improvements

within a specific value stream

• Uses the Structure of the A3 (9 box approach) to

determine the Agenda

• A3 thinking is foundational to all the other elements

involved in Value Stream Analysis (Standard Work, Managing for

Daily Improvement, Leadership Standard Work, Audits, Golden Tickets, etc.)

• Is more strategic in nature, since the VSA is more of a

planning workshop – VSA itself doesn’t result in changes

to the processes within a value stream, but yields a Plan

to bring about the desired changes and improvements

Value Stream Analysis A3

VSA Event – A3 Format

• VSA & Introductory Lean Training

• Box 1: Business Case of Department

• Box 2: Current State Analysis (or review)

• Ideal State (Right Brain / Left Brain Activity)

• Box 3: Future State Development of new Value Stream

• Box 4: Gap Analysis – what is missing current to future?

• Box 5: Hypothesis -Brainstorm how to address Gaps

• Box 6: Plan Experiments - Actions to achieve Future State

• Box 7: Action Plan: RIE’s / A3 Projects / Just-Do-Its / JSI

• Box 8: Metrics to Monitor – Metrics for Department

• Box 9: Lessons Learned

Unique Elements of a VSA A3

Box 1: Business Case

• more rationale than problem definition

Box 2: Current State Patient Testimonials, Waste Walk

Box 3: Future State Goals, Vision

Box 4: Gap Analysis

• Affinity Diagram of gaps, improvement ideas, identified waste, etc.

Box 5: Hypothesis

If We….

(Insert improvement ideas and

suggestions here)

Then We Expect…

(Insert expected outcomes, improvements, and benefits

that will result from the suggested improvement ideas)

Unique Elements of a VSA A3

Box 6: Experiments

• Instead of experiments to try, usually a group of A3’s (boxes 1-3

completed), List of Projects, and some Just-Do-Its


• 12-18 month calendar of RIEs, Projects and Just-Do-Its


• 12-18 months of tracking the overall Value Stream Metrics (driver

and watch metrics) – not the typical 30-60-90 day tracking

Example – VSA A3

Event #: 1 Revision: 5

1. BUSINESS CASE

May 2013

PI Coach(es):

Description:

Steering Committee:

Sponsor(s):

Process Owner(s):

Site/Location:

Sensei:

Event D

ate:

May 8

, 9 an

d 1

0

2. CURRENT STATE

Currently 3 rooms are dedicated to Electrophysiology procedures and 5

rooms are dedicated to Coronary Catheterization procedures, one

additional room is offline and one room is located at HDVCH (10 total

rooms). It is believed that it is cost prohibited to outfit each room to

perform both EP and Coronary procedures. EP cases scheduled for 5

hrs/ea., coronary 60-75 min/ea.

People: People involved inVSA improvement = 0

Quality & Safety: Optimal Site Access = xyz / Door-to-Balloon time = 55

min.

Patient Experience: First case on time starts = 25% / All case starts = n/a

/ Same Day Discharges = 28% of eligible

Growth: Monthly = 183 cases (EP) and = 550 cases (Coronary/PV)

Financial Stewardship: Room Utilization = 60% (coronary) and 63% (EP) /

Trigger:

Physician referral

4. GAP ANALYSIS

5. HYPOTHESIS

7. COMPLETION PLAN

8. CONFIRMED STATE

Need to adjust the capacity of Interventional Cardiology Services to respond to

the projected demand growth for EP procedures (5% in FY13) and the volume

decrease in Coronary Procedures (6% experienced in FY12 expected to remain

flat in FY13).

To effectively achieve this we must:

1. Improve our util ization of current Cath Labs from 74% to 80%. See Note 1.

2. Evaluate need to redistribute block time between EP and Coronary.

3. Improve productivity in the Cath Lab, patient, staff and physician satisfaction

by achieving first case on time starts at 100%.Note 1: Calculation = fi rs t pt in, las t pt out, anything less than (2) hrs not counted.In Scope: Coronary Cath

Procedures including

Done:

Receive Payment for

services

3. FUTURE STATE

Improve coronary effeciency to free up two/three 10 hour blocks of

time to dedicate to EP procedures per week. Schedule is smoothed to

better utilize staff and facilities.

Better cross training of staff to move from Cath to EP procedures.

People: People involved in VSA improvement = 30

Quality & Safety: Optimal Site Access - tbd / Door to Balloon Time = 55

min.

Patient Experience: First Case On Time Start = 90% / All cases = 50% /

Same Day Discharges = 30%

Growth: FY13 EP 5% increase Volume = 193/month FY13 Cath Volume

remains flat = 550/month

Financial Stewardship: Room Utilization for EP and Coronary labs = 70%.

Access Site set-up scrap = $110/week. Potential cost avoidance of $1-2

M for not revamping cath lab #4.

9. LESSONS LEARNED

Out of Scope:

EP and HDVCH Cath Lab

6. EXPERIMENTS

1

2

3

4

5

6

7

8

9

RIE's:1) Implement MDI access site / start times2) "Set-up" flow cell3) Scheduling Guidelines -Block time rules / Physician Request4) Schedule the Case Pre-encounter work PPP/Auth5) "Patient Prep" flow cell / "Patient Check-In" flow cell6) "Procedure" flow cell7) "Room turnaround" flow cell8) "Patient Recovery" flow cell

Activity June 4, 2012 July 9, 2012 August 6, 2012 Sept. 10, 2012 Oct. 15, 2012 Nov. 12, 2012 Dec. 10, 2012 January, 2013 February, 2013 March, 2013 April, 2013 May, 2013

Pro

ject

RIEs

Do-

Its

Stop-

Its

Implement MDI access site w/start

times

Set up flow cell

Scheduling guidelines -Block time

rules

Physician request

Anne & TiffanieCommunication

PlanShare the work

we have done -Get the team excited about

the work

June 1

PatriceDevelop

Steering Committee

June 1

Laura

Reduce P/R

charge phone call

from registration

RebeccaPatient tracking

for family

volunteer groupJuly 1

KimCross-training

between

service lines EP/Coronary

Start measuring

room

utilization accurately

Anne/KimTransport dept.

procedure

tracking systemJuly 1

Stop patient transport electronic

dispatch system

Non-RIEMDI

assessment

BridgetteConnect with

outside offices

September 30

Cath Lab VS A3 assessment

Steering

Committee

Schedule the case

Pre-encounter

workPPP/Auth/

Patient PrepFlow cell

Patient Check-In

Flow Cell

MDI Assessment

Cath LabVS A3

Assessment

Cath Lab "Procedure"

Flow cell

Documentation that reflects attempted

procedures and

failed devices/supplies

(Measure first)Room turn-over

Flow cell

charge capture

Patient Recovery Flow

cell

MDI Assessment

Cath LabVS A3

Assessment

If we… Then we expect…

Centralize communication Track consent, lab status Add specifics, re: procedure

Transparency

Less waste, phone call, etc.

Better informed staff/families

Improve throughput

Decrease lab turnover time

Improve start times

Decentralize Faster availability

Decrease wait time

Can do other tasks in addition to transport

We can prioritize tasks

Eliminate patient stop in registration Decrease wait time

Free up waiting room space

Decrease patient frustration

Eliminates double verification and increases quality improvement

Free up a FTE

Complete med rec only in prep/ recovery Eliminate two phone calls and errors

Improve accuracy because we have actual medications to look at

Complete our own labs Decrease wait time

Faster results

More QAs to do

Have a designated area for charts Charts are easier to find

Can we eliminate the paper chart?

Could use one system Are not working in between programs

Wouldn’t double document

Save waste and time

Knew access ahead of time Less waste of time and equipment

Simplified Less fallout

Changed culture to return equipment when done using it Less time running around finding it

If we… Then we expect…

Standardize workflow Completed in timely manner

Change all-around expectation Improved throughput

Increase capacity

Standardize rotation Increased efficiency

Less unknown

Have prior data available as a standard Physicians to be informed/ prepared

Improves process and quality

Captured it Increased capture

Standardize workflow of room turnover (physician and staff) order entry/Provation

Increase consistency

Decrease ambiguity

Broke the room for lunch Clinical consistency

Clarify order and standardize meds and labs (e.g., creatine/INR)

Less rework day of procedure

Quicker set-up time

Improved communication for bed requests (SWAN)

Less calls regarding lab values and meds held

Consolidate to one patient contact within one team (centralized)

Standardize scheduling (rules/ guidelines)

Increase patient experience

Increase quality (demo/ins)

Increase safety (med list)

Reduce expense due to over-processing

Reduce process lead time

Reduce capital expense

Better utilization of lab time (pt/staff)

Less delays for patient and staff

Check in patient in prep room Eliminate patient waiting in lobby

Increase patient satisfaction

Reduce lead time

Reduce defects by facilitating lab draws

• Used to determine improvements for a specific portion of

the value stream or problem chosen

• Uses the Structure of the A3 (9 box approach) to

determine the Agenda for the event week

• Focused on training staff to design, test and implement

improvements (results) by the end of the event (week)

• Is more tactical in nature, focusing on problem solving

and improvement opportunities

Kaizen (Rapid Improvement - RIE) A3

A facilitated, highly structured, multi-day, team activity dedicated

making specific improvements within a value stream

Rapid Improvement (Kaizen) Event – A3 Format

• RIE & Introductory Lean Training

• Box 1: Business Case for chosen Event

• Box 2: Current State Analysis (or review)

• Box 3: Future State Target

• Box 4: Gap Analysis – Root Cause Analysis, Cause & Effect

• Box 5: Hypothesis -Brainstorm potential solutions or improvement ideas

• Box 6: Plan Experiments - Actions to achieve Future State, solve the

problem

• Box 7: Action Plan

• Box 8: Metrics to Monitor – Metrics for Department

• Box 9: Lessons Learned

Unique Elements of an RIE A3

Box 1: Business Case

• more rationale than problem definition

Box 3: Future State

• goals, vision, Future State Gemba Walk

Box 4: Gap Analysis

• Affinity Diagram of gaps, improvement ideas, identified waste, etc.

Box 5: Hypothesis

If We….

(Insert improvement ideas,

suggestions, and potential

solutions here)

Then We Expect…

(Insert expected outcomes, improvements,

and benefits that will result from the

suggested improvement ideas or solutions)

Unique Elements of an RIE A3

Box 6: Experiments

• Actually test identified solutions and improvement ideas


• List and track remaining action items that couldn’t be completed

within the RIE


• Track the outcomes / improvements for 30-60-90 days post

implementation

Example – RIE A3


Who When Status

9/10



6. EXPERIMENTS DO

Hackley Campus


TRU

E NO

RTH

METR

ICS

Door- discharge: % of patients meeting 45 minute goal

(Feb)13.30%

Door- doc: % of

patients meeting 15

minute goal

52% 80% 78%

Door- doc: % of

patients meeting 45

minute goal


Patient satisfaction during pilot of new process

compared to current state

A process for low acuity patients similar to other best practices.

Pe

op

le C

en

tere

d, Q

uality &

Safety,

Co

lleague, P

op

ulatio

n H

ealth

, Finan

cial

Stew

ardsh

ip

What went well…

Door- doc: % of patients meeting 15 minute goal (Feb) 52%


13.30% 75%

7/1

6/2

01

5

Cu

rren

t

Re

vision

Date

:

Door to doc time is increasing

No process for low acuity patients

Throughput is a top priority for department


CompletedPatient enters Hackley

Emergency department

Patient discharge

5/18Nursing & Tech in-service

Physician & Extender in-service

KICK OFF DATE!


Furniture for waiting rooms after 90 day

review

See Tea

m Photo

TEAM


Low acuity patients only (ESI

level 4 &5)

Vertica l unit

High acuity patients only (ESI level 1,2,&3)


Current UOM

Trigger


A3 Description: Hackley Fast Track Design Physician Champion

See Implemenation Plan for details

Action Item-What

133.1

Exec. Sponsor(s): A3 Owner(s): PEx: Team Leader:

4/2

/20

15

Cre

ation

Date

:

1. BUSINESS CASE PLAN 4. GAP ANALYSIS PLAN 7. COMPLETION PLAN DOResearch shows that the emergency department can work extermely well, but if

there is a significantly long wait to see the physician, it is almost impossible to

please your patients and increase patient satisfaction- The Definitive Guide to ED

Operational Imrovement by Jody Crane, MD & Chuck Noon.

The Hackley ED does not have a seperate process flow for low acuity patients.

There are serveral best practices that have proven a significant reduction in wait

time and increase in patient satisfaction through implemenation of a low acuity

patient flow process.

Eliminate current state barriers

identified during RIE

Increase patient satisfaction

Decrease overall length of stay

Decrease LBE rate

5/11

6/1

Goal for relocations

PLAN

Staffing model

Process for Vertical Unit

Equipment needs

Resources to support rapid turnover

If We… Then We Expect… See separate data analysis

Implement a Fast Track process for

low acuity patients….

5/15

25%

Highlights:

Door- doc: % of patients meeting 15 minute goal %

Door- discharge: % of patients meeting 45 minute goal %

Practically Speaking . . .

My car has a flat tire…what should I do? Just change it!

What if it’s the 3rd time this month? Simple PS A3

What if I decide it’s time to buy a new car? Strategy A3

• Work as a team at your table.

• Choose a problem from the Group Exercise packet at

your table.

• Determine the scope of the problem solving effort

needed (VSA, RIE, Facilitated A3 Problem Solving workshop or

simple problem-solving A3) and generate an A3.

• Use either of the A3 “simple” problem solving formats

or the 9 box A3.

• 15 minutes to complete the A3, 5 Minute Debrief.

Group Exercise – Problem Solving A3

Creative Use of A3’s

• Plan and Conduct a Quality Summit

• Personal Development

Planning and Conducting a Quality “Summit” (VTE)

• Utilize A3 Thinking and the format of the 9 box A3 to Plan and

Conduct the multi-day summit.

Box 2: Current State:

• Review of current hospital metrics/dashboard regarding VTE

measures

• Review of current patient stories & case studies

• Review of anticoagulant medications on formulary, including

indications, risks and safety practices

• Breakout groups map current state workflows for various topics

related to VTE

Planning and Conducting a Quality “Summit”

Box 3: Future State:

• Keynote speaker on VTE prevention, current best practices

• Demonstration of proposed VTE Advisor software tool in EMR

• Breakout groups review specialty-specific evidence around VTE

prophylaxis and identified best practices, and develop future state

improvement ideas

Box 4: Gap Analysis:

• Breakout groups identified gaps between current practices and

evidence-based, best practices, and developed action plans

Planning and Conducting a Quality “Summit”

Box 5: Hypothesis:

• Breakout groups identified potential

solutions and improvement ideas for the

gaps, based on “If we . . . Then we . . .”

Box 6: Experiments:

• Each group developed ideas to review with staff or try within a 24

hour period and report “results” back to summit next day


• Main deliverable from summit is the Action Plan going forward

Personal Development A3

• Similar to a Strategy A3

• Describes the Current State of career or personal life

• Describes the desired Future State

• Perform a Gap Analysis and identify Gaps that you want

to close over the next 12 months

A3 – Personal Development Plan

Who When Status



TBD (FY2014)

6. EXPERIMENTS DO

Brian

PLAN

Determine appropriate conference to attend

and make formal request - opportunities,

interests and VSA activity schedule haven't

yielded the right opportunity yet

Develop Abstract and seek potential

publication/presentation opportunities. -

Currently submitted abstract to MLC for

presentation at conference in August, 2013.

1. BUSINESS CASE PLAN 4. GAP ANALYSIS PLAN 7. COMPLETION PLAN DO

Action Item-What

Participate in 2P/3P or Lean Project Plan

event - No opportunity has been available

5/31/13

1. Little or No involvement or experience with a 2p/3p event or Lean

Project Plan (Vertical Value Stream).

2. Some gaps in Advanced Knowledge category of the PI Skills Matrix.

3. Able to facilitate some sessions of RIE with assistance from Sensei.

4. Haven't written an article/paper or presented at a regional/national

conference in past 5 years.

Current UOM

To be determined (FY2014)


Brian

The Operational Improvement Department is transitioning into a

"lean" transformation model making use of Value Stream Analysis

(VSA) and Rapid Improvement Events (RIE) to achieve measurable

improvements. The role of the Process Engineer is also transitioning

into a consulting/teaching role (Sensei) role, requiring new and

enhanced skill sets.

In order to meet the demand of current and future value stream

customers, I must further assess and develop my skill sets to meet

the new requirements.



If I… Then I Expect…

1. Participate on 2P/3P event or

Lean Project Plan event.

2. Teach modules in the Lean

Fundamentals training

3. Join Michigan Lean Consortium

4. Attend a National Lean/Quality

/Healthcare Conference

5. Publish or present paper related

to process improvement in Cath

Lab

1. To be able to help facilitate a 2P/3P

event or Lean Project Plan within my VS

2. to close the gap on Advanced

Knowledge areas

3. to better apply lean concepts

creatively within SH

4. Increased knowledge of applying lean

in healthcare

5. increased comprehension of concepts

and application to healthcare

5/31/13

1/31/13

5/31/13

5/31/13

Teach modules within Fundamentals of Lean

or other training - no opportunities yet

Join Michigan Lean Consortium - COMPLETED

Brian

Brian

Brian


2. Having at least one example and

having prior experience with A3s

1. How to think about PDP in terms of

Currrent State and Future State

2. To truly do a PDP well, requires this

type of approach & time investment

2. have some training available on

how to complete a PDP A3

3. Should have had more formal

review w/ upline (in transition)

1. Had a more "formal review" with

my manager for feedback sooner

2. Engaged the Sensei more in

developing this PDP A3

What did we learn… What would you do differently…



To be determined (FY2014)

1.Participate in 2P/3P or Lean Project Plan Event - if feasible.

2. Obtain additional training in the areas where gaps on Skills Matrix

exist.

3. Facilitate RIE and/or VSA sessions with very minimal assistance

from Sensei.

4. Submit paper or article for publication or presentation at

conference in 2013.

1. Participate on 2P/3P event and/or Lean Project Plan event

2. Teach modules in the Lean Fundamentals training

3. Join Michigan Lean Consortium

4. Attend a National Lean/Quality /Healthcare Conference

5. Write/Publish article related to process improvement in Cath Lab

What went well…

1. Initial mentoring from Sensei 1. Have more examples available

• Develop a Personal Development A3 for the coming year

– rough draft.

• Use either of the A3 formats available at your table.

• 10 Minutes, 5 Minute Debrief.

Individual Exercise

In Review . . . from front line staff JDI to complex value streams

• A3 thinking (including an appropriate form/format) is

applicable to all types of situations.

• Leverage the scope as necessary to ensure success.

• 1 or 2 people < 1 hour Golden Ticket

• 1 person, 2-4 hours Simple Problem Solving A3

• Up to 4 people x 4 hours Just-Do-It, Targeted or project A3

• Manageable, cross-functional issue Facilitated A3 workshop

• Complex, Cross-departmental, system issue RIE A3

A3 References

• Leading the Lean Enterprise Transformation – Second Edition

- George Koenigsaecker

• Lean Leadership for Healthcare – Approaches to Lean Transformation

- Ronald G. Bercaw

• Managing to Learn – Using the A3 management process to solve problems,

- John Shook

• The Toyota Way Fieldbook

- Jeffery Liker and David Meier

• Toyota’s 8-Steps to Problem Solving

- Robert H. Goldsmith

• Understanding A3 Thinking

- Durward K. Sorbek II and Art Smalley

QUESTIONS ?

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