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Building Consensus and Generating Authority
Jack Billi, [email protected]/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
Managing with A3 Thinking
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A Question For You
What makes projects fail?
• Think of a specific project…• Why did it not succeed?
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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!
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• “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, …”
So Many Solutions!
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Is the Issue Agreement?
Current State
Future State
Transit
ion Plan
Do we really agree on the where we are? On the current condition?
Do we really agree on the where we want to go? On what the gap in performance is?
Do we really agree on how we will get there?
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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
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How Do We Get Agreement?
Meeting people into submission
$495
I’ve got the data Do the Hard
Sell
Force your perspective
State your case more strongly than others
Where is Disagreement?
Your Idea
“You won’t believe what they want us to do”
“Yea, like I’m going to do that”
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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?
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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-Solving
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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 Thinking”A Template for Structured Problem-Solving
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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
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Scientific Method (PDCA Cycle)
Plan(Hypothesis)
Do(Try)
Check(Reflect)
Act(Adjust)
Grasp the Situation
Countermeasures implemented as Experiments
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Scientific Method (PDCA Cycle)
Plan(Hypothesis)
Do(Try)
Check(Reflect)
Act(Adjust)
Grasp the Situation
Countermeasures implemented as Experiments
Title: What we are talking about.Background
Current Situation
Goal
Analysis
Recommendations
Plan
Follow - up
Of all our problems, why this one? The “ugly story”…
Where do we stand?
Problem Statement:
What is the specific change we want to accomplish now?
-What are the root causes, requirements, constraints?
What are your proposed countermeasures, strategies, alternatives?
What activities will be required?
What , Who, When?
How we will know?
What remaining issues?
Modified -Verble/Shook
Date: Owner:
An A3 Template
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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 Benefits
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• 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
A3 Benefits
Title: What we are talking about.Background
Current Situation
Goal
Analysis
Recommendations
Plan
Follow - up
Of all our problems, why this one? The “ugly story”…
What is the specific change we want to accomplish now?
-What are the root causes ,requirements, constraints?
What are your proposed countermeasures, strategies, alternatives?
What activities will be required?
What , Who, When?
How we will know?
What remaining issues?
Modified -Verble/Shook
Date: Owner:
A3 - A Template For Structured Problem Solving……Does this sound familiar??
Where do we stand?
Problem Statement:
Name of Patient:
History
Physical Exam
Impression - Diagnoses
Plans
Follow - up
Date: Clinician:New Patient H&P
Chief Complaint
History of Present Illness
Past Medical & Surgical History
Medications and Allergies
Family and Social History
Review of Systems
General Appearance, Vital Signs
HEENT
Heart & Lungs
Abdomen
Extremities
Neuro
1.
2.
3.
Diagnostic:
1, 2, 3,
Treatment:
1, 2, 3,
Monitor x, y, z
Return visit:
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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 date2. Background 3. Current situation, Current State Map4. Goal or target 5. Investigation of facts, analysis, root cause analysis 6. Recommendations, countermeasures, strategies,
alternatives7. Action Plan – what, who, when8. Verification of countermeasures9. Review/Critique 10. Possible next steps, further action, follow up
Adapted from John Shook
Which Tool Could Be Used …
BACKGROUND Graph SketchINVESTIGATION Tally-sheet HistogramCURRENT STATE Pareto Diagram Graph
Scatter Diagram SketchControl Chart CS Map
TARGET, OUTCOMES Chart SketchACTION PLAN Gantt Chart ANALYSIS Cause-and-Effect Fishbone Control Chart
Relation Diagram HistogramTree Diagram GraphPareto Diagram SketchScatter Diagram
COUNTERMEASURES Graph ChartSketch FS Map
VERIFICATION OF Pareto Diagram Graph COUNTERMEASURES Histogram Sketch
Scatter Diagram Chart PREVENTIONS Sketch Chart REVIEW/CRITIQUE
• 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.
Adapted from John Shook
Title: What we are talking about.
Current Situation
Goal
Analysis
Recommendations
Plan
Follow - up
Of all our problems, why are we talking about this one? The “ugly story”… Historical/organizational/business context…
Where do we stand? What is our current performance?Trend chart, current state value stream map
What is the target condition or performance improvement you want now? Measurable, by when?
What are the root causes of the problem? (Fishbone, 5 Whys, Pareto)
What requirements, constraints and alternatives need to be considered?
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?
What , Who, When? What activities will be required for implementation and who will be responsible for what and when?
How we will know if the actions have the impact needed? What remaining issues can be anticipated? When/how will we follow up?
Date: Owner:An A3 Template
Background
Clear Problem Statement
Goal
Reviewed By: Date:Modified from Verble, Shook, LaHote, Billi
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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
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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?
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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”
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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)
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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”
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Physical Therapist
Nurse
Grandson
A3
Pull-Based Authority
Early Mobilization of ICU Ventilator Patients
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IHI Open School – student organized QI learning –MD, RN, Pharm, Soc Work, Engineer, MPH, MBAA3 workshop: multidisciplinary problem solving
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Practice in A3 problem-solving, presenting, critiquing
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
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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
