a3 problem solving in healthcare

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From Pitfalls to Progress: Effective A3 Thinking in Healthcare

July 25, 2024 Written by Anthony Pepe

In recent years, we’ve seen more and more healthcare organizations adopt A3 reports and A3 thinking as their problem-solving methodology. This proliferation of scientific thinking is helping to deliver significant improvements for patients, healthcare staff, and communities in many places. However, some organizations fall into significant traps with A3 thinking, which at best, hinder individual problem-solving efforts and at worst, derail the adoption of scientific problem-solving across the entire organization. This post will highlight some of the most common pitfalls and provide actionable suggestions for avoiding them.

Pitfall #1: Jumping to solutions

Do instead: state the problem as a gap to standard.

How many times have you heard someone say, “We just need to do ___ and our problem will be solved!” Unfortunately, jumping to solutions is one of the most common pitfalls with A3 thinking. Any time you hear (or read on an A3 report) things like “must do ___” or “need to improve ___”, it’s a signal that the problem-solvers might be jumping to solutions.

One way to avoid this trap is to clearly define the problem, which means stating the problem as a gap to the standard—there is no problem without a standard! To be clear, standard can mean an expectation, a goal, a norm, an objective, a desired condition, etc. Any condition that doesn’t meet the standard is a problem, whether that’s not achieving the standard, variation in meeting the standard, or requiring a higher standard than previously achieved.

A simple way to think about defining the problem is target-actual-gap . Target: What is the standard? What should be happening? What level of performance is expected or needed? Actual: What is actually happening now? What is the current level of performance? Gap: What is the difference between the standard and what’s actually occurring? For example, the problem isn’t that we need a new scheduling system, it’s:

Target: no more than 2 open appointment slots per day

Actual: averaging 4 open slots per day in June 2024

Gap: ~2 slots daily

Target: schedule 100% of our patients within 1 week of their request

Actual: currently schedule 100% of patients within 2 weeks of their request

Gap: 1 week

Once we’ve clearly stated the problem in terms of target-actual-gap , we can then seek to better understand the current situation.

Pitfall #2: Solving problems in the wrong place with the wrong information

Do instead: go and see where the problem actually occurs to get the facts.

Another common pitfall that we see is solving problems from a conference room or from behind a desk. Unless the problem occurs in the conference room or while you’re working at your desk, you can’t solve the problem there!

Similarly, we’ll often see organizations rely on reports or data from the electronic medical record (EMR) or other sources and treat them as gospel. While data is important to our problem-solving, it is still a human-made construct that we can’t treat as absolute fact. For example, I once worked with an emergency department team where the “door-to-doc” time for fast-track patients was averaging less than 10 minutes, confirmed by data from the EMR, yet they were getting many patient complaints about waiting too long. Observation revealed that some of the emergency physicians were signing up for multiple patients at once, which would record 0-minute “door-to-doc” times in the EMR for each of those patients; however, only the first patient had actually seen the doctor, and the second, third, or even fourth patients were all sitting there waiting!

On the other end of the spectrum, we’ll see problem-solving efforts that stem from anecdotal reports. Someone might complain that “___ ALWAYS happens” or “___ is NEVER done right” without turning the anecdote into something objective by quantifying the problem.

What we really need are facts, which we can only gather by going to the place where the problem occurs, making direct observations of what happens there, and interacting with the people who experience the problem. I like to think of it as a crime scene investigation—evidence is perishable. Consequently, we must respond rapidly to solve problems as close as possible to when they occurred, in the place where they occurred, and connect directly with the people involved.

Pitfall #3: Not engaging the right people

Do instead: directly involve the people who do the work/experience the problem.

Another pitfall we often see is not getting the right people involved in problem-solving. Unfortunately, sometimes A3 thinking becomes a leaders-only activity, where directors, managers, and/or supervisors effectively end up imposing “solutions” on teams rather than engaging them in improvement. Worse yet, sometimes well-meaning but misguided improvement coaches do the problem-solving on behalf of the leaders. Some organizations even lock away A3 thinking behind complex project intake and/or chartering processes that make it extremely difficult for frontline staff to get involved, or even want to do so because the barriers to entry are so high. Each of these traps is harmful to creating a culture of continuous improvement—everyone, everywhere, every day improving their work.

The Rules in Use, a.k.a. the principles for designing, operating, and improving all work, provide a powerful framework for problem-solving. Rule 4, the Improvement Rule, tells us that all improvements must be made using the scientific method, under the guidance of a teacher, at the lowest possible level in the organization, towards the ideals. While there is much to unpack in Rule 4, in the most simplistic terms, what it means is that the people who do the work and experience the problem must be the ones who work on solving the problem, with coaching and support from their leader. A3 thinking is for everyone!

Read more about the Rules in Use in the Harvard Business Review

When I worked in operations management at Alcoa, it was common to see frontline machine operators and material handlers writing A3 reports when they experienced problems. In fact, I first learned about A3 thinking from a veteran machine operator whom I supervised. On my very first nightshift with my team, we had a problem on the hot rolling mill, and I asked the operator how we solve problems here; he responded that we use A3s, proceeding to pull out an A3 template and show me what he meant.

Now, Alcoa was an organization that had a very mature culture of organizational excellence at the time, so we can’t expect this sort of engagement to happen right way in healthcare organizations where A3 thinking is new to many people. However, what we can do is ensure we have frontline staff involvement in every A3, and we can teach people about scientific method problem-solving through Plan-Do-Check-Act learning cycles to run experiments aimed at improving their work.

Pitfall #4: Making it about the tool or template

Do instead: emphasize scientific thinking and learning.

Some organizations put too much emphasis on tools and templates. In fact, we’ve seen a few places where arguments about which A3 template to use become so crippling that people are barely solving problems at all! Another failure mode is solving problems unscientifically using traditional fire-fighting methods, then taking credit for A3 thinking by shoe-horning information into an A3 report after the fact.

With problem-solving, what really matters is using the scientific method and the thinking and learning process around it. Whether your organization subscribes to Plan-Do-Check-Act (PDCA)/Plan-Do-Study-Adjust (PDSA), Define-Measure-Analyze-Improve-Control (DMAIC), Problem-Cause-Solution-Action-Measure (PCSAM), or something else, it’s all about analyzing problems scientifically and learning from testing hypotheses via experimentation. It is not about the tool or template you use. To me, an A3 template is like a set of training wheels on a bike—the template helps guide us and keep us from falling off the path while we’re learning to solve problems more effectively.

Rather than worrying about which template to use or whether people are filling them out correctly, focus on the thinking process behind the problem-solving and whether people are learning from the problem-solving. Here are some helpful questions to consider:

• Is the problem defined in terms of a gap to a standard?
• Has the current condition been understood through direct observation and engaging the people who do the work?
• Has the problem been broken down and the root cause(s) identified?
• What is the hypothesis?
• Do the countermeasures address the root cause(s)? Test this by asking, if the countermeasures work, will they prevent the root cause from happening again?
• Has an experiment been run to test the hypothesis and countermeasures?
• What has been learned from the experiments?
• Based on the learnings, what will be done next?

Pitfall #5: Picking “low-hanging fruit”

Do instead: think systemically.

Recently, an improvement coach at a large academic medical center told me about an A3 she was coaching aimed at decreasing the time it took to hire a new employee, which had been taking 110 days on average. Unfortunately, the team spent so much time analyzing and debating potential causes with a fishbone diagram and developing long lists of action items to address the “low-hanging fruit” that progress had ground to a halt. In fact, the analysis paralysis was so bad she had been working with the team for over a year and it was still taking about 110 days to hire a new person. Trying to “pick the low-hanging fruit”—i.e., solve many small problems—had made the problem-solving effort more complex, not yielding any measurable improvement in a process that desperately needed it. We’ve seen similar pitfalls in many other problem-solving efforts and organizations.

Some might blame the coach, the leaders, or even the team members for how they were managing the work or for not getting the action items done, but the real issue was that the team was working in siloes on small problems and not addressing the bigger barriers to flow across the system. For example, the recruiters were diligently working on providing better information to candidates via new email templates, but at that time, no one had recognized that candidates were receiving double-digit messages from various roles across the hiring process, sometimes with conflicting information, or that if candidates missed a particular instructional email (they would regularly get lost in junk mail folders), they wouldn’t be able to complete later parts of the process.

Again, the Rules in Use are very helpful here. Using the 5-Why technique, try to classify each potential root cause as a violation of one of the four Rules. Said another way, if you can spot a violation of one of the Rules, then it’s a signal you’ve identified an actionable root cause. Now, when you look at the root causes, you only have four problems to solve (Pathways, Connections, Activities, Improvements), not dozens! This enables people to work across siloes in a way that addresses the problem systemically across the organization rather than working on small problems within their own areas. After identifying the root cause(s) and classifying them as violations of the Rules in Use:

• Redesign the pathway so that it’s simpler and more direct, without loops and forks
• Fix connections between customers and suppliers in the pathway so that they’re direct, binary, and unambiguous; specify quantity, type, time, to, from
• Specify each supplier’s activities in terms of content, sequence, timing, location, outcome
• Specify how improvements to the new design will be made (using scientific thinking, of course!)
• Develop built-in tests to signal problems with pathways, connections, activities, and improvements in the new design
• Test the new design; when problems occur with the design, solve them as close as possible to occurrence in time, place, and person
• Apply learnings from problem-solving to improve the design

This systematic process not only solves problems more effectively but also helps to create an organizational learning culture.

In conclusion, while these certainly aren’t the only failure modes with A3 thinking, these are some of the more common ones we see in healthcare. Hopefully, your organization has avoided these pitfalls, but if not, perhaps you can improve your problem-solving capability with some of the tips here. Just remember to test your hypothesis and adjust based on what you learn!

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Written by Anthony Pepe

Prior to joining Value Capture, Anthony coached at Penn Medicine Lancaster General Health for five years. There he supported hospital operations, including inpatient nursing, perioperative services, the emergency department, guest services, and more. Anthony is passionate about helping healthcare executives, leaders, and team members solve problems and improve safety and outcomes.

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A Step-by-Step Guide to A3 Problem Solving Methodology

Author: Daniel Croft

Daniel Croft is an experienced continuous improvement manager with a Lean Six Sigma Black Belt and a Bachelor's degree in Business Management. With more than ten years of experience applying his skills across various industries, Daniel specializes in optimizing processes and improving efficiency. His approach combines practical experience with a deep understanding of business fundamentals to drive meaningful change.

Problem-solving is an important component of any business or organization. It entails identifying, analyzing, and resolving problems in order to improve processes, drive results, and foster a culture of continuous improvement. A3 Problem solving is one of the most effective problem-solving methodologies.

A3 Problem solving is a structured and systematic approach to problem-solving that originated with the lean manufacturing methodology. It visualizes the problem-solving process using a one-page document known as an A3 report. The A3 report provides an overview of the problem, data analysis, root causes, solutions, and results in a clear and concise manner.

A3 Problem Solving has numerous advantages, including improved communication, better decision-making, increased efficiency, and reduced waste. It is a powerful tool for businesses of all sizes and industries, and it is especially useful for solving complex and multi-faceted problems.

In this blog post, we will walk you through the A3 Problem Solving methodology step by step. Whether you are new to A3 Problem Solving or simply want to improve your skills, this guide will help you understand and apply the process in your workplace.

What is A3 Problem Solving?

A3 Problem Solving is a structured and systematic approach to problem-solving that makes use of a one-page document called an A3 report to visually represent the process. The A3 report provides an overview of the problem, data analysis, root causes, solutions, and results in a clear and concise manner. The method was created within the framework of the Lean manufacturing methodology and is based on the principles of continuous improvement and visual management.

Looking for a A3 Problem solving template? Click here

Origin and History of A3 Problem Solving

A3 Problem Solving was developed by Toyota Motor Corporation and was first used in the manufacture of automobiles. The term “A3” refers to the size of the paper used to create the report, which is an ISO standard known as “A3”. The goal of the A3 report is to provide a visual representation of the problem-solving process that all members of the organisation can easily understand and share. A3 Problem Solving has been adopted by organisations in a variety of industries over the years, and it has become a widely used and recognised method for problem-solving.

Key Principles of A3 Problem Solving

The following are the key principles of A3 Problem Solving:

• Define the problem clearly and concisely
• Gather and analyze data to gain a deep understanding of the problem
• Identify the root causes of the problem
• Develop and implement effective solutions
• Evaluate results and continuously improve

These principles serve as the foundation of the A3 Problem Solving methodology and are intended to assist organisations in continuously improving and achieving their objectives. Organizations can effectively solve problems, identify areas for improvement, and drive results by adhering to these principles.

Step 1: Define the Problem

Importance of clearly defining the problem.

The first step in the A3 Problem Solving process is critical because it lays the groundwork for the remaining steps. To define the problem clearly and accurately, you must first understand the problem and identify the underlying root cause. This step is critical because if the problem is not correctly defined, the rest of the process will be based on incorrect information, and the solution developed may not address the issue effectively.

The significance of defining the problem clearly cannot be overstated. It aids in the collection and analysis of relevant data, which is critical for developing effective solutions. When the problem is clearly defined, the data gathered is more relevant and targeted, resulting in a more comprehensive understanding of the issue. This will enable the development of solutions that are more likely to be effective because they are founded on a thorough and accurate understanding of the problem.

However, if the problem is not clearly defined, the data gathered may be irrelevant or incorrect, resulting in incorrect conclusions and ineffective solutions. Furthermore, the process of collecting and analysing data can become time-consuming and inefficient, resulting in resource waste. Furthermore, if the problem is not accurately defined, the solutions developed may fail to address the root cause of the problem, resulting in ongoing issues and a lack of improvement.

Techniques for Defining the Problem

The first step in the A3 Problem Solving process is to clearly and accurately define the problem. This is an important step because a clearly defined problem will help to ensure that the appropriate data is collected and solutions are developed. If the problem is not clearly defined, incorrect data may be collected, solutions that do not address the root cause of the problem, and time and resources may be wasted.

A problem can be defined using a variety of techniques, including brainstorming , root cause analysis , process mapping , and Ishikawa diagrams . Each of these techniques has its own advantages and disadvantages and can be used in a variety of situations depending on the nature of the problem.

Best Practice for Defining the Problem

In addition to brainstorming, root cause analysis, process mapping, and Ishikawa diagram s, best practices should be followed when defining a problem in A3 Problem Solving. Among these best practices are:

• Define the issue in a specific and quantifiable way: It is critical to be specific and concise when defining the problem, as well as to quantify the problem in terms of its impact. This will help to ensure that all stakeholders understand the problem and that data collection is focused on the right areas.
• Focus on the problem’s root cause: The A3 Problem Solving methodology is intended to assist organisations in identifying and addressing the root cause of a problem, rather than just the symptoms. Organizations can ensure that their solutions are effective and long-lasting by focusing on the root cause of the problem.
• Ascertain that all stakeholders agree on the problem’s definition: All stakeholders must agree on the definition of the problem for the A3 Problem Solving process to be effective. This ensures that everyone is working towards the same goal and that the solutions developed are relevant and appropriate.
• Consider the problem’s impact on the organisation and its stakeholders: It is critical to consider the impact of the problem on the organisation and its stakeholders when defining it. This will assist in ensuring that the appropriate data is gathered and that the solutions developed are relevant and appropriate.

Organizations can ensure that their problem is defined in a way that allows for effective data collection, analysis, and solution development by following these best practices. This will aid in the development of appropriate solutions and the effective resolution of the problem, resulting in improvements in the organization’s processes and outcomes.

Step 2: Gather Data

Gathering data in a3 problem solving.

Data collection is an important step in the A3 Problem Solving process because it allows organisations to gain a thorough understanding of the problem they are attempting to solve. This step entails gathering pertinent information about the problem, such as data on its origin, impact, and any related factors. This information is then used to help identify root causes and develop effective solutions.

One of the most important advantages of data collection in A3 Problem Solving is that it allows organisations to identify patterns and trends in data, which can be useful in determining the root cause of the problem. This information can then be used to create effective solutions that address the problem’s root cause rather than just its symptoms.

In A3 Problem Solving, data collection is a collaborative effort involving all stakeholders, including those directly impacted by the problem and those with relevant expertise or experience. Stakeholders can ensure that all relevant information is collected and that the data is accurate and complete by working together.

Overall, data collection is an important step in the A3 Problem Solving process because it serves as the foundation for effective problem-solving. Organizations can gain a deep understanding of the problem they are attempting to solve and develop effective solutions that address its root cause by collecting and analysing relevant data.

Data Collection Methods

In A3 Problem Solving, several data collection methods are available, including:

• Observations
• Process diagrams

The best data collection method will be determined by the problem being solved and the type of data required. To gain a complete understanding of the problem, it is critical to use multiple data collection methods.

Tools for Data Analysis and Visualization

Once the data has been collected, it must be analysed and visualised in order to gain insights into the problem. This process can be aided by the following tools:

• Excel Spreadsheets
• Flow diagrams
• Pareto diagrams
• Scatter Plots
• Control diagrams

These tools can assist in organising data and making it easier to understand. They can also be used to generate visual representations of data, such as graphs and charts, to communicate the findings to others.

Finally, the data collection and analysis step is an important part of the A3 Problem Solving process. Organizations can gain a better understanding of the problem and develop effective solutions by collecting and analysing relevant data.

Step 3: Identify Root Causes

Identifying the root causes of the problem is the third step in the A3 Problem Solving process. This step is critical because it assists organisations in understanding the root causes of a problem rather than just its symptoms. Once the underlying cause of the problem is identified, it can be addressed more effectively, leading to more long-term solutions.

Overview of the Root Cause Analysis Process

The process of determining the underlying causes of a problem is known as root cause analysis. This process can assist organisations in determining why a problem is occurring and what can be done to prevent it from recurring in the future. The goal of root cause analysis is to identify the underlying cause of a problem rather than just its symptoms, allowing it to be addressed more effectively.

To understand Root cause analysis in more detail check out RCA in our Lean Six Sigma Yellow Belt Course Root Cause Analysis section

Techniques for Identifying Root Causes

There are several techniques for determining the root causes of a problem, including:

• Brainstorming
• Ishikawa diagrams (also known as fishbone diagrams)
• Root Cause Tree Analysis

These methods can be used to investigate the issue in-depth and identify potential root causes. Organizations can gain a deeper understanding of the problem and identify the underlying causes that must be addressed by using these techniques.

Best Practices for Conducting Root Cause Analysis

It is critical to follow these best practices when conducting root cause analysis in A3 Problem Solving:

• Make certain that all stakeholders participate in the root cause analysis process.
• Concentrate on determining the root cause of the problem rather than just its symptoms.
• Take into account all potential root causes, not just the most obvious ones.
• To identify root causes, use a systematic approach, such as the 5 Whys or root cause tree analysis.

Organizations can ensure that root cause analysis is carried out effectively and that the root cause of the problem is identified by adhering to these best practises. This will aid in the development of appropriate solutions and the effective resolution of the problem.

Step 4: Develop Solutions

Developing solutions is the fourth step in the A3 Problem Solving process. This entails generating ideas and options for dealing with the problem, followed by selecting the best solution. The goal is to develop a solution that addresses the root cause of the problem and prevents it from recurring.

Solution Development in A3 Problem Solving

A3 solution development Problem solving is an iterative process in which options are generated and evaluated. The data gathered in the previous steps, as well as the insights and understanding gained from the root cause analysis, guide this process. The solution should be based on a thorough understanding of the problem and address the underlying cause.

Techniques for Developing Solutions

There are several techniques that can be used to develop solutions in A3 Problem Solving, including:

• Brainwriting
• Solution matrix
• Multi voting
• Force field analysis

These techniques can help to generate a range of options and to select the best solution.

Best Practice for Developing Solutions

It is critical to follow the following best practices when developing solutions in A3 Problem Solving:

• Participate in the solution development process with all stakeholders.
• Make certain that the solution addresses the underlying cause of the problem.
• Make certain that the solution is feasible and achievable.
• Consider the solution’s impact on the organisation and its stakeholders.

Organizations can ensure that the solutions they develop are effective and sustainable by adhering to these best practises. This will help to ensure that the problem is addressed effectively and that it does not reoccur.

Step 5: Implement Solutions

The final and most important step in the A3 Problem Solving methodology is solution implementation. This is the stage at which the identified and developed solutions are put into action to address the problem. This step’s goal is to ensure that the solutions are effective, efficient, and long-lasting.

The implementation Process

The implementation process entails putting the solutions developed in the previous step into action. This could include changes to processes, procedures, and systems, as well as employee training and education. To ensure that the solutions are effective, the implementation process should be well-planned and meticulously executed.

Techniques for Implementing Solutions

A3 Problem Solving solutions can be implemented using a variety of techniques, including:

• Piloting the solution on a small scale before broadening its application
• Participating in the implementation process with all relevant stakeholders
• ensuring that the solution is in line with the goals and objectives of the organisation
• Monitoring the solution to determine its effectiveness and make any necessary changes

Best Practice for Implementing Solutions

It is critical to follow these best practices when implementing solutions in A3 Problem Solving:

Make certain that all relevant stakeholders are involved and supportive of the solution. Have a clear implementation plan that outlines the steps, timeline, and resources required. Continuously monitor and evaluate the solution to determine its efficacy and make any necessary changes. Encourage all stakeholders to communicate and collaborate openly. Organizations can ensure that solutions are effectively implemented and problems are effectively addressed by adhering to these best practices. The ultimate goal is to find a long-term solution to the problem and improve the organization’s overall performance.

In conclusion, A3 Problem Solving is a comprehensive and structured methodology for problem-solving that can be applied in various industries and organisations. The A3 Problem Solving process’s five steps – Define the Problem, Gather Data, Identify Root Causes, Develop Solutions, and Implement Solutions – provide a road map for effectively addressing problems and making long-term improvements.

Organizations can improve their problem-solving skills and achieve better results by following the key principles, techniques, and best practices outlined in this guide. As a result, both the organisation and its stakeholders will benefit from increased efficiency, effectiveness, and satisfaction. So, whether you’re an experienced problem solver or just getting started, consider incorporating the A3 Problem Solving methodology into your work and start reaping the benefits right away.

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Daniel Croft

Hi im Daniel continuous improvement manager with a Black Belt in Lean Six Sigma and over 10 years of real-world experience across a range sectors, I have a passion for optimizing processes and creating a culture of efficiency. I wanted to create Learn Lean Siigma to be a platform dedicated to Lean Six Sigma and process improvement insights and provide all the guides, tools, techniques and templates I looked for in one place as someone new to the world of Lean Six Sigma and Continuous improvement.

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A3 Problem Solving for Healthcare

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The A3 process is a way to look with "new eyes" at a specific problem identified by direct observation or experience. It offers a structure that begins by always defining the issue through the eyes of the customer.In A3 Problem Solving for Healthcare Cindy Jimmerson explains an essential tool borrowed from the Toyota Production System, which is an extension of work identified with the well-known Value Stream Map. She offers an easy-to-learn problem-solving method that can be used in every aspect of healthcare to identify, understand, and improve processes that don't support workers in doing their good work. In this compelling book you get: The expertise of a recognized industry expert in Lean principles A practical, easy-to-use workbook Concepts illustrated with numerous A3s in various stages of development Explanation of how to extend the VSM philosophy to a more focused perspective An extensive exploration of the A3 problem-solving tool in healthcare the first book to do so Through case studies and actual A3s, this book illustrates the simplicity and completeness of the A3 tool and its applications to regulatory documentation as well as activities of daily work.

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More than just a paper size: The A3 as a powerful problem-solving tool

At first glance, you may write off the A3 as a simple problem-solving tool. Named after the size of paper it’s printed on (approximately 11 by 17 inches), this humble but mighty tool provides a framework for continuous improvement that can be used across several industries. There are many layers to this onion so sit back while we take a deep dive into what it all means and how it can make your life better.

Table of contents

Introduction and applications, a3 structure: rigour, standardization and documentation, benefits of using the a3, tips for more efficient a3 forms, making a3s work for you.

The A3 form’s origin story harkens back to the Toyota Lean Management system as part of its production process. That said, A3s certainly have application in other industries, including health care; many health organizations use it to examine processes ranging from quality improvement (QI) to patient care .

Historically, the A3 form has been used as a problem-solving tool, as it has a structured mechanism to organize our thoughts. However, it is a flexible tool, and can also be used for other purposes such as strategy development and reporting. This may require modifying the questions slightly to fit your application—for example, a problem solving A3 can have up to eight steps, while a proposal-style A3 sticks with the standard six steps. This should not affect the rigour of the tool if the same components largely remain intact and in the same order

Additionally, by documenting the thought process, the A3 can serve as a powerful communication tool to succinctly tell the project’s story. This can be helpful when engaging with both internal and external stakeholders. Currently, HQC uses a modified version as a tool to support our project management and reporting processes. This one-page snapshot is updated quarterly.

The A3 form breaks down problem solving by creating sequential boxes (numbered 1-6). This allows the user to focus on one aspect at a time, in a linear fashion. The left side focuses on clarifying the problem, while the right side is more reactionary— what are you going to do about it? Additionally, the amount of space allocated to each component is intentional to inspire brevity (if you can’t say it with one page, you’re not concise enough, says QI leader KaiNexus ) while providing enough space to include relevant details.

While the rigour of the form allows teams to have a consistent approach to problem solving, in documenting the process, an A3 can also serve as a communication or reporting tool to concisely share the methodical approach to addressing the problem.

You may have encountered terms associated with the A3 form—such as A3 thinking and A3 process. This is the term applied to the process of working through the problem in a systematic way, using the A3 form as a template or guide.

Using the example above, we can identify six steps:

• Problem statement : Describe the problem you are trying to solve. What is the current state and the rationale for the action? In this case, it’s a lack of hand hygiene in a long-term care home. (Note: Some templates split problem identification and the current state description into separate boxes. The current state could also include visuals such as a process map to articulate the scenario.)
• Root cause analysis : Analyze what is causing the problem and the evidence to support the analysis. Here it is helpful to incorporate baseline data. There are some QI tools that can help with the root cause analysis, such as a fish bone diagram and 5 whys exercise—categories such as people , process , equipment , environment and management are common.
• Target statement : Identify what future state looks like by a certain day (in our form, it is based on the March 31 planning year). Be specific.
• Implementation plan : Describe key milestones, who is responsible to complete them and by when.
• Metrics : Identify how will you know if the approach is successful.
• Engagement: Describe how relevant stakeholders are engaged in the plan.

While there isn’t universal consensus on the specific steps, most A3 forms generally align with the plan, do, study, act (PDSA) cycle –where the left-side is the plan portion and the right side is the do, study, act portion of the cycle.

The A3 builds critical analysis skills—that is, an ability to look at a process and, using data, objectively assess how to improve it. This requires practice to improve and stay sharp, like practicing a sport or a hobby. Over time, however, it helps us to think quicker and become more responsive problem solvers—and less likely to jump to conclusions or bandage solutions.

A3 are also a useful collaborative tool. They promote team consensus-building and provides a method to approach problems in a standardized way; this streamlining of processes allows for greater efficiency and less wasted resources. It can also capture the status of a project at a point in time and support a team in communicating, on one page, the rationale, current state and future state of a project.

Here are some tips so you too can complete your A3 like a pro:

Never A3 alone: Think back to your childhood and the buddy system when completing an A3 form. This tool was made for collaboration to allow diverse perspectives, especially on the root cause analysis portion. One option might be to do individual reflection on why the problem is happening, then discuss as a group.

Follow the order: It may be tempting to jump ahead to solutions without fully examining the other steps. However, to fully consider the problem at hand (and devise the best solution possible), it’s advised to go through each of the steps, in order.

Allow yourself time: Root cause analysis accounts for about 70 per cent of the A3 process, so allocate accordingly.

Lather, rinse, repeat: As much as the A3 form components align with the PDSA cycle, the form itself is also meant to be reviewed and updated until the problem is solved—it is recommended you use a pencil or, if working on an electronic document, mark it as a draft.

The A3 form is a flexible, dynamic tool used by QI professionals in countless industries and areas of work, and typically align with the PDSA cycle. The form itself is just one aspect of A3 thinking, which is a wider-scale and involves process management to address the root cause of issues. This structured, systematic approach is useful for comprehensively examining an issue, building group consensus and ultimately creating consistency in the problem-solving process. The next time that you have a problem and need to document the thinking (with perhaps larger stakeholder groups involved), using the A3 may be a helpful tool for you.

Other resources

• HQC modified A3 template
• A3 problem solving
• PDSA template

Recommended Content

• Plan-Do-Study Act Cycles: A problem-solving tool for improvement work
• Sharing the wisdom of quality improvement: 11 tips and tricks from HQC's in-house QI experts

Recent Blog Posts

A3 Problem Solving for Teachers

“A3 Thinking is as much about developing good problem-solvers as it is about effectively solving problems.” D.K. Sobek II and A. Smalley, Understanding A3 Thinking.

The “A3 Assessment Toolkit” is a self-instruction package for individuals teaching quality improvement in healthcare to:

• Learn about creating A3s and about assessing them
• Practice assessing A3s and check your assessments

Click on the tabs below for more information.

• Instructions
• Learn about A3s
• Learn about A3 Assessments
• Practice accessing A3s
• Using Materials with Learners
• Additional Resources

Example 1 – Assessments/explanations

• “ A3 Template ” and “ A3 Content Guide ” to learn about A3 proposals 
• “ Example 1 – A3 ”  to see a well done A3
• “ A3 Assessment Tool with Description of Response Options for Each  Item ” and  “ Example 1 – Assessments and Explanations “  to see how to assess an A3 and an assessment example.  
• Jones AC, Shipman SZ, Ogrinc G. Key characteristics of successful quality improvement curricula in physician education: A realist review.  BMJ Quality & Safety, 2015; 77-88
• Wong, B M, Levinson W, Shojania, DG.  Quality improvement in medical education: current state and future directions.  Medical Education, 2012; 46:107-119
• Starr SR, Kautz JM, Sorita A, et al. Quality Improvement Education for Health Professionals: A Systematic Review. Am J Med Qual. 2016 May;31(3):209-16
• Boonyasai RT, Windish DM, Chakraborti C, Feldman LS, Rubin HR, Bass EB. Effectiveness of teaching quality improvement to clinicians: a systematic review. JAMA. 2007 Sep 5;298(9):1023-37.
• Leenstra J, Beckman TJ, Reed, D, et al. Validation of a Method for Assessing Resident Physicians’ Quality Improvement Proposals. J Gen Intern Med. 2007; 22(9): 1330-34. 
• Rosenbluth G, Burman NJ, Ranji SR, Boscardin CK. Development of a Multi Domain Assessment Tool for Quality Improvement Projects. J Grad Med Educ. 2017;9(4):473-478.
• Steele EM, Butcher R, Carluzzo KL, Watts BV. Development of a Tool to Assess Trainees’ Ability to Design and Conduct Quality Improvement Projects. Am J Med Qual. 2019 Jun 12: 1062860619853880. doi: 10.1177/1062860619853880. [Epub ahead of print]
• Jennifer Myers, MD, Professor of Clinical Medicine, Perelman School of Medicine, University of Pennsylvania, email:  [email protected]  
• R. Van Harrison, PhD, Professor of Learning Health Sciences, University of Michigan Medical School, email:  [email protected]  
• Jeanne Kin, MHS, JD, Continuous Improvement Specialist, University of Michigan, email:  [email protected]
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Comparing the Effects of Design Thinking and A3 Problem-Solving on Resident Attitudes Toward Systems Change

Ryan buckley.

At the time of research, Ryan Buckley, MD, was a Faculty Member, Perelman School of Medicine at the University of Pennsylvania, and is now Assistant Professor of Clinical Medicine, Section of Hospital Medicine, Division of General Internal Medicine & Public Health, Department of Medicine, Vanderbilt University Medical Center

Anthony Spadaro

Anthony Spadaro, MD, MPH, is a Resident Physician, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania

Roy Rosin, MBA, is Chief Innovation Officer, Penn Medicine, University of Pennsylvania

Judy A. Shea

Judy A. Shea, PhD, is Professor of Medicine, Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania

Jennifer S. Myers

Jennifer S. Myers, MD, is Professor of Clinical Medicine, Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania

Associated Data

Quality improvement (QI) is a required component of graduate medical education. Many medical educators struggle to foster an improvement mindset within residents.

We conducted a mixed-methods study to compare a Design Thinking (DT) approach to QI education with a Lean, A3 problem-solving approach. We hypothesized that a DT approach would better promote a mentality of continuous improvement, measured by residents' resistance to change.

Thirty-eight postgraduate year 2 internal medicine residents were divided into 4 cohorts during the 2017–2018 academic year. One cohort participated in an experimental QI curriculum utilizing DT while 3 control cohorts participated in the existing curriculum based on Lean principles. Participants voluntarily completed a quantitative Resistance to Change (RTC) scale pre- and post-curriculum. To inform our understanding of these results, we also conducted semistructured interviews for qualitative thematic analysis.

The effect size on the overall RTC score (response rate 92%) was trivial in both groups. Three major themes emerged from the qualitative data: factors influencing the QI learning experience, factors influencing creativity, and general attitudes toward QI. Each contained several subthemes with minimal qualitative differences between groups.

Conclusions

This study found similar results in terms of their effect on attitudes toward systems change, ability to promote creative change agency, and educational experience. Despite positive educational experiences, many residents still did not view systems-based problem-solving as part of their professional identity.

We conducted a mixed-methods study comparing Design Thinking and Lean A3 Problem Solving as frameworks for an experiential quality improvement (QI) curriculum for postgraduate year 2 internal medicine residents.

Design Thinking and Lean A3 Problem Solving methods yield similar qualitative and quantitative results in their ability to foster a mindset of continuous improvement among internal medicine residents.

Limitations

This study was conducted at a single center, with one cohort of categorical internal medicine residents.

Bottom Line

Design Thinking could expand the toolset of a QI educator, but many residents do not view systems problem solving as part of their future professional identity.

Introduction

Quality improvement (QI) is a required component of graduate medical education (GME). 1 In 2017, the Accreditation Council for Graduate Medical Education (ACGME) formalized the expectations for QI education in the Common Program Requirements, prompting even more curricula in this area. 2

Teaching QI in GME often involves guiding residents through a project designed around a local gap in health care quality, using A3 problem-solving. 3 , 4 These curricula are based on principles from Lean 5 – 7 and the Model for Improvement 8 , 9 which use the plan-do-check-act (ie, Deming) cycle. 10 However, many medical educators still struggle with how to adapt them to health care and meaningfully engage residents in ways that promote a mentality of continuous improvement. 11 – 13

Innovation frameworks such as Design Thinking (DT) are now being taught in some medical schools. 14 Several major health care systems have leveraged these frameworks to improve patient outcomes while remaining economically viable in the volatile health care market. 15 , 16 DT emphasizes observation, empathic interviewing, and immersing oneself in a problem from another person's perspective. The insights gained inspire inexpensive, low-effort prototypes that can be rapidly tested through small-scale iterative experiments to methodically test evolving hypotheses ( Table 1 ). 17 , 18

Curricular Concepts and Activities for A3 Problem-Solving (Control) and Design Thinking (Experimental) Quality Improvement Curricula

We hypothesized that a DT approach to QI would more strongly promote a mindset of continuous improvement in residents, compared with traditional QI curricular approaches because of the similarities between DT and clinical medicine, namely their explicit focus on empathic problem-solving. Since all QI work requires change, we drew from Rogers' Diffusion of Innovations Theory, which posits that an individual's willingness to adopt change falls on a bell-shaped curve. 19 We then hypothesized that learning a structured approach to problem-solving in a familiar health care context with conceptually accessible QI tools could positively affect one's own attitude toward systems change, regardless of where one might naturally fall along Rogers' curve. We utilized a quantitative measure of residents' attitudes toward change as a curriculum evaluation measure for our research, then performed qualitative interviews to inform our understanding of this measure and which elements of the curriculum had the most influence on resident attitudes.

Setting and Participants

The QI curriculum for categorical internal medicine residents at our institution is delivered during the postgraduate year (PGY)-2 in the form of an experiential longitudinal project, facilitated by a faculty member with QI training and experience. The curriculum includes 16 in-person contact hours distributed over 10 months in the form of 1- or 3-hour teaching sessions every 8 weeks. During our study period, there were 38 categorical residents in the PGY-2 class. Residents are randomly grouped into 4 cohorts of 8 to 12 residents. Each cohort works on a different project that is facilitated by 1 of 4 faculty members. These faculty members, referred to as core QI faculty in our residency program, are proficient in A3 problem-solving and had at least 3 consecutive years of experience teaching QI to residents prior to the study. During this study, one core QI faculty member (R.B.) had both Lean A3 training and DT training. This study took place during the 2017–2018 academic year.

While our institution utilizes a blended QI framework that incorporates elements from both the Model for Improvement and Lean, the internal medicine residency program utilizes the Lean A3 problem-solving approach as the scaffolding for its curriculum.

Intervention

During the study period, we had one experimental group of residents (cohort D) who learned and applied the DT framework to approach a local QI problem. The other 3 groups of residents (cohorts A–C) served as control groups and learned to apply the A3 problem-solving framework to a local QI problem. The curriculum for the experimental DT cohort (provided as online supplementary data) was developed using tools and resources available online to the public through IDEO and The Hasso Plattner Institute of Design at Stanford 17 , 18 as well as educational resources recommended by the chief innovation officer at our institution. 20 – 22 The curriculum for the 3 control cohorts was developed and refined by our faculty over many years and is grounded in the A3 problem-solving approach to QI. 3 An outline of this curriculum can be found in the online supplementary data. The characteristics of each cohort's QI project can be found in Table 2 . QI projects were selected based on resident interest (cohorts A and B) or departmental and residency program strategic priorities for QI that involved residents (cohorts C and D). During the study period, residency program leadership requested that one cohort work on the problem of handoff interruptions. The QI faculty member for cohort D (R.B.) addressed this problem with his cohort.

Characteristics of Quality Improvement Projects in a Study of Design Thinking vs A3 Problem-Solving in an Internal Medicine Residency Program

We used the Resistance to Change (RTC) scale (provided as online supplementary data) as a quantitative measure of residents' attitudes toward systems change before and after the curriculum. 23 Semistructured interviews were analyzed using thematic analysis 24 as the qualitative evaluation to inform our understanding of resident attitudes toward health care systems change, how the curriculum may have impacted their views of change, other aspects of the curriculum, and QI as a discipline.

Quantitative Outcomes

The RTC scale is a 17-item, 6-point survey instrument that has validity evidence through studies in adult populations and was “designed to measure an individual's dispositional inclination to resist changes.” 23 It was administered on paper before and after participation in the QI curriculum. Each response form was deidentified, but pre-post linkage was maintained using unique identifier codes.

RTC scale responses were tabulated and analyzed for effect size using Cohen's d. 25 Effect size was chosen as the statistical measure for this study because of the small size of our experimental group. Using Cohen's standards, an effect size with an absolute value < 0.2 was considered trivial, ≥ 0.2 to < 0.5 was considered small, ≥ 0.5 to < 0.8 was considered medium, and ≥ 0.8 was considered a large effect. A negative effect size indicated a decreased resistance to change and was considered the desirable outcome.

Qualitative Outcomes

An interview guide (provided as online supplementary data) was developed through an iterative process by the research team, comprised of 2 medical educators with QI expertise (R.B. and J.M.), a qualitative researcher (J.S.), an MD/MPH candidate (A.S.), and the chief innovation officer of our institution (R.R.). All residents were invited to participate in a semistructured interview via email. No additional incentives were provided. Interviews were conducted in person or over the phone from May to July 2018 by a trained interviewer (A.S.) who had no association with the development of the QI curriculum or the leadership of the internal medicine residency program. All interviews were audio-recorded, transcribed, deidentified, and loaded into NVivo 12 (QSR International Inc, Burlington, MA) for analysis. Interview transcriptions were reviewed for accuracy against the audio recordings.

The research team developed a codebook for analysis through an iterative process. Interviews were analyzed by 2 investigators (R.B. and A.S.) who met routinely to review and refine coding. Four interviews were selected for duplicate coding with interrater reliability reaching an initial median kappa of 0.57 (-0.01–0.95). Coding differences were discussed until agreement was reached, changes were made to the codebook, and a second round of duplicate coding with 4 more interviews was conducted. After this round, the combined interrater reliability reached a median kappa of 0.66 (0.22–0.89) for all 8 interviews. Again, differences were discussed until agreement was reached with a focus on those codes with lower kappa scores. The codebook was adjusted, and remaining transcriptions were divided and coded by 1 of the 2 investigators. Once coding was complete, the research team used thematic analysis to identify emergent themes from the data. 26 – 28

The study was reviewed and considered exempt by the University of Pennsylvania Institutional Review Board. While resident participation in the QI curriculum was a mandatory residency component, completion of surveys and interviews was voluntary, and verbal informed consent was obtained.

The experimental group included 11 residents (11 of 38, 29%), while the other 27 residents (27 of 38, 71%) were divided among 3 control groups. Twenty residents (20 of 38, 53%) volunteered to participate in interviews, and we reached saturation of themes with these interviews. Eight of these residents (40%) were from the experimental group and 12 of 20 (60%) were from the control groups. All 38 residents completed the pre-curriculum RTC questionnaire, while 35 of 38 (92%) completed the post-curriculum questionnaire. The post-curriculum response rates in the experimental and control groups were 11 of 11 (100%) and 24 of 27 (89%), respectively.

Quantitative Results

At baseline, the average overall RTC score for the entire study population was 2.97. During validation studies, Oreg found means ranging 3.00–3.36. 23 At baseline, the average overall RTC score was higher, indicating more resistance to change, in the experimental group (3.26 of 6) compared to the control group (2.84 of 6). Postintervention, the effect size on the overall RTC score within each group was trivial, measuring 0.03 and 0.16 for the experimental and control groups, respectively.

Qualitative Results

Three major themes emerged from the qualitative data: factors influencing the QI learning experience, factors influencing creativity, and general attitudes toward QI. Within each major theme, there were several subthemes. Table 3 contains a full list of these subthemes with sample quotations. We will focus on the most prominent themes and note any differences between the groups.

Themes, Subthemes, and Illustrative Quotes from Internal Medicine Residents Who Participated in a Longitudinal Quality Improvement (QI) Project-Based Curriculum

Factors Influencing the QI Learning Experience

The 2 most prominent factors influencing the QI learning experience were peer engagement and learning a systematic methodology. Residents from both groups cited examples of how their peers' level of interest or excitement about the project directly impacted their overall experience. These comments carried both positive and negative connotations in both groups. Both groups viewed learning a systematic approach, either DT or A3 problem-solving, as a positive contributor to their experience. Facilitator factors such as enthusiasm, organizational skills, and delegation were noted by several residents as was the importance of having a personal connection to the problem they were trying to solve. Residents reported that working on a project that was meaningful to them and/or addressed a problem that they encountered in their work led to a more positive experience. This sentiment was expressed by residents in the cohorts who self-selected their QI project and the cohorts who worked on leadership-selected projects with relevance to residents.

Factors Influencing Creativity

Creative agency, or the recognition that an individual or team was able to creatively affect their environment, was noted by residents in both groups. Residents described that the curriculum helped them feel empowered to impact the health care system in a creative way. Most residents, regardless of group, believed in creative plasticity, or the thought that creativity could be learned to some degree. However, the experimental group more frequently displayed creative confidence or a positive self-image about their own creative skillset. Furthermore, the experimental group more frequently identified specific curricular activities as promoting creativity, describing many creative tools within the methodology. Residents from both groups described seeing medicine as the antithesis of creativity, citing treatment algorithms and clinical pathways as evidence. While this was not a widespread sentiment, some felt strongly that these skills were unfamiliar and at times even unnecessary in clinical practice.

Attitudes Toward QI

General attitudes toward QI surfaced when questions related to prior QI experiences and future career plans were explored. There were no qualitative differences between groups under this theme. There was a mix of positive and negative attitudes with many residents simultaneously offering both views. One resident reported that their QI curricular experience helped them discover a new career interest in QI. Many residents identified applications in their future career for lessons learned during the curriculum. Some who identified specific career interests in basic science research or medical education saw a potential translation of QI methodology, such as creative problem-solving skills, to their specific career goals. Others saw benefits of QI knowledge and soft skills that they developed through their QI project, such as communicating with stakeholders and empathic interviewing. Still, while many residents saw opportunities to apply these lessons learned, several specifically mentioned that QI work was not part of their career plans.

This study suggests equipoise between DT and A3 problem-solving as frameworks for QI curricula in their effect on internal medicine residents' attitudes toward systems change. While there were minimal differences between groups, our qualitative findings can help inform QI curriculum development in several respects. The most surprising results were that residents did not necessarily view creative problem-solving as a useful skill for their careers as physicians, and that despite being able to see other applications of QI skills, many residents did not view QI as part of their clinical work or professional identity as a physician.

Regardless of the curricular framework utilized, residents found value in learning a logical, systematic approach to QI. Perhaps this can be attributed in part to similarities between these frameworks. While the terminology is different, they are both rooted in the scientific method. Furthermore, residents are familiar with applying a structured approach to history-taking, differential diagnosis generation, and other aspects of clinical medicine, so this was not surprising. Similarly, it was expected that the level of peer engagement directly affected the learning experience. Since interpersonal dynamics are a key factor to the success of any team, and all QI work involves a team, this should be a deliberate consideration in QI curriculum design.

Other key factors to consider when developing a QI curriculum, regardless of framework, include project selection and faculty development. Our residents wanted to feel a personal connection to the problem they were solving. This sentiment did not seem to be directly related to the residents' control over project selection. However, residents who can select their own project are likely to choose something meaningful to them. This presents a challenge to QI educators who are trying to balance resident engagement with the desire to engage them in interprofessional projects that are aligned with local clinical quality goals. 12 , 29 Indeed, finding a QI problem that is meaningful to the residents, measurable, actionable, and institutionally aligned is the elusive holy grail of QI education. Since residents remarked on several facilitator factors such as enthusiasm for the subject, investing in professional development for QI faculty is likely to pay dividends both for assistance with project selection and for residents' learning experiences.

While curricula can be modified to influence the QI learning experience for residents, it is much more challenging to foster a mindset of continuous improvement. Residents in both the DT and Lean groups of our study recognized that QI concepts and skills could be applied to aspects of their future careers, but also did not view QI as part of their future work. QI education remains unpopular with many residents and medical students 30 , 31 ; thus, the applicability of QI principles to other aspects of a physicians' career may be a critical “hook” for QI educators. It remains concerning that many of the residents in this study did not view improving health care as part of their future work as physicians. Some also viewed clinical practice as algorithmic, precluding creativity. Solving problems for individual patients and solving problems for the local health care system appeared to be conceptually different to our residents.

For resident physicians, the feeling of being powerless to effect change can loom large. While it was encouraging that residents across both groups reported feeling empowered to have a creative impact on their environment, we did not find meaningful quantitative shifts in either groups' overall RTC score. However, the qualitative differences in factors influencing creativity suggest that DT may have more effective applications for specific learners or specific problems. It is important to note that these frameworks contain tools, not formulas, and we believe that other QI educators could benefit from the expanded curricular toolbox that DT provides.

This study is limited in that only internal medicine residents in one cohort at a single institution were included, which limits generalizability. Comparison across groups is confounded by faculty differences. While all our faculty were proficient in QI methods, teaching abilities and level of enthusiasm for the subject among the faculty may have varied, which in turn could impact the residents' satisfaction with their education. Similarly, the selection of QI projects (resident selected vs leadership selected) varied among cohorts, which could have impacted resident attitudes. However, our qualitative results emphasized that the relevance of the problem to residents' work, rather than whether they selected the problem, was the more important factor. As we modify available DT resources to meet our curricular needs, other applications might produce different resident perceptions. The RTC scale has some validity evidence but was not designed to measure creative tendencies and has not been used with physicians, thus it may not have effectively captured resident attitudes toward change. The study was not designed to examine other outcomes such as QI knowledge or skills, so we are unable to determine if our approaches influenced these outcomes. Participants did not provide feedback on our qualitative analysis findings, and the interview guide was not piloted with residents prior to use.

Future research steps may include exploring factors that influence resident professional identity formation related to QI and interventions or curricula that promote openness and creativity related to systems-based problem-solving.

This study, the first to compare different problem-solving methodologies for use in QI education, revealed qualitative and quantitative equipoise between DT and Lean A3 frameworks with both curricula fostering creative agency yet producing trivial effect size on residents' RTC. While our residents identified creative positive changes that they were able to effect on the clinical environment, as well as the broad applications of the skills learned, many still did not see systems-based problem-solving as part of their future professional identity or practice.

Supplementary Material

Funding: The authors report no external funding source for this study.

Conflict of interest: The authors declare they have no competing interests.

This work was previously presented at the NEGEA Annual Conference, Philadelphia, Pennsylvania, April 4–6, 2019.

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Development and validation of an A3 problem-solving assessment tool and self-instructional package for teachers of quality improvement in healthcare

Affiliations.

• 1 Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA [email protected].
• 2 Quality, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.
• 3 Medicine and Learning Health Sciences, Michigan School of Medicine, University of Michigan, Ann Arbor, Michigan, USA.
• 4 Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA.
• 5 Integrative Systems and Design, College of Engineering, University of Michigan, Ann Arbor, Michigan, USA.
• 6 Biobehavioral Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA.
• 7 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
• 8 Learning Health Sciences, University of Michigan Health System, Ann Arbor, Michigan, USA.
• PMID: 33771908
• DOI: 10.1136/bmjqs-2020-012105

Purpose: A3 problem solving is part of the Lean management approach to quality improvement (QI). However, few tools are available to assess A3 problem-solving skills. The authors sought to develop an assessment tool for problem-solving A3s with an accompanying self-instruction package and to test agreement in assessments made by individuals who teach A3 problem solving.

Methods: After reviewing relevant literature, the authors developed an A3 assessment tool and self-instruction package over five improvement cycles. Lean experts and individuals from two institutions with QI proficiency and experience teaching QI provided iterative feedback on the materials. Tests of inter-rater agreement were conducted in cycles 3, 4 and 5. The final assessment tool was tested in a study involving 12 raters assessing 23 items on six A3s that were modified to enable testing a range of scores.

Results: The intraclass correlation coefficient (ICC) for overall assessment of an A3 (rater's mean on 23 items per A3 compared across 12 raters and 6 A3s) was 0.89 (95% CI 0.75 to 0.98), indicating excellent reliability. For the 20 items with appreciable variation in scores across A3s, ICCs ranged from 0.41 to 0.97, indicating fair to excellent reliability. Raters from two institutions scored items similarly (mean ratings of 2.10 and 2.13, p=0.57). Physicians provided marginally higher ratings than QI professionals (mean ratings of 2.17 and 2.00, p=0.003). Raters averaged completing the self-instruction package in 1.5 hours, then rated six A3s in 2.0 hours.

Conclusion: This study provides evidence of the reliability of a tool to assess healthcare QI project proposals that use the A3 problem-solving approach. The tool also demonstrated evidence of measurement, content and construct validity. QI educators and practitioners can use the free online materials to assess learners' A3s, provide formative and summative feedback on QI project proposals and enhance their teaching.

Keywords: continuing education; continuing professional development; graduate medical education; health professions education; healthcare quality improvement; lean management.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

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Conflict of interest statement

Competing interests: None declared.

• Starting off on the right foot: providing timely feedback to learners in quality improvement education. Mayo AL, Wong BM. Mayo AL, et al. BMJ Qual Saf. 2022 Apr;31(4):263-266. doi: 10.1136/bmjqs-2021-013251. Epub 2021 Sep 22. BMJ Qual Saf. 2022. PMID: 34551994 No abstract available.

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A3 Problem Solving for Healthcare: A Practical Method for Eliminating Waste 1st Edition

The A3 process is a way to look with "new eyes" at a specific problem identified by direct observation or experience. It offers a structure that begins by always defining the issue through the eyes of the customer. In A3 Problem Solving for Healthcare Cindy Jimmerson explains an essential tool borrowed from the Toyota Production System, which is an extension of work identified with the well-known Value Stream Map. She offers an easy-to-learn problem-solving method that can be used in every aspect of healthcare to identify, understand, and improve processes that don't support workers in doing their good work. In this compelling book you get:

• The expertise of a recognized industry expert in Lean principles
• A practical, easy-to-use workbook
• Concepts illustrated with numerous A3s in various stages of development
• Explanation of how to extend the VSM philosophy to a more focused perspective
• An extensive exploration of the A3 problem-solving tool in healthcare―the first book to do so

Through case studies and actual A3s, this book illustrates the simplicity and completeness of the A3 tool and its applications to regulatory documentation as well as activities of daily work.

• ISBN-10 1563273586
• ISBN-13 978-1563273582
• Edition 1st
• Publication date June 11, 2007
• Language English
• Dimensions 11.02 x 8.27 x 0.37 inches
• Print length 176 pages
• See all details

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Editorial Reviews

When applying Lean thinking successfully to healthcare, two things are of paramount importance: (1) Keeping it simple and (2) Providing an engaging route map for improvement. With A3 Problem Solving for Healthcare, you get the recipe for both. I thoroughly recommend it. ― Professor Peter Hines, Director, Lean Enterprise Research Centre, Cardiff University, UK Doing more, better, faster, and with less is our new reality. Cindy, because of her curiosity, creativity and clinical acumen, demonstrates that solutions originating outside of our healthcare enterprise can realize (previously) unrealized results. ― Professor Kathy Okland, RN, MPH, Clinical Applications Consultant, Herman Miller Healthcare

What a great book to address a huge gap in healthcare process improvement! Having a source book to teach continuous change and illustrate waste reduction based on the Toyota Production System to busy healthcare practitioners has been sorely lacking until now. I have used the A3 in my hospital and it works! Clinical workers can see the entire project on one piece of paper as well as areas of obvious waste. Since the A3 clearly focuses on changing processes, the clinical workers are motivated to communicate across silos, successfully implement countermeasures, and look at the achieved target condition as the new current condition. The illustrations are superb and I loved all the practical examples. Great work Cindy! ― James Nesbitt, MD, MMM, Project Manager, Providence Alaska Medical Center This book is to be recommended for all hospitals that want to work with Lean and the A3 Problem Solving methodology. The book gives a great view of how The Toyota Production System can be applied to Healthcare all over the world. This book is written by a clinician for clinicians and is the book we have been waiting for. ― Inge Holck, General Manager, Lean Healthcare Europe

About the Author

Product details.

• Publisher ‏ : ‎ Productivity Press; 1st edition (June 11, 2007)
• Language ‏ : ‎ English
• Paperback ‏ : ‎ 176 pages
• ISBN-10 ‏ : ‎ 1563273586
• ISBN-13 ‏ : ‎ 978-1563273582
• Item Weight ‏ : ‎ 14.4 ounces
• Dimensions ‏ : ‎ 11.02 x 8.27 x 0.37 inches
• #574 in Quality Control (Books)
• #1,699 in Health Care Delivery (Books)
• #11,946 in Business Management (Books)

About the author

Cindy leduc jimmerson.

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Continuous Improvement Toolkit

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A3 Thinking: A Structured Approach to Problem Solving

• 5 MINUTES READ

Also known as A3 Problem Solving.

Variants include 8D and CAPA.

A significant part of a leader’s role involves addressing problems as they arise. Various approaches and tools are available to facilitate problem-solving which is the driving force behind continuous improvement. These methods range from the advanced and more complex methodologies like Six Sigma to the simpler and more straightforward A3 thinking approach.

The power of the A3 approach lies in its systematic and structured approach to problem-solving. Although it appears to be a step-by-step process, A3 is built around the PDCA philosophy. It relies on the principle that it is much better to address the real root-cause rather than trying to find a solution. Hence, it’s important not to jump to the solution when solving a problem as it is likely to be less effective.

A3 thinking provides an effective way to bring together many of the problem-solving tools into one place. For example, techniques such as the 5 Whys and fishbone analysis can be used during the ‘Analysis’ stage to help identifying the root causes. Additionally, visual aids and graphs are highly recommended in the A3 report, as they are more effective than text in communicating ideas and providing concise project updates.

A3 thinking involves the practice of consolidating the problem, analysis, countermeasures, and action plan onto a single sheet of paper, commonly an A3-sized sheet. This brief document serves as a summary of the project at hand and is regarded as a valuable storytelling tool for project communication. Utilizing the A3 approach doesn’t require any specialized software or advanced computer skills. You may however use readily available A3 templates , or rely on basic tools such as paper, pencil and an eraser as you will need to erase and rewrite several times.

One of the characteristics of the A3 approach is that it does not get into specific details. Detailed documents are usually attached to the A3 report to prevent overwhelming the reader with an excess of information.

The A3 process is typically structured in multiple stages based on the PDCA model. The primary focus is on developing understanding of the current situation and defining the desired outcome before thinking about the solution. While the exact number of stages may vary depending on the preference of the company, what truly matters is adhering to a structured approach to problem-solving.

A3 Seven Stages Model

An A3 process is often managed by an individual who should own and maintain the A3 report. This individual takes the lead in steering the process, facilitating team involvement, and preparing the A3 report with team input. One of the most common models for A3 thinking is the seven stages model which is described in the following.

1. Background – The first step is to identify the business reason for choosing this problem or opportunity. In this stage, you need to identify the gap in performance and the extent of the problem.

2. Current situation – The purpose of this stage is to document the current state of the problem. You may need to refer to the process map or go to the Gemba to truly understand the current situation.

3. Target – The purpose of this stage is to define the desired future state. Clearly identify the expected benefits from solving the problem, the scope, and the key metrics that will help measure the success of the project.

4. Analysis – The objective of this stage is to conduct an in-depth analysis of the problem and understand why it’s happening. It might involve tools like the 5 Whys and cause-and-effect analysis, as well as advanced statistical methods.

5. Countermeasures – Countermeasures are the actions to be taken to eliminate root causes or reduce their effects. The team should brainstorm and evaluate possible countermeasures based on the analysis conducted earlier.

6. Implementation Plan – To achieve the target, develop a workable plan to implement the countermeasures. Gantt charts are great ways to manage implementation plans very simply and easily. Once the action plan is finalized, the team should begin working on the activities needed to implement the countermeasures.

7. Follow-up – The final stage involves evaluating the implementation of the plan and the results achieved. Follow-up actions are important to ensure the benefits extend beyond the project’s completion.

A3 thinking is considered to be the practical form of the PDCA model.

There are many online templates that can be used to manage your problem-solving efforts. One of the simplest and most straightforward ways is to use this A3 problem solving template .

Wrapping Up

A3 thinking represents a logical and structured approach for problem solving and continuous improvement. This approach can be used for most kinds of problems and in any part of the business. Originating from the Toyota Production System (TPS), it has been adopted by many Lean organizations around the world.

A3 thinking not only provides a systematic approach for problem-solving. The development of a continuous improvement culture is at the core of A3 thinking. It has become one of the most popular Lean tools today where people and teams work together to solve problems, share results and learn from each other.

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A3 Problem Solving and Its Use in Healthcare

By OpEx Learning Team , Last Updated October 1, 2017

The A3 problem solving method originated at Toyota, but since then it’s spread all over the world and to many different industries. It’s flexible enough to be easily adapted to a variety of contexts, and it doesn’t take too long to get used to applying it to your own company. Healthcare in particular is a field that has benefited a lot from the adoption of the A3 method, and it’s not hard to find examples with a little research. How exactly does the method benefit this particular environment though, and why has it gained so much popularity among healthcare workers?

A Constant Need for Change

Healthcare is a hectic world and it’s one of the fields that is noticeably impacted by developments in technology. This means that a design that worked well yesterday might be practically obsolete tomorrow, and you have to always be on your toes when designing the layout of your facilities.

The A3 method allows you to get a concise, sensible overview of your current operations, and figure out exactly where potential bottlenecks could be. It’s not that easy to get this kind of overview when looking at raw data alone, and visualizing the problem with the help of the typical charts used in the A3 method can be extremely helpful.

Avoiding Mistakes

Doctors are regularly under a lot of pressure, and it’s frighteningly common for professionals in this field to make mistakes. It can sometimes take a long time until the root cause of a recurring error is discovered, and it’s also not rare to learn that the problem has been right under your nose the whole time.

For example, if certain mandatory reports don’t always pass through the appropriate channels for them, this might not get reflected in the general documentation, and it’s the type of problem that could easily slip through the cracks. When you do make a good top-down overview of the whole operation, you should start seeing the important patterns quickly enough, and any problems should become obvious.

On the other hand, the A3 problem solving method is also ideal for creating an environment where everyone has an appropriate level of accountability for their actions, as it helps you link every person in the organization to a trail that’s easy to follow.

Laying down the Foundation for Constant Improvement

As we mentioned above, medical facilities tend to be subject to rapid development and they regularly get access to new technology to use. This also means that the staff must be kept in the right mindset for constant improvement, and this is something that the A3 method can help with. If you keep running into issues with implementing a certain type of new technology, you can break down the problem into its fundamental components and figure out where the major bottlenecks are. Again, a top-down view of the whole operation of the hospital/clinic can go a long way in ensuring that no issues come up when something new has to be brought into the picture.

Ideal Physical Layout for Patient Convenience

Last but definitely not least, you can improve your operations a lot by making the place more physically convenient for patients. The A3 method is an obvious contender here, as it can give you a very convenient overview of how your current layout is affecting the rate at which patients can be treated. This in turn can have quite the impact on the general morale in the facility, and it can improve the relations between your physicians to a great extent. This might sound exaggerated, but in the end, addressing simple problems one by one can result in positive effects tacking up quite quickly.

There’s a good reason the A3 problem solving method has gained popularity outside of its original field of inception, and healthcare is just one example. We’re sure that we’re going to see many more in the coming years, especially when one also considers how much evolution lean-related methodologies have been seeing recently. If you’re interested in how A3 can help your own place out, definitely take a look at recent developments in the field and see if it would be appropriate for the issues you’re experiencing.

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