A3 Problem-solving for healthcare
January 4, 2017
By: Ted Schmidt, R.Ph., CERM
I read in Forbes that a new study (published in October 2015 issue of Anesthesiology) finds that medication errors occur in one-half (50%) of all surgeries. This incorporates the perioperative, surgery and postoperative periods. The data supports the cold reality that as healthcare providers, we must change to protect our patients. Part of the needed change is the way in which we solve problems.
Many may be familiar with the Problem-solving tool, A3. It originates from Toyota and has been used for decades to help with problem solving and continuous improvement. A3 is based on the P-D-C-A model for process management, so it aligns with our accreditation requirements from ISO 9001. In case you’re ever on a game show, the origin of “A3” has its roots in ISO. A3 is a size of paper that is 11 in. x 14 in. and the tool used this size by design to manage the problem solving activity on one-page. The ISO standard that dictates paper sizes is ISO 216. A3 was chosen by Toyota because it was large enough to hold all the data, yet force conciseness.
Here are the basic steps for completing an A3. Note that there are multiple sources online for details on how to complete an A3. The A3 tool has been used extensively in “lean” environments, mostly in manufacturing. There are many hybrids of the A3 and all meet a special need. For healthcare, we recommend a simpler format with a deeper dive in each section, specifically where we need help in healthcare.
Step 1- Identify the problem or need
You must be concise when describing the problem. You are simply defining the problem, not finding the cause. Describe the problem, such as “central line infections increased 25% in last 6 months in male CABG patients over 70 y/o not in CICU.” Other problems may be more qualitative, such as “scanning insurance cards in patient registration for same-day surgery has reduced since new software was implemented”. Qualitative or quantitative, be as concise as possible.
Step 2- Understand current condition
You need to state why this is a problem and the effect or potential effect on the hospital. This is where you validate the need to pursue this problem to effective resolution. Use a chart or some visual representation that will demonstrate quickly and completely the current state. Consider comparing current state to the objective(s) to show the disparity.
Step 3- Develop the target/proposal or goal statement
Describe what you are trying to achieve as quantitatively as possible. For instance, “reduction in central line infections (in above mentioned patients) to hospital goal of 0.15%”. Of course, different problems have different goals, so be appropriate and realistic. Some problems can have short-term and long-term goals. That’s totally appropriate and the long-term goals can still be managed through appropriate follow-up.
Step 4- Conduct a root cause analysis
Here is where all ISO organizations struggle, hospitals are no exception. We usually don’t have time or make time to fix the problem correctly, but we find time to fix it again. That's where we fail ourselves and our patients. There are a multitude of reasons why this is an issue in itself, so I’ll only focus on the need to conduct a thorough root cause analysis using all appropriate parties affected by or affecting the problem…including that are indirectly related to the problem. This is where we struggle. Albert Einstein said that if he had one hour to fix a problem, he’d spend 55 minutes determining the cause and 5 minutes fixing the problem. This same logic should be adopted in hospitals. Use the tools that work best for your hospital and your culture. Determining the correct root cause(s) to the problem will better ensure sustainability of the fix and likely prevent the problem from recurring. Place your results of your root cause analysis in the proper block on your A3.
Step 5- Brainstorm countermeasures and create implementation plan
Once we know the cause, the countermeasure usually comes to us quickly. Likely the same group that determined the cause will assist with the fix, maybe some minor additions/deletions. Be specific in the plan with details, such as who will do what action, when they will do the action, where the action may be taken, etc. This can be managed simply or more robustly, depending on the degree of risk associated with the problem. This plan should also be updated as actions occur.
Step 6- Follow-up by checking results to confirm effectiveness and sustainability
Remember the goal statement in Step 3 above? We need to review the progress and effectiveness of the actions taken to ensure that the problem resolves and does not recur. We also need to be aware that there are no unintended consequences for these actions taken. Long-term objectives will require long-term follow-up. We should also keep records of these follow-ups to show progress over time.
Some closing points about the A3 problem-solving tool: A3 is an easy tool to use; it follows the requirements in the ISO chapter for nonconformity and corrective action. It is traditionally a lean tool, so all your data about the problem should fit on the one 11 x 14 paper. It should be visual and concise. If you follow the flow of the A3 tool, it should begin in the upper-left hand side and flow to the bottom right-hand side, telling the story of the problem…and the solution! There should be a moderator or facilitator for each A3; someone to ensure the A3 process is maintained. The format is not as important as the process and the work that takes place getting to the actions and follow-up.
A3s are a simple tool. Many hospitals use this method for process improvements as well as corrective actions. It is designed to be effective and “lean”, so you can have time to work in other areas of your hospitals, like addressing opportunities. The simple discipline that an A3 brings can be a part of our “accreditation revolution”…using existing infrastructure and resources to help make our hospitals a safer place for our patients….and reduce the number of surgery patients that experience medication errors down to the hospital goal…say 0.15%?
Download a sample A3 tool below.
Ted Schmidt is a Pharmacist, a Certified Enterprise Risk Manager (CERM©), and a Senior Advisor with BlueSynergy Associates, LLC. BlueSynergy Associates maximize innovation, experience and customer perspective to reduce risk and make hospitals a safer environment. He currently advises and instructs hospitals in quality, risk, safety and environmental management systems. Ted led the largest ISO 9001 implementation in healthcare at the Veterans Administration. He is a Senior Member of the American Society for Quality and a certified Lead Auditor in quality management systems by Exemplar Global. He can be reached by email at tschmidt@bluesynergyassociates.com. Follow BlueSynergy on LinkedIn and Twitter
By: Ted Schmidt, R.Ph., CERM
I read in Forbes that a new study (published in October 2015 issue of Anesthesiology) finds that medication errors occur in one-half (50%) of all surgeries. This incorporates the perioperative, surgery and postoperative periods. The data supports the cold reality that as healthcare providers, we must change to protect our patients. Part of the needed change is the way in which we solve problems.
Many may be familiar with the Problem-solving tool, A3. It originates from Toyota and has been used for decades to help with problem solving and continuous improvement. A3 is based on the P-D-C-A model for process management, so it aligns with our accreditation requirements from ISO 9001. In case you’re ever on a game show, the origin of “A3” has its roots in ISO. A3 is a size of paper that is 11 in. x 14 in. and the tool used this size by design to manage the problem solving activity on one-page. The ISO standard that dictates paper sizes is ISO 216. A3 was chosen by Toyota because it was large enough to hold all the data, yet force conciseness.
Here are the basic steps for completing an A3. Note that there are multiple sources online for details on how to complete an A3. The A3 tool has been used extensively in “lean” environments, mostly in manufacturing. There are many hybrids of the A3 and all meet a special need. For healthcare, we recommend a simpler format with a deeper dive in each section, specifically where we need help in healthcare.
Step 1- Identify the problem or need
You must be concise when describing the problem. You are simply defining the problem, not finding the cause. Describe the problem, such as “central line infections increased 25% in last 6 months in male CABG patients over 70 y/o not in CICU.” Other problems may be more qualitative, such as “scanning insurance cards in patient registration for same-day surgery has reduced since new software was implemented”. Qualitative or quantitative, be as concise as possible.
Step 2- Understand current condition
You need to state why this is a problem and the effect or potential effect on the hospital. This is where you validate the need to pursue this problem to effective resolution. Use a chart or some visual representation that will demonstrate quickly and completely the current state. Consider comparing current state to the objective(s) to show the disparity.
Step 3- Develop the target/proposal or goal statement
Describe what you are trying to achieve as quantitatively as possible. For instance, “reduction in central line infections (in above mentioned patients) to hospital goal of 0.15%”. Of course, different problems have different goals, so be appropriate and realistic. Some problems can have short-term and long-term goals. That’s totally appropriate and the long-term goals can still be managed through appropriate follow-up.
Step 4- Conduct a root cause analysis
Here is where all ISO organizations struggle, hospitals are no exception. We usually don’t have time or make time to fix the problem correctly, but we find time to fix it again. That's where we fail ourselves and our patients. There are a multitude of reasons why this is an issue in itself, so I’ll only focus on the need to conduct a thorough root cause analysis using all appropriate parties affected by or affecting the problem…including that are indirectly related to the problem. This is where we struggle. Albert Einstein said that if he had one hour to fix a problem, he’d spend 55 minutes determining the cause and 5 minutes fixing the problem. This same logic should be adopted in hospitals. Use the tools that work best for your hospital and your culture. Determining the correct root cause(s) to the problem will better ensure sustainability of the fix and likely prevent the problem from recurring. Place your results of your root cause analysis in the proper block on your A3.
Step 5- Brainstorm countermeasures and create implementation plan
Once we know the cause, the countermeasure usually comes to us quickly. Likely the same group that determined the cause will assist with the fix, maybe some minor additions/deletions. Be specific in the plan with details, such as who will do what action, when they will do the action, where the action may be taken, etc. This can be managed simply or more robustly, depending on the degree of risk associated with the problem. This plan should also be updated as actions occur.
Step 6- Follow-up by checking results to confirm effectiveness and sustainability
Remember the goal statement in Step 3 above? We need to review the progress and effectiveness of the actions taken to ensure that the problem resolves and does not recur. We also need to be aware that there are no unintended consequences for these actions taken. Long-term objectives will require long-term follow-up. We should also keep records of these follow-ups to show progress over time.
Some closing points about the A3 problem-solving tool: A3 is an easy tool to use; it follows the requirements in the ISO chapter for nonconformity and corrective action. It is traditionally a lean tool, so all your data about the problem should fit on the one 11 x 14 paper. It should be visual and concise. If you follow the flow of the A3 tool, it should begin in the upper-left hand side and flow to the bottom right-hand side, telling the story of the problem…and the solution! There should be a moderator or facilitator for each A3; someone to ensure the A3 process is maintained. The format is not as important as the process and the work that takes place getting to the actions and follow-up.
A3s are a simple tool. Many hospitals use this method for process improvements as well as corrective actions. It is designed to be effective and “lean”, so you can have time to work in other areas of your hospitals, like addressing opportunities. The simple discipline that an A3 brings can be a part of our “accreditation revolution”…using existing infrastructure and resources to help make our hospitals a safer place for our patients….and reduce the number of surgery patients that experience medication errors down to the hospital goal…say 0.15%?
Download a sample A3 tool below.
Ted Schmidt is a Pharmacist, a Certified Enterprise Risk Manager (CERM©), and a Senior Advisor with BlueSynergy Associates, LLC. BlueSynergy Associates maximize innovation, experience and customer perspective to reduce risk and make hospitals a safer environment. He currently advises and instructs hospitals in quality, risk, safety and environmental management systems. Ted led the largest ISO 9001 implementation in healthcare at the Veterans Administration. He is a Senior Member of the American Society for Quality and a certified Lead Auditor in quality management systems by Exemplar Global. He can be reached by email at tschmidt@bluesynergyassociates.com. Follow BlueSynergy on LinkedIn and Twitter
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