Building Consensus and Generating Authority Managing with A3 Thinking Building Consensus and Generating Authority Jack Billi, M.D. jbilli@umich.edu sitemaker.umich.edu/jbilli Michigan Quality System: med.umich.edu/mqs Adapted from John Shook, Dave LaHote, Margie Hagene, with permission Michigan Quality System: Quality Safety Efficiency Appropriateness Service

A Question For You What makes projects fail? Think of a specific project… Why did it not succeed?

What makes lean projects (or any project) fail? John Shook * David Verble What makes lean projects (or any project) fail? lack of knowledge? lack of a plan? lack of leadership? lack of discipline? lack of commitment? lack of a champion? lack of resources? lack of focus? lack of…AGREEMENT! May 1, 2001 12

So Many Solutions! “We need to implement lean to reduce waste and improve efficiency” “We need white boards in patient rooms so patients know who their doctors are” “We need a new EMR to consolidate and organize patient information” “We need more exam rooms, more nurses, more ORs, more instruments, …”

Is the Issue Agreement? Future State Transition Plan Current State Do we really agree on the where we want to go? On what the gap in performance is? Future State Do we really agree on how we will get there? Transition Plan Do we really agree on the where we are? On the current condition? Current State 5

How do you get agreement? John Shook * David Verble How do you get agreement? Sample answers: Persuade with logic Appeal to emotion Overwhelm with data Dictate Threaten Manipulate Trade favors Compromise Others? Pro’s / Con’s 26

How Do We Get Agreement? State your case more strongly than others Force your perspective Meeting people into submission $495 I’ve got the data Do the Hard Sell

Where is Disagreement? “You won’t believe what they want us to do” Your Idea “You won’t believe what they want us to do” “Yea, like I’m going to do that”

How do you get agreement? John Shook * David Verble How do you get agreement? Most effective is to tell a persuasive story,  if so, Would it not be best to tell it concisely, preferably visually and in a standard format? May 1, 2001 26

“A3 Thinking” A Template for Structured Problem-Solving Background: “A3” is just a paper size (~11” x 17”) 1960s: Quality Circles problem-solving format At Toyota, it evolved to standard format: Problem-solving Proposals Plans Status reviews “A problem clearly defined is half solved” Adapted from John Shook

“A3 Thinking” A Template for Structured Problem-Solving Traits: An A3 lays out an entire plan, large or small, on one sheet of paper. It should tell a story, laid out from upper left to lower right, which anyone can understand. It should be visual and extremely concise. What is important is not the format, but the process and thinking behind it, and the conversations it facilitates. Adapted from John Shook

A3 Discipline State the issue and why it is important Provide background to facilitate understanding Current performance and future goals Analysis and root causes Countermeasures and action plans Measurement and adjustment methods

Scientific Method (PDCA Cycle) Grasp the Situation Plan (Hypothesis) Do (Try) Check (Reflect) Act (Adjust) Countermeasures implemented as Experiments

Scientific Method (PDCA Cycle) Plan (Hypothesis) Do (Try) Check (Reflect) Act (Adjust) Grasp the Situation Countermeasures implemented as Experiments

Modified -Verble/Shook An A3 Template Title: What we are talking about. Date: Owner: Background Recommendations Of all our problems, why this one? The “ugly story”… What are your proposed countermeasures, strategies, alternatives? Current Situation Where do we stand? Problem Statement: Plan What activities will be required? What , Who, When? Goal What is the specific change we want to accomplish now? Analysis -What are the root causes, requirements, constraints? Follow - up How we will know? What remaining issues? Modified -Verble/Shook

A3 Benefits Purpose: A standard communication tool to make it easier to understand each other: Fosters effective and efficient dialogue. Develops thinking problem-solvers. Encourages front-line initiative. Cascades responsibility. Clarifies who is responsible for problems or steps. Exposes lack of agreement that can undermine plans. Adapted from John Shook

A3 Benefits Builds consensus and gives the authority to take action – pull-based authority Encourages PDCA (Plan, Do, Check, Adjust) – scientific problem solving. Forces “5S for information.” Clarifies the link (or lack) among problems, root causes, countermeasures. It leads to effective countermeasures and solutions based on facts and data. Adapted from John Shook

A3 - A Template For Structured Problem Solving… …Does this sound familiar?? Title: What we are talking about. Date: Owner: Background Recommendations Of all our problems, why this one? The “ugly story”… What are your proposed countermeasures, strategies, alternatives? Current Situation Where do we stand? Problem Statement: Plan Goal What activities will be required? What , Who, When? What is the specific change we want to accomplish now? Analysis Follow - up -What are the root causes ,requirements, constraints? How we will know? What remaining issues? Modified -Verble/Shook

Impression - Diagnoses New Patient H&P Name of Patient: Date: Clinician: History Impression - Diagnoses Chief Complaint History of Present Illness Past Medical & Surgical History Medications and Allergies Family and Social History Review of Systems 1. 2. 3. Plans Diagnostic: 1, 2, 3, Treatment: Physical Exam General Appearance, Vital Signs HEENT Heart & Lungs Abdomen Extremities Neuro Follow - up Monitor x, y, z Return visit:

A3 Outline (Boxes) Title (theme), owner, draft date Background Create about five to seven boxes, combining the appropriate items to make your story as simple and clear as possible. Title (theme), owner, draft date Background Current situation, Current State Map Goal or target Investigation of facts, analysis, root cause analysis Recommendations, countermeasures, strategies, alternatives Action Plan – what, who, when Verification of countermeasures Review/Critique Possible next steps, further action, follow up Adapted from John Shook

Which Tool Could Be Used … Each item (box) should contain a graph, chart, or sketch. Use words only when a graph, chart, or sketch cannot show the details of the contents, or it is impossible to explain the contents with them. BACKGROUND Graph Sketch INVESTIGATION Tally-sheet Histogram CURRENT STATE Pareto Diagram Graph Scatter Diagram Sketch Control Chart CS Map TARGET, OUTCOMES Chart Sketch ACTION PLAN Gantt Chart ANALYSIS Cause-and-Effect Fishbone Control Chart Relation Diagram Histogram Tree Diagram Graph Pareto Diagram Sketch Scatter Diagram COUNTERMEASURES Graph Chart Sketch FS Map VERIFICATION OF Pareto Diagram Graph COUNTERMEASURES Histogram Sketch Scatter Diagram Chart PREVENTIONS Sketch Chart REVIEW/CRITIQUE Adapted from John Shook

Title: What we are talking about. Date: Owner: Background An A3 Template Title: What we are talking about. Date: Owner: Background Recommendations Of all our problems, why are we talking about this one? The “ugly story”… Historical/organizational/business context… What are your proposed countermeasures, strategies, alternatives? Do they link directly to the root cause? Include options (some needing no resources) Future State Value Stream Map? Current Situation Where do we stand? What is our current performance? Trend chart, current state value stream map Plan What , Who, When? What activities will be required for implementation and who will be responsible for what and when? Clear Problem Statement Goal Goal What is the target condition or performance improvement you want now? Measurable, by when? Analysis Follow - up What are the root causes of the problem? (Fishbone, 5 Whys, Pareto) What requirements, constraints and alternatives need to be considered? How we will know if the actions have the impact needed? What remaining issues can be anticipated? When/how will we follow up? Reviewed By: Date: Modified from Verble, Shook, LaHote, Billi

A3 Roles 3 Roles: Creating the A3 encourages systematic problem solving, using “go see, ask why, respect people” Presenting the A3 fosters consensus, commitment to move forward Discussing the A3 fosters critical analytic skills, communication, respect

A3 Thinking is about Reaching Consensus Consensus on: What is the problem? Who owns the problem? Why is this problem important? - ‘The ugly story’. What are our goals? What are the root causes? What strategies/options will we try to overcome the root causes? What plan will we use to try the strategies? - Who will do what, when? When/where will we follow up?

Evolving Uses of A3 at UMHS To Build Consensus on Tough Problems: Planning the Lean Transformation in Ambulatory Care Redesign of a Regional Health Coalition: Employers/Payers/Providers: purpose, process, people University’s 5 Year Health Benefits Strategy: “Healthy and Solvent University Community” IT strategy – from “best-of-breed” to “prime vendor”

Evolving Uses of A3 at UMHS To Build Consensus Around Proposals (plan) Improving Acute Medical and Surgical Streams Single county-wide ACO Major clinical expansion in a geographic region IT capital project review ($50M in requests v. $13M) Annual PDCA and plan for Michigan Quality System Requests for central lean coach resources Creation of a claims data warehouse for Michigan physician organizations, with Blue Cross Fourth year medical student projects (1 mo. elective)

Evolving Uses of A3 at UMHS To Provide Status Reports – (check and adjust) Creating the Ideal Patient Care Experience Tracking each of 7 planks Improvements to Children’s OR flow Acute Medical Stream improvements Progress on Strategic Plan “strategies”

Pull-Based Authority A3 Early Mobilization of ICU Ventilator Patients Physical Therapist Nurse Grandson Pull-Based Authority A3

IHI Open School – student organized QI learning – MD, RN, Pharm, Soc Work, Engineer, MPH, MBA A3 workshop: multidisciplinary problem solving

Practice in A3 problem-solving, presenting, critiquing

A3 References 05.17.10 Books with Focus on A3 Use: Shook. Managing to Learn. (Best book on leadership in a lean organization and A3 use) Sobek, Smalley. Understanding A3 Thinking. (Problem solving and A3 use) Dennis. Getting the Right Things Done. (Strategy deployment or hoshin kanri) Liker, Meier. Toyota Way Fieldbook. (Practical lean tools) Baker, Taylor. Making Hospitals Work. (Workbook from Lean Enterprise Academy, UK) Graban. Lean Hospitals. (General lean healthcare reference) Lean Web Resources: Michigan Quality System at UMHS: med.umich.edu/mqs Lean Enterprise Institute: www.lean.org webinars, books, meetings… Lean Healthcare Leaders Network www.healthcarevalueleaders.org Lean Enterprise Academy (UK): www.leanuk.org 05.17.10

A3 Presentation Etiquette Model respect: in presentation and feedback Presenter gives everyone an 11”x17” copy, for notes Present straight through from the A3, not slides or memory If you have a “better story”, use it in the A3 Listeners don’t interrupt: only clarifying questions Plenty of time for feedback: time for mentoring Open ended questions, not answers Ask questions you don’t know the answer to Presenter modifies A3 right now, based on the feedback/questions