1. Building Consensus and Generating Authority
Managing with A3 Thinking
Building Consensus and Generating Authority
Jack Billi, M.D.
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

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

3. 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

4. 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, …”

5. 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

6. 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

7. 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

8. 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”

9. 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

10. “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

11. “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

12. 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

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

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

15. 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

16. 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

17. 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

18. 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

19. 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:

20. 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

21. 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

22. 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

23. 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

24. 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?

25. 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”

26. 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)

27. 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”

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

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

32. Practice in A3 problem-solving, presenting, critiquing

33. 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: webinars, books, meetings…
Lean Healthcare Leaders Network
Lean Enterprise Academy (UK):

34. 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