1 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 Managing with A3 Thinking

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? 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!

4 “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, …” So Many Solutions!

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

6 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

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

8 Where is Disagreement? 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? 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?

10 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

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

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

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

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

16 Purpose: A standard communication tool to make it easier to understand each other: It fosters effective and efficient dialogue within the organization. It develops thinking problem-solvers. It encourages front-line initiative. It cascades responsibility. It clarifies who is responsible for problems or steps. It exposes lack of agreement that can undermine plans. Adapted from John Shook A3 Benefits

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

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

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

20 A3 Outline (Boxes) Create about five to seven boxes, combining the appropriate items to make your story as simple and clear as possible. 1.Title (theme), owner, draft date 2.Background 3.Current situation, Current State Map 4.Goal or target 5.Investigation of facts, analysis, root cause analysis 6.Recommendations, countermeasures, strategies, alternatives 7.Action Plan – what, who, when 8.Verification of countermeasures 9.Review/Critique 10.Possible next steps, further action, follow up Adapted from John Shook

Which Tool Could Be Used … BACKGROUNDGraphSketch INVESTIGATIONTally-sheetHistogram CURRENT STATEPareto DiagramGraph Scatter DiagramSketch Control ChartCS Map TARGET, OUTCOMESChartSketch ACTION PLANGantt Chart ANALYSISCause-and-Effect FishboneControl Chart Relation DiagramHistogram Tree DiagramGraph Pareto DiagramSketch Scatter Diagram COUNTERMEASURESGraphChart SketchFS Map VERIFICATION OFPareto DiagramGraph COUNTERMEASURESHistogramSketch Scatter DiagramChart PREVENTIONSSketchChart REVIEW/CRITIQUE Each item (box) should contain a graph, chart, or sketch. Use words only when a graph, chart, or sketch cannot show the details of the contents, or it is impossible to explain the contents with them. Adapted from John Shook

22 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

23 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?

24 Evolving Uses of A3 at UMHS To Build Consensus on Tough Problems: UMHS annual operating budget 10 year Strategic Financial Plan Planning the Lean Transformation in Ambulatory Care Why we’re having problems creating the Ideal Patient Care Experience 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”

25 Evolving Uses of A3 at UMHS To Build Consensus Around Proposals Improving Acute Medical and Surgical Streams Advanced Medical Home 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) To Provide Status Reports –Track progress on top objectives (Children’s OR flow)

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

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

30 Practice in A3 problem-solving, presenting, critiquing

31 A3 Group Learning Exercise Work in teams Imagine clearly the story: the proposal you want to make or the problem you want to solve. Focus on the left hand side: –What is the problem? Who owns the problem? –Why is it important to the organization? –How does it punch through to hurt a customer? –What is the current state? –What are our goals? –(What are the root causes? Not today! No why before its time - David Verble) Before filling in the right: –Recommendations, countermeasures, plans…

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

33 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

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