1 Building Consensus and Generating Authority Jack Billi, M.D. jbilli@umich.edu...

1

Building Consensus and Generating Authority

Jack Billi, M.D.jbilli@umich.edusitemaker.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 implementlean to reduce waste andimprove 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

Transit

ion 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

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:

• 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

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

1.

2.

3.

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 date2. Background 3. Current situation, Current State Map4. Goal or target 5. Investigation of facts, analysis, root cause analysis 6. Recommendations, countermeasures, strategies,

alternatives7. Action Plan – what, who, when8. Verification of countermeasures9. Review/Critique 10. Possible next steps, further action, follow up

Adapted from John Shook

Which Tool Could Be Used …

BACKGROUND Graph SketchINVESTIGATION Tally-sheet HistogramCURRENT STATE Pareto Diagram Graph

Scatter Diagram SketchControl Chart CS Map

TARGET, OUTCOMES Chart SketchACTION PLAN Gantt Chart ANALYSIS Cause-and-Effect Fishbone Control Chart

Relation Diagram HistogramTree Diagram GraphPareto Diagram SketchScatter Diagram

COUNTERMEASURES Graph ChartSketch FS Map

VERIFICATION OF Pareto Diagram Graph COUNTERMEASURES Histogram Sketch

Scatter Diagram Chart PREVENTIONS Sketch Chart 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

Title: What we are talking about.

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? What is our current performance?Trend chart, current state value stream map

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 and alternatives need to be considered?

What are your proposed countermeasures, strategies, alternatives? Do they link directly to the root cause?Include options (some needingno resources)Future State Value Stream Map?

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?

Date: Owner:An A3 Template

Background

Clear Problem Statement

Goal

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

Physical Therapist

Nurse

Grandson

A3

Pull-Based Authority

Early Mobilization of ICU Ventilator Patients

29

30

31

IHI Open School – student organized QI learning –MD, RN, Pharm, Soc Work, Engineer, MPH, MBAA3 workshop: multidisciplinary problem solving

32

Practice in A3 problem-solving, presenting, critiquing

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/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

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