Steps of the A3 Process

The following steps will guide you through the A3 Process. To get a more in-depth explanation of the step, click on the step and a popup window will appear with more information. If you're using Internet Explorer and have popups blocked, you will have to unblock them to see the window.
Step Step Step Step Step Step Step 0: 1: 2: 3: 4: 5: 6: Identify a problem or need Conduct research to understand the current situation Conduct root cause analysis Devise countermeasures to address root causes Develop a target state Create an implementation plan Develop a follow-up plan with predicted outcomes

The results of steps 0-6 can be recorded on an A3 report. Click hereto download an MS Word template of an A3 Report. Step Step Step Step 7: Discuss plans with all affected parties 8: Obtain approval for implementation 9: Implement plans 10: Evaluate the results

Note that the A3 process is rooted in the more basic PDCA cycle. Steps 1-8 are the Plan step (with step 5 planning the Do step and step 6 planning the Check step). Step 9 is the Do step, and step 10 is the Check step. Based on the evaluation, another problem may be identified and the A3 process starts again (Act).

STEP 0: Identify Problem or Need

Whenever the way work happens is not ideal, or when a goal or objective is not being met, you have a problem (or, if you prefer, a need). The best problems to work on are those that arise in day-to-day work and prevent you from doing your best.

EXAMPLE: Patients in a hospital were not arriving to the diagnostic departments during their allotted time. Because the patients were late, the diagnostic departments were getting backed up. Thus the problem to be addressed was: reducing patient back-ups in the hospitals diagnostic departments due to late arriving patients.

STEP 1: Understand Current Situation

Before a problem can be properly addressed, one must have a firm grasp of the current situation. To do this, Toyota suggests that problem-solvers:

Observe the work processes first hand, and document ones observations. Create a diagram that shows how the work is currently done. Any number of formal process charting or mapping tools can be used, but often simple stick figures and arrows will do the trick. Quantify the magnitude of the problem (e.g., % of customer deliveries that are late, # of stock outs in a month, # of errors reported per quarter, % of work time that is value-added); if possible, represent the data graphically.

EXAMPLE: Below is an example of the diagram representing the current condition of patient transport in a hospital, showing how transporters are contacted to transport patients with mobility difficulties to their appointments in the diagnostic departments. The storm bursts call out problems with the current situation. The data indicate the ranges and averages of patient delivery time.

STEP 2: Root Cause Analysis

Once you have a good understanding of how the process (i.e., the one that needs to be fixed) currently works, its time to figure out what the root causes are to the errors or inefficiency. To accomplish this, first make a list of the main problem(s). Next, ask the appropriate why? questions until you reach the root cause. A good rule-of-thumb is that you havent reached the root cause until youve asked why? at least five times in series.

EXAMPLE: A team trying to improve patient transport processes recognized that the main problem was that patients were not arriving on time for their diagnostic procedures, causing severe back ups in the diagnostic departments. In this case, three causes to patients arriving late were identified by observation, and each was pursued to a root cause, as shown below.

Problem: Backups in diagnostic departments Why? Patients arriving late

Why? Transporter not called on time Why? Ward secretaries are busy and often forget. Why? No written message Why? No protocol Why? Transport unable to locate patient Why? Page does not include patient location (name only) Why? No standard protocol for transport paging Why? Patient not ready for transport Why? Nurses unaware of prescribed test Why? No mechanism to inform RN of scheduled procedure

The root cause analysis revealed that patients were arriving late because the hospital had no procedure for notifying appropriate personnel of a transportation need, and that transporters and RNs were not contacted directly by the requesting department.

STEP 3: Countermeasures
Once the current situation is fully understood and the root cause(s) for the main problem(s) has been unveiled, its time to devise some countermeasures. Countermeasures are the changes to be made to the work processes that will move the organization closer to ideal, or make the process more efficient, by addressing root causes. Generally speaking, we recommend that countermeasures help the process conform to three rules borrowed from Steven Spear and Kent Bowen1 and slightly expanded: Specify the outcome, content, sequence, and task of work activities Create clear, direct connections between requestors and suppliers of goods and services Eliminate loops, workarounds, and delays

EXAMPLE: The team investigating delayed transport of patients to diagnostic departments discovered that the root cause was lack of clear protocol for communicating between the diagnostic department, RN of the clinical department, and the transporter. To fix this problem, they came up with some countermeasures that included: A new protocol where the diagnostic department pages the charge RN and the transporter at the same time (thus eliminating the ward secretary as an intermediary). Specified information content of pages. New patient preparation procedures involving both the RN (or technician designated by the RN) and the transporter

See: S.J. Spear and H.K. Bowen, The DNA of the Toyota Production System, Harvard Business Review, Sep-Oct 1999.

STEP 4: Develop the Target State

The countermeasure(s) addressing the root cause(s) of the problem will lead to new ways of getting the work done, what we call the target condition or target state. It describes how the work will get done with the proposed countermeasures in place. In the A3 report, the target condition should be a diagram (similar to the current condition) that illustrates how the new proposed process will work. The specific countermeasures should be noted or listed, and the expected improvement should be predicted specifically and quantitatively.

EXAMPLE: A target condition for a revamped patient transportation process is depicted below.

STEP 5: Implementation Plan

In order to reach the target state, one needs a well thought-out and workable implementation plan. The implementation plan should include a list of the actions that need to be done to get the countermeasures in place and realize the target condition, along with the individual responsible for each task and a due date. Other relevant items, such as cost, may also be added.

EXAMPLE: An example of a simple implementation plan is below. Note that the task, the person responsible, deadlines and the outcome of the tasks are all specified.

STEP 6: Follow-up Plan

A critical step in the learning process of problem-solvers is to verify whether they truly understood the current condition well enough to improve it. Therefore, a follow-up plan becomes a critical step in process improvement to make sure the implementation plan was executed, the target condition realized, and the expected results achieved. You can state the predicted outcome here rather than in the target condition, if you prefer.

EXAMPLE: The manager of transportation, and head of the A3 process team, set the goal for patient transport time at 30 minutes, maximum. Once a month, for three months after the initial implementation, he would measure a sample of transportation pages, and calculate the average time from transportation page to patient arrival at the diagnostic department.

STEP 7: Discuss With All Affected Parties

Its VITALLY important to communicate with all parties affected by the implementation or target condition, and try to build consensus throughout the process. We have included it as a specific step before approval and implementation to make sure it does not get skipped. But the most successful process improvement projects we have witnessed do this step at each critical juncture. Concerns raised should be addressed insomuch as possible, and this may involve studying the problem further or reworking the countermeasures, target condition, or implementation plan. The goal is to have everyone affected by the change aware of it and, ideally, in agreement that the organization is best served by the change.

EXAMPLE: To make sure that all affected parties were involved in the process improvement effort, the manager of the transportation first gathered a cross-functional team together to study the problem and come up with countermeasures. Then, once the countermeasures and target condition were created, he communicated with key representatives of the participating departments to a) solicit their agreement, and b) plan the education and training in the new systems. In this case, only minor adjustments to the proposed changes were needed. The implementation plan then reflected the outcomes of those meetings.

STEP 8: Get Approval

If the person conducting the A3 process is not a manager, its imperative to remember the importance of obtaining approval from an authority figure to carry out the proposed plan. The authority figure should verify that the problem has been sufficiently studied and that all affected parties are on board with the proposal. The authority figure may then approve the change and allow implementation.

EXAMPLE: The manager of the transportation department was in a position to approve changes to procedures of the transporters, but he had to obtain approval for his changes and implementation from the managers of all of the affected departments. Ideally, his manager would have approved the change in order to provide a mentoring opportunity, but this did not happen in this case.

STEP 9: Implementation
Without implantation, no change occurs. The next step is to execute the implementation plan.

EXAMPLE: The A3 process team had a meeting, charted their specific actions/tasks and deadlines in their implementation plan. Once the proper approvals were given, they executed their designated tasks and completed them by the deadlines.

STEP 10: Evaluate the Results

Process improvement should not end with implementation. It is very important to measure the actual results and compare to predicted. If the actual results differ from the predicted ones, research needs to be conducted to figure out why, modify the process and repeat implementation and follow-up (i.e., repeat the A3 process) until the goal is met.

EXAMPLE: The manager of transportation picked specific dates to check the outcome of the countermeasures and implementation plan created by the A3 process team. On three specific dates, he timed twenty patient transports from the initial page to patient arrival at the diagnostic department, and recorded the results with dates on the A3 report. The results were: March, 14.7 minutes April, 11 minutes May, 9.15 minutes These exceeded the goal of 30 minutes.

The A3 Report
The A3 Report goes hand-in-hand with steps 0-6 of the A3 Process. The purpose of the A3 Report is to: Document the learning, decisions, and planning involved with solving a problem, Facilitate communication with people in other departments, and Provide structure to problem-solving so as to maximize learning. The report (template) is designed to be printed on 11x17 inch paper (or two pieces of 8.5x11 inch paper) as shown in the diagram below. For additional explanations of the individual parts of the report, click on the title box for that part. You can also download an A3 Report template in MS Word format; however, remember this is a flexible tool and can be adapted to specific situations--just don't short circuit the process!

 Download A3 Report Template (MS Word) Download A3 Report Format (PDF)

Theme:
The theme of your A3 report should be a concise statement of what the A3 report is about. It should answer the question, What are we trying to do here?

An example of a theme might be, decrease patient transport time to diagnostic departments.

Background:
The background section includes any contextual or background information necessary to fully understand the issue. Its also important to indicate how this problem relates to the companys goals or values.

Example: The transportation department regularly receives complaints from diagnostic departments that patients arrive late for their appointments. This causes delays in patient treatment, idle time for diagnostic department staff members, and backups in the diagnostic areas resulting in long patient wait times.

Current Condition:

For the A3 report, the current condition needs to be an image illustrating how the current process works. Its important to label the diagram so that anyone knowledgeable about the process will be able to understand it. Major problems also need to be included. Put them in storm bursts so they are set apart from the diagram. Hand-drawn diagrams (in pencil) are often the most effective because they can be done quickly and changed easily on-the-spot.

Cause Analysis:
To start your root cause analysis, make a list of the main problem(s). Next ask the appropriate why? questions until you reach the root cause. A good rule-of-thumb is that you havent reached the root cause until youve asked why? at least five times. Record the causal chain(s) on the A3 report.

Example: Problem: Backups in diagnostic departments Why? Patients arriving late Why? Transporter not called on time Why? Ward secretaries are busy and often forget. Why? No written message

Why? No protocol Why? Transport unable to locate patient Why? Page does not include patient location (name only) Why? No standard protocol for transport paging Why? Patient not ready for transport Why? Nurses unaware of prescribed test Why? No mechanism to inform RN of scheduled procedure

Target Condition:
Comparable to the current condition, the target condition diagram should illustrate how the proposed process will work with the countermeasures in place, with appropriate labels. Its also important to note or list the specific countermeasures that will address the root cause(s). Finally, the problem-solver (or team) should predict the expected specifically and quantitatively, and note it.

Implementation Plan:
The implementation plan is the set of tasks required to develop the countermeasures, put them in place, and realize the target condition. For each task, a person responsible for that task is listed along with a deadline for task completion. It may also be helpful to list the expected outcome of each task, as shown below.

Follow-up Plan and Results:

In the left-hand side, record the plan to measure the effectiveness of the proposed change: what will be measured, when, and who will do the measuring. Leave the right-hand side blank for recording the actual results. Then, after implementation, complete the follow-up plan and record the results of implementation and dates of the actual follow-up.

A Case Study in A3 Problem-Solving

Long Patient Transportation Times

The Context
At Community Medical Center (CMC), two types of patients are sent to the diagnostic departments for the procedures: outpatients and inpatients. The outpatients come to the hospital, register, complete the procedure, and leave on the same day. The inpatients reside in the clinical departments overnight and are sent to the diagnostic departments for various procedures depending on the medical necessity. Once the procedure is complete, s/he is returned to the clinical department. Some of the outpatients who come for the procedures are old and frail and therefore unable to walk to the diagnostic department. It is the responsibility of the transportation department to provide a transporter to transport the patient to the appropriate department for procedures. Similarly, it is the responsibility of the transporter to transport the inpatients to the diagnostic department from the clinical departments as and when they are scheduled for a procedure. The diagnostic departments (Operating Room, Radiology, Nuclear Medicine, Cardiology, Endoscopy, and Emergency Room) in CMC regularly complained that patient transporters took an exceedingly long time causing delays in treatment and patient waits, and they blamed the transporters for the delays. Many thought that the transporters were having long coffee breaks and did not transport. They sometimes called the manager of transportation and complained, We called 35 minutes ago and the patient is not here The transportation manager became exasperated with the influx of complaints and decided to address the issue with an A3 process and report.

The A3 Process
A group of individuals representing the diagnostic departments (Radiology, Endoscopy, Special Procedures, Cardiology), Nursing, Transportation, and Quality Risk Management met to discuss the issue and initiate the A3 problem solving method. These individuals formed the core A3 problem solving team. To understand the problem first hand, the transportation manager and four transporters observed the current process. They observed the patient request to transportation process as it unfolded every day for10 hours for 10 days. He also contacted and interviewed different individuals in the diagnostic departments and the clinical departments to get first hand information about the process. The transportation manager said, We observed all nursing stations and procedure areas, and noted a process full of miscommunications. For example, I observed the ward secretary She said she would call [a transporter] right away. She actually made the call 37 minutes later, 3 minutes before the procedure. This happened frequently. The procedure department and the nursing station never communicated as to the expected patient transport times or procedure times. The patients nurse often did not even know the patient was going to a procedure so the patient medications were not always met for the procedure. In addition, using a self-devised form, the manager of transportation completed a patient transportation survey. In his survey, he measured the time difference between the transporters receiving a beep (a request from the diagnostic department) to the time the patient was transported (delivered) to the diagnostic department or the procedure area. The results of 23 patients surveyed over a three-day period (1/15/031/17/03) showed an average request to delivery time of 56 minutes. The actual patient transport time was only 5 minutes and the rest was preparation time and delays in communication. The communication delays caused delays in timely procedures, resulting in unhappy patients, clinical workers, and physicians. In the current state, somebody from the diagnostic department, usually a technician called or paged the transporter. At other times, somebody from the diagnostic department called the ward secretary on the floors who then called the RN and the transporter. The transporter did not know who was paging. Sometimes the message the transporter received said, Bring down John Doe to Radiology. There was no information on the room number, bed number, floor, or area. The transporter did not know from where the person was paging and did not always know whom to call to clarify. She only knew a patient needed to be transported. A great deal of time was thus expended by the transporter on patient search. If the information was complete and the patient was ready for the procedure, the transporter reached the patient and transported him or her to the diagnostic department. However, in many situations when the transporter reached the patient (usually inpatients), s/he was not ready and was in need of medications, Magnetic Resonance Imaging (MRI) screen, bathroom, IV change or other needs. In those situations, as the patient was not ready for transport, the transporter contacted the nurse. The transporter left the room and waited for the call from the nurse when the patient was ready for the procedure. The transportation manager drew the current state (patient ready for transport) drawing on the A3 Report with appropriate icons and arrows to indicate the flow of information and patient through the system (see diagram below). On the current state drawing, he recorded the shortest (9 minutes), longest (177 minutes), and average transportation time (56 minutes) from the data collected earlier. The problems he identified were no written message to request a transporter and late arrival by the patients at the diagnostic departments. These are depicted as storm clouds on the current state diagram.

The A3 problem solving team brainstormed the root causes to the problems using the 5-Whys approach. The analysis of the first storm cloud revealed that the staff members calling from the diagnostic department were often too busy to send written messages to the transporter or to the floors and therefore the message lacked complete information causing delays. The analysis of the second storm cloud revealed that as the RNs or the ward secretaries were sometimes not aware that a patient needed a procedure, and therefore, they failed to prepare the patient on time which eventually led to late arrival of the patient at the diagnostic department. Based on the understanding of the current state and the associated root causes, the team embarked on devising the target state. The transportation manager termed the problem solving as Road to Recovery. In the target state, the staff in the diagnostic department (usually a technician in Radiology or Endoscopy, or ward secretary in Surgery) will page both the charge RN and the transporter at the same time. The information included in the page is complete information for effective transport of the patient to the diagnostic department (i.e. patients first and last name, medical record number, room number, destination, etc.). The charge RN will attend to the nursing care needs of the patient and the transporter will attend to the comforts during transport such as shoes, blankets, chairs/stretcher etc. If everything is found in order, the patient will be transported to the diagnostic department for the procedure. On completion of the procedure, the diagnostic department will page the transporter who will return the patient back to his/her room. The transportation manager drew the target state drawing on the A3 report as illustrated below:

The specific countermeasures to achieve the target state, then, were: Diagnostic departments will beep the charge RN and the transporter at the same time; The page will include specific information, and a reference card; The charge RN (or a person designated by the charge RN) and the transporter will attend the patient, with specific responsibilities; and, Make the patient aware of the ensuing procedure; and As part of the implementation plan, the team created a specific action plan. First a designated transporter and a staff responsible for communications in CMC developed a group page whereby two or more people could be paged simultaneously by the diagnostic departments. Second, the transportation manager and the charge RNs met and developed a patient tracking sheet (a log sheet for the floor staff to sign off when the patient is transported). Third, the transportation manager and the designated transporter developed a reference card that contains the pager numbers of the charge RNs of each clinical department (Obstetrics, Medical Surgical Floor, Intensive Care Unit, Orthopedic, Rehab Nursing Unit, etc.), and the transport pager number that the diagnostic departments should page. It contains the information that needs to be paged by the diagnostic department when asking for a patient transport. This information includes: Name of the department from where the message is paged First and last name of the patient Patients Medical Record # Room # Patients destination Preferred mode of transport (chair, stretcher). The reference card also contains the step-by-step procedure for requesting a transporter by the diagnostic departments. The transportation manager sent copies of the cheat sheet to every department to ensure safe, accurate, and efficient transport of patients.

To ensure smooth implementation of the improved process, the transportation manager met with key individuals in all clinical departments on a one-on-one basis, explained to them about the necessity of the new process and got their feedback on the new process and how it could be improved. He also had couple of meetings with the house supervisors to get them on board with the new process. The transportation manager mentioned that the ward secretaries were tough to deal with initially. But the house supervisors were very supportive. They hit the nail. They made the ward secretaries conform to the policies, said the transportation manager. The procedural departments were very supportive as well. The transportation manager set the target time from request to delivery at 30 minutes. When asked about the rationale for setting such a high time, he responded, The procedural departments were happy with 30 minutes. They were tickled to death. Moreover, most procedure departments schedule in 30 minutes increments. He carried out follow-up surveys at regular intervals to continue to assess transport time. The following table presents the collected data:
Survey Date March, 2003 April, 2004 September, 2004 May, 2005 Time (In Mins) 14.7 11 11.5 9.15

Reactions to the A3 Process

The transportation manager felt the A3 process was every effective for problem solving in healthcare. He wrote, I find the [A3 Process] a very important tool for evaluating problems and/or processes. It allows a person or team to look at how a process flows and where the problem or work around area may be. It promotes team work on solving problems by giving a global and unbiased look into procedures. It involves a positive thought process and invigorates the mind to think in alternative ways of problem solving by including all aspects of a process. It gives all parties involved a way to express and present their perceptions, fact or data on a process/problem. The end result is a quantitative measure if there is an improvement and if it can be sustained. On a scale of 1-10, ten being the highest, I would rate the [A3 Process] at a 10. In my case it has given me the tool for myself and staff to become involved in a data driven process that can prove perceived outcomes. Without TPS process it would be very difficult to outline how an improvement plan will really be effective.