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Today we continue further into our “How to Create an A3” blog series.  Step 4 is Target Condition and Countermeasures.  In previous posts we covered defining the Problem Statement, Understanding the Current Condition, and Root Cause Analysis.

Target Condition is not the result you will achieve; it is an IDEAL state to strive for.  We do not just want to uncover solutions to problems; we want to design the work to create a new and better reality.  Bad systems beat good people, and our job is to change the system. Countermeasures, covered next week, are how you will change the work in order to get to the IDEAL state.  Toyota calls improvements countermeasures (rather than the ubiquitous “solutions”) because it implies:

a) We are countering a specific problem
b) It is what we will use now until we discover an even better countermeasure

When developing a Target Condition, you should strive to eliminate the work-arounds and re-work involved in the Current Condition.  Create a graphic of the IDEAL state (remember why we use graphics rather than text from our Current Condition explanation).  Rather than problematic storm clouds, we now have highlighted good features with fluffy clouds.  Remember, the IDEAL state should be defect free, no waste, and safe for all.

Applying this to our continued phlebotomy example, we can develop a target condition that might look like this:

Dan has 30 years of healthcare experience in many clinical and leadership roles. He leads Lean and process improvement consulting engagements for HPP.  His experience includes deploying Lean across numerous healthcare disciplines including Imaging, Laboratory, Nursing, Pharmacy, and Physician Offices.  Dan began his healthcare career as a nuclear pharmacist and has also severed as Director of Operations, responsible for 13 facilities.  He has been a featured speaker at a variety of healthcare industry events.

Dan holds a Master’s Degree in Business Administration from the University of Pittsburgh, Bachelor’s Degree in Pharmacy from Purdue University and a Specialty Certification in Nuclear Pharmacy from Butler University.

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Today we are continuing our “How to Create an A3” blog series with Step 3 – Root Cause Analysis.  In previous posts we covered defining the Problem Statement and the Current Condition.

Today’s blog will cover Step 3: Root Cause Analysis.  Just like defining the current condition, this is not a sit-down exercise.  Once at the workplace, while observing processes, you can utilize a method known as the “5 Whys.”  This method provides a level of inquiry deep enough to get to the root cause of a problem by asking “Why?” five times.  Each Why question is dependent upon the answer to the previous question.  It goes something like this:

My college-age son just received a failing grade on an advanced calculus exam.  My assumption was that he is in over his head by taking too difficult a course.  But, I must get at the root cause for his failing grade before I can give him any advice on what to do.

Question 1:      Why did you not score well on the quiz?
Answer:           I didn’t study.

Question 2:      Why did you not to study?
Answer:           I overslept the morning of the quiz.

Question 3:      Why did you oversleep?
Answer:           I stayed up too late the night before.

Question 4:      Why were you up so late?
Answer:           I was socializing.

Question 5:      Why were you socializing instead of thinking about your studies?

Clearly from this answer, I will take a different course of action than what I originally planned.

Recall the phlebotomy problem statement from our previous example and on-going discussion:

Phlebotomy draws by nursing staff often result in the wrong tube being used.  The problem started about 12 months ago when the laboratory issued 4 different reference guides and did not include photos.  This has resulted in re-draws of 25% and an increase in TAT of 50%. 

The 5 Whys for this problem could look like this:

Question 1:      Why did the nurse use the wrong tube?
Answer:           She was confused about which tube was correct to use.

Question 2:      Why was she confused?
Answer:           She could not find the answer in the lab guide.

Question 3:      Why couldn’t she find it in the guide?
Answer:           She stopped looking after 5 minutes.

Question 4:      Why did she stop after 5 minutes?
Answer:           She did not have time to look in all 4 guides.

Question 5:      Why are there 4 reference guides?
Answer:           ??

Now, we know that we have to focus our problem-solving efforts on the reference guides.  Jumping to solutions too quickly can mean solving the wrong problem or merely alleviating a symptom and not the problem.  Use the “5 Whys” as skillfully as a surgeon uses his scalpel and you will be well on your way to effective problem solving.

Next week we will continue our walk through each step in A3 problem solving with Part 4 – Target Condition and Countermeasures.

Dan has 30 years of healthcare experience in many clinical and leadership roles. He leads Lean and process improvement consulting engagements for HPP.  His experience includes deploying Lean across numerous healthcare disciplines including Imaging, Laboratory, Nursing, Pharmacy, and Physician Offices.  Dan began his healthcare career as a nuclear pharmacist and has also severed as Director of Operations, responsible for 13 facilities.  He has been a featured speaker at a variety of healthcare industry events.

Dan holds a Master’s Degree in Business Administration from the University of Pittsburgh, Bachelor’s Degree in Pharmacy from Purdue University and a Specialty Certification in Nuclear Pharmacy from Butler University.

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Today we continue in “How to Create an A3” with Part 2 of the series—Define the Current Condition.  If you missed the first blog in this series, Step 1 - The Problem Statement, you can catch up here.

So, we’ve created our Problem Statement and now we move to the second part of the A3 to define the current condition. This is not a sit-down exercise; it is an activity. Go observe. See what is actually happening. You want the as-is, not the supposed-to-be or the “my belief is” version of reality.

The data used to develop the current condition diagram is collected through direct observation. This gives you an in-depth and detailed understanding of the current process as it is actually performed–not how it should be done or how someone says it is done. Workers and supervisors can often describe how the process generally works or how it is supposed to work, but deviations from this general or hypothetical conception usually hold the key to addressing the problem. The data for describing the extent of the problem should also be actual data, perhaps collected in a logbook if necessary, not educated guesses. The power of direct observation is the objectivity of the information, void of emotion or assumption.

Next you should create a visual representation of the current condition in a diagram. There are several purposes of diagramming and quantifying the problem.  First, the act of drawing a diagram helps the author come to a deeper understanding by forcing him/her to organize knowledge and learning gained from observation in a compact manner.  Second, the diagram quickly and effectively communicates the core issues to others.  The graphical medium can contain a very dense amount of information, and yet readers can pick it up quickly because of the pictorial representation.  Thirdly, by diagramming the system, problem-solving efforts are focused on the system rather than the people.  It results in a much more objective approach with less defensive posturing and finger-pointing.  Our experience has been that problem-solving efforts often fail in implementation because the author(s) did not sufficiently understand the current condition.  Rarely is failure due to incompetence or lack of ingenuity.

Recall the phlebotomy problem statement from our last discussion:

Phlebotomy draws by nursing staff often result in the wrong tube being used.  The problem started about 12 months ago when the laboratory issued 4 different reference guides and did not include photos.  This has resulted in re-draws of 25% and an increase in TAT of 50%.

The current condition process flow diagram would look like this:

There is software available to construct diagrams and it can be helpful, but not necessary.  If all you have is paper and sticky notes – use them!  The most important thing is that you go to the Gemba to see the activity as it actually exists. 

Next week we will continue our walk through each step in A3 problem solving with Part 3 –  Root Cause Analysis

Dan has 30 years of healthcare experience in many clinical and leadership roles. He leads Lean and process improvement consulting engagements for HPP.  His experience includes deploying Lean across numerous healthcare disciplines including Imaging, Laboratory, Nursing, Pharmacy, and Physician Offices.  Dan began his healthcare career as a nuclear pharmacist and has also severed as Director of Operations, responsible for 13 facilities.  He has been a featured speaker at a variety of healthcare industry events.

Dan holds a Master’s Degree in Business Administration from the University of Pittsburgh, Bachelor’s Degree in Pharmacy from Purdue University and a Specialty Certification in Nuclear Pharmacy from Butler University.

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There are many Lean tools available to use to improve a process.  But often times it is difficult to select the appropriate one because the issue is not clearly defined.  This leaves managers asking “What tool is the most appropriate? How do I communicate the need for this process change?  Is the issue worthy of a full Lean event such as Kaizen or can I solve the problem in a different way?”

The A3 approach might be the way to go.  What is A3?  By most people’s definition it is an international standard paper size similar to an 11 X 17 sheet of paper.  But in Lean terminology, it is more than that.  It can be waste-free report writing, a continuous improvement activity, a form of visual management, or a method of communication.  However you decide to use the tool, there are 6 steps to the process:

Step 1: Identify a Problem or Need

Step 2: Define the Current Condition

Step 3: Root Cause Analysis

Step 4: Target Condition and Countermeasures

Step 5: Implementation Plan

Step 6: Follow-Up Plan

Today’s blog will cover Step 1, Identifying a Problem or Need, or, the Problem Statement, with the other steps discussed in future posts.

There are few things both more fundamental and more frequently fouled than the problem statement. How you structure the problem statement determines your focus. Make sure your problem statement is actually about the current observable condition, not about a perceived solution, cause, or what you want.  Be descriptive, focus on the problem—not solutions. Do not combine multiple problems into one and provide background information that is essential to understanding the extent and importance of the problem—such as, how the problem was discovered, why the problem is important to the organization’s goals, the various parties involved, and the problem symptoms.  The problem statement could also be referred to as the issue and the background.

A problem statement in healthcare might look like this:

Phlebotomy draws by nursing staff often result in the wrong tube being used.  The problem started about 12 months ago when the laboratory issued 4 different reference guides and did not include photos.  This has resulted in re-draws of 25% and an increase in TAT of 50%.

Or this:

Denial correspondence from insurance companies is received by mail.  Processing this correspondence requires manual transportation of the paper information across 4 buildings.  This consumes the resources of 9 FTE’s resulting in TAT of 9-11 days, which is 125% greater than the dept. goal of 4 days.

Seems simple enough right?  The goal is to ensure that your problem does not suffer an identity crisis because it was not accurately defined.  Staying true to this one concept will keep your problem solving efforts on track and ensure success.

Stay tuned as we walk through each step in A3 problem solving? How do you structure your problem statements? How do you prevent jumping to conclusions?

Dan has 30 years of healthcare experience in many clinical and leadership roles. He leads Lean and process improvement consulting engagements for HPP.  His experience includes deploying Lean across numerous healthcare disciplines including Imaging, Laboratory, Nursing, Pharmacy, and Physician Offices.  Dan began his healthcare career as a nuclear pharmacist and has also severed as Director of Operations, responsible for 13 facilities.  He has been a featured speaker at a variety of healthcare industry events.

Dan holds a Master’s Degree in Business Administration from the University of Pittsburgh, Bachelor’s Degree in Pharmacy from Purdue University and a Specialty Certification in Nuclear Pharmacy from Butler University.

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