journal of health management 2012 ghosh 1 11

8/12/2019 Journal of Health Management 2012 Ghosh 1 11

1/12

http://jhm.sagepub.com/ Journal of Health Ma nagement

http://jhm.sagepub.com/content/14/1/1The online version of this article can be foun d at:

DOI: 10.1177/097206341101400101

2012 14: 1Journal of Health Management Manimay Ghosh

CareA3 Process: A Pragmatic Problem-Solving Technique for Process Improvement in Health

Published by:

http://www.sagepublications.com

can be found at:Journal of Health Management Additional services and information for

http://jhm.sagepub.com/cgi/alertsEmail Alerts:

http://jhm.sagepub.com/subscriptionsSubscriptions:

http://www.sagepub.com/journalsReprints.navReprints:

http://www.sagepub.com/journalsPermissions.navPermissions:

http://jhm.sagepub.com/content/14/1/1.refs.htmlCitations:

What is This?

- Mar 8, 2012Version of Record>>

by guest on May 4, 2014 jhm.sagepub.comDownloaded from by guest on May 4, 2014 jhm.sagepub.comDownloaded from
http://jhm.sagepub.com/http://jhm.sagepub.com/http://jhm.sagepub.com/http://jhm.sagepub.com/content/14/1/1http://jhm.sagepub.com/content/14/1/1http://www.sagepublications.com/http://jhm.sagepub.com/cgi/alertshttp://jhm.sagepub.com/cgi/alertshttp://jhm.sagepub.com/subscriptionshttp://www.sagepub.com/journalsReprints.navhttp://www.sagepub.com/journalsReprints.navhttp://www.sagepub.com/journalsPermissions.navhttp://jhm.sagepub.com/content/14/1/1.refs.htmlhttp://jhm.sagepub.com/content/14/1/1.refs.htmlhttp://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://jhm.sagepub.com/content/14/1/1.full.pdfhttp://jhm.sagepub.com/content/14/1/1.full.pdfhttp://jhm.sagepub.com/http://jhm.sagepub.com/http://jhm.sagepub.com/http://jhm.sagepub.com/http://jhm.sagepub.com/http://jhm.sagepub.com/http://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://jhm.sagepub.com/content/14/1/1.full.pdfhttp://jhm.sagepub.com/content/14/1/1.refs.htmlhttp://www.sagepub.com/journalsPermissions.navhttp://www.sagepub.com/journalsReprints.navhttp://jhm.sagepub.com/subscriptionshttp://jhm.sagepub.com/cgi/alertshttp://www.sagepublications.com/http://jhm.sagepub.com/content/14/1/1http://jhm.sagepub.com/


2/12

Article

Journal of Health ManagementA3 Process: A Pragmatic 14(1) 111 2012 Indian Institute of Problem-Solving Technique Health Management Research

SAGE Publications

for Process Improvement Los Angeles, London,New Delhi, Singapore,in Health Care Washington DCDOI: 10.1177/097206341101400101

http://jhm.sagepub.com

Manimay Ghosh

AbstractShort-term approaches or patch working are the predominant modes of solving process-related prob-

lems in organizations. As a result, problems recur at regular intervals and inhibit their smooth function-ing. Organizational leaders have adopted various quality initiatives to produce sustainable change, butthe existing literature suggests that many of them have met with limited success. The A3 Process,adapted from Toyota Motor Corporation, has been proposed as a pragmatic problem-solving tech-nique for creating sustainable organizational change. Observing, drawing iconic sketches, discussingwith other stakeholders, and experimenting has helped each stakeholder gain a deeper, contextualizedunderstanding of the problem. These activities influenced knowledge validation and/or knowledge crea-tion, both instrumental in transforming the stakeholders passive mindset to a collaborative and activemindset. This article presents one of the many applications of the A3 Process that produced enduringchange in a health care environment.

KeywordsHealth care, A3 Process, A3 Report, Toyota, lean, process-improvement

Introduction

Health Care in the United States

There are innumerable articles in health care literature that seem to suggest that US health care is in trou- ble. According to the Kaiser Family Foundation report (2007), the United States spent two trillion dollarson health care in 2005, which represents 16 per cent of the gross domestic product or GDP and US $6,697

per person. By the end of 2016, the Centres for Medicare and Medicaid Services (CMS) projects pre-dicted that the health care spending would reach approximately 19.6 per cent of the GDP. In fact, healthcare costs have grown by 2.5 per cent faster than US GDP since 1970s (Kaiser Family Foundation Report2007). Additionally, extant literature reports multitude of other problems: high rate of medical errors(Assaf et al. 2003; Spear 2005, 2006), high costs and uneven clinical and service quality, staff shortages,

Manimay Ghosh, Associate Professor, Operations Management, Institute of Management Technology, Nagpur.Email:[email protected]

by guest on May 4, 2014 jhm.sagepub.comDownloaded from
mailto:[email protected]://jhm.sagepub.com/http://jhm.sagepub.com/http://jhm.sagepub.com/mailto:[email protected]


3/12

2 Manimay Ghosh

low productivity and consumer dissatisfaction (Nembhard et al. 2009). In sum, despite its critical role inthe US economy and its impact on the lives of Americans, many experts argue that the US health caresystem needs to be rejuvenated to satisfy its customers, that is, patients.

Some experts attribute many of health cares woes to its work systems. They reason that health carework systems are broken (Begun and Kaissi 2004; Spear 2006; Thompson et al. 2003), and therefore,operationally inefficient (Tucker 2004). To address systemic issues, health care leaders have adoptedvarious powerful quality initiatives from the manufacturing sector. For example, Total Quality Manage-ment (TQM) was imported in the mid 1980s to revamp the health care system but existing literature sug-gests limited success (Blumenthal and Kilo 1998; Huq and Martin 2001). The extant literature reportsdiminishing levels of scientific problem-solving (Blumenthal and Kilo 1998; Ovretviet 1997; Patwardhanand Patwardhan 2007; Shortell et al. 1998), and dominance of short-term approaches or patch-workingto address problems (Tucker and Edmondson 2002, 2003; Tucker et al. 2002). Consequently, problemsrecur at regular intervals. Thus, health care leaders find sustainable change of work systems a significantchallenge. This article presents a case example of A3 Process, a systematic problem-solving technique

borrowed from Toyota Motor Corporation, which was adapted for use in health care for sustainable

change.

The Case

The study was conducted at a mid-sized hospital in northwest America. The hospital is a 146-bed, acute-care facility and offers services in paediatrics, cardiology, obstetrics, surgery, neo-natal intensive care,rehabilitation, radiology, nuclear medicine and general medical care. This study was a part of a biggercollaborative project between a state university in northwest America and the hospital, on the applicationof Toyota Production System (TPS) principles and practices to improve health care operations.

The Problem

The Radiology department in the hospital is responsible for various imaging techniques such as X-rays,ultrasound and magnetic resonance imaging (MRI) to diagnose and treat a wide variety of diseases. They

perform diagnostic procedures based on the orders of the physicians. At the end of the procedures, theysend reports to the clinical departments (ICU, Medical Surgical Floor, Emergency Room, OutpatientSurgery, Orthopaedic, Rehab Nursing Unit, Paediatrics and so forth) which are annotated to the patientsmedical chart. The charts are reviewed by the physicians for further clinical care. The focus of this studywas on the process of sending X-ray reports from the Radiology department to the other clinical depart-ments. The problem-solving effort was initiated by a transporter, a front-line employee, in the hospital.

For each X-ray procedure, the Radiology department printed two copies of the X-ray report: a pre-liminary and a final, which were hand-delivered by the transporter to the concerned clinical department.Occasionally, an electronic report would also be sent to the clinical department. However, it was oftenfound that the X-ray reports from the Radiology department would not be sent timely to the clinicaldepartments. Consequently, the reports would not be annotated in the medical charts by the unit secre-taries in time, which created resentment among the physicians. On other occasions, two reports were

Journal of Health Management, 14, 1 (2012): 111

http://jhm.sagepub.com/http://jhm.sagepub.com/http://jhm.sagepub.com/


4/12

3 A Pragmatic Problem-Solving Technique

sent: a paper report, which was hand delivered, and an electronic report, which would be printed by theclinical department. In those situations, the clinical departments discarded the paper reportsa waste ofstationery. The problems of delayed patient-care and waste of unnecessary stationery were noted by atransporter, who delivered patients as well as paper X-ray reports to various clinical departments. Sincethe traditional tools (i.e., Kanban, Single Minute Exchange of Die and Just-in-Time) of Toyota ProductionSystem were not easily transferable to health care, and people have very little time for actual problem-solving, the A3 Process was instituted for the study. The A3 Process provides a methodical approach toaddress and solve problems.

The nine steps of the A3 Process (see Figure 1), after a problem has been identified, are:

1. Observing the current process2. Drawing a diagram to represent the current process3. Determining the root causes to the problem by asking 5 Whys4. Developing the counter-measures based on the design rules to address the root causes to the

problem5. Drawing a diagram of the envisioned process (target process) based on consensus with the affected

parties6. Planning the implementation7. Discussing all of the above with the affected parties8. Implementing the actions planned9. Collecting follow-up data on the outcome of the new process and comparing it against pre-speci-

fied targets

Steps 1 through 7 refer to the Plan, Step 8 refers to the Do, and Step 9 refers to the Check stagesof the PDCA cycle (Deming Wheel). The Act stage is the creation of new organizational work routineswhen they prove worthy in Step 9. These nine steps provide an approximate order of solving problems.

The Solution

Under the tutelage of the transportation manager, an inter-disciplinary problem-solving team was formed.The team comprised secretaries from the Radiology department, Intensive Care Unit, the Medical andSurgical department, a system analyst, a transcriptionist from the Hospital Information Managementdepartments and four transporters.

The first and foremost step in the A3 Process is to physically travel to the actual location of the prob-lem, observe the situation first-hand, and then diagram it with a pencil on the A3 Report (one side of an11 by 17 inches sheet of paper) with appropriate icons and arrows. The left-hand side of the A3 Reportis used to show the current process and the right-hand side is used to show the improved process. Thetemplate of the A3 Report is shown in Figure 1.

Observing the problem first-hand not only provides objectivity to its understanding, but also ensuresaccuracy in the information gathered. Furthermore, observation is an effective way to confront onesown assumption, biases, and misconceptions about a particular situation (Sobek and Smalley 2008).Additionally, observation provides new relevant information to the observer which would have remained




5/12

F i g

u r e

1 .

T e m p

l a t e

o f A 3 R e p o r t

S o u r c e :

J i m m e r s o n e t a l . (

2 0 0 5 ) .

http://jhm.sagepub.com/http://jhm.sagepub.com/http://jhm.sagepub.com/http://jhm.sagepub.com/


6/12


unknown otherwise. Diagrammatic representation of the current state, on one hand, captures the tacitunderstanding of the group of individuals and on the other explicates the problem very concisely andeffectively. The free-hand sketch overtly appears to be simple but captures dense information, and

presents lucidly. Diagramming with a pencil fulfils the need to revise the sketch to represent the collab-orative understanding of the problem. Figure 2 presents the current state observed.

Figure 2. Current State DrawingSource: Author.

In the current state, the Radiologist checked the X-ray reports on the computer screen and then printedthe preliminary and final X-ray reports. The transporter checked with the Radiology department every2050 minutes; or as often as possible, to collect paper copies of the preliminary and final X-ray reportsthough nobody from the Radiology department called or beeped the transporters to let them know thatthe reports were ready for delivery. When she reached the Radiology department, sometimes she found




7/12

6 Manimay Ghosh

reports to deliver in the delivery box and sometimes she did not. Cases were not rare when the unit sec-retary would deliver a batch of X-ray reports to the delivery box, right after the transporter had left. When-ever she found the reports, she sorted those reports by clinical departments and then hand-delivered tothe inboxes in each clinical department. The transporter again checked 2050 minutes later from thecompletion of the previous delivery. However, the delivery process was occasionally interrupted as thetransporter had to transport patients in between report deliveries. As a result, the reports lay for one houror more and were delivered late to the clinical departments. Consequently, the physicians complainedabout missing X-ray reports in patients medical charts, which resulted in delayed patient care.

As the Radiology department occasionally sent electronic copies of the reports to the clinical depart-ments, the secretaries discarded the paper reports hand-delivered by the transporter because they alreadyhad a report downloaded from the computer. That resulted in unnecessary waste of stationery and trans-

porters time.The lead transporter and two of her colleagues spent 17 days observing the current process and col-

lecting data using a self-devised form. The intent was to find how the current process worked and tomeasure how many paper reports they delivered and how much time was spent delivering those reports.Table 1 presents the observed data:

Table 1. Current State Data

# of Paper Reports Delivered Total Time TakenDate Observed to the Clinical Departments to Deliver (minutes)11-Oct-04 272 8012-Oct-04 241 6213-Oct-04 311 9825-Oct-04 216 8027-Oct-04 333 9526-Oct-05 130 601-Nov-04 309 892-Nov-04 401 923-Nov-04 191 764-Nov-04 194 765-Nov-04 218 8020-Dec-04 329 8721-Dec-04 184 6022-Dec-04 211 7410-Jan-05 142 6511-Jan-05 216 7012-Jan-05 204 60Source: Author.

The observed data revealed that the transporters delivered 240 reports per day on average and 75minutes were consumed every day to deliver those reports. The lead transporter drew the current state onthe A3 Report using appropriate icons and arrows to depict the aforesaid scenario. The storm clouds sheidentified were delay in delivering the reports to the clinical department, delayed patient care and wasteof stationery in producing duplicate reports.




8/12


The problem-solving team brainstormed to find the root causes to the problem using the 5-Whysapproach advocated by Toyota. The intent for such brainstorming is to investigate deeply to ascertain theroot causes. The root cause that emerged from the brainstorming was inadequate understanding of workat the functional boundaries by health care staff. Stated differently, the Radiology department staff mem-

bers lacked clear understanding of how their functioning affected other functional departments.Based on the understanding of the current state and the root causes, the problem-solving team

embarked on hand-sketching the consensual target state on the A3 Report. The proposed improved proc-ess was fairly simple. In the target state, the Radiologist would check the X-Ray report on the computerscreen and would send it electronically to the clinical departments. The unit secretaries would print thereports and append to the medical chart of the patient. In essence, the transporter would no longer hand-deliver paper reports from the Radiology department to the other clinical departments. The fluffy cloudsshe identified were: timely delivery of reports to the physicians and nurses for better patient care, freedtime for the transporters to do other tasks, and reduced paper usage. Figure 3 presents the target statedrawn.

Figure 3. Target State DrawingSource: Author.

To achieve the desired target state, the team met with staff from Management Information System andidentified printers in each clinical department to print the X-Ray reports. The improved process wasimplemented immediately.




9/12

8 Manimay Ghosh

Toyota Motor Corporation advocates conducting a simple experiment to measure the effectiveness ofthe improved process. In this case, follow-up data were collected by the team leader and others to meas-ure the efficacy of the new process. There were initial glitches with the new process as the printers werenot set up in all the departments, and so a few reports were hand-delivered in the first two weeks ofimplementation. Thereafter, no reports were hand-delivered to the clinical departments. Table 2 presentsthe data collected:

Table 2. Follow-Up Data

# of Paper Reports Delivered Total Time TakenDate Observed to the Clinical Departments to Deliver (minutes)9-Feb-05 2 510-Feb-05 1 411-Feb-05 2 514-Feb-05 3 515-Feb-05 4 4

16-Feb-05 2 31728 Feb, 2005 0 0Mar-05 0 0Apr-05 0 0112 May 2005 0 0Source: Author.

By instituting the improved process, the hospital saved an estimated US $1,120 (INR 50,000 approx.) per year in paper expense and an estimated US $5,200 (INR 2,10,000 approx.) was saved in productivetime of the transporters. Apart from the financial gains, the key benefit was that the Radiology depart-ment was able to support the physicians in offering timely patient-care through quick delivery of elec-tronic X-ray reports.

Discussion

This case demonstrates how a simple repetitive process of delivering X-ray reports from the Radiologydepartment to the clinical departments was broken and how it delayed patient-care and contributed tounnecessary costs. The present example is just one of the many problem-solving exercises that the authorobserved in the hospital site. The A3 Process was applied in various departments (administrative andclinical) of the hospital and, in every case, the results were very encouraging.

The A3 Process was successful in a health care setting because of multiple reasons. In a majority

of the cases reported in the TQM literature, the managers or the senior staff members would handle problem-solving efforts, and hence, problem-solving seemed divorced from the actual problem site and became de-contextualized. Objectively validating existing knowledge was unclear in those efforts;for example, in one study, the problem-solvers (senior staff in the organization) assumed the source ofthe problem without any prior research (Walley and Gowland 2004). Therefore, there was no individualvalidation of the current process by the problem solver(s) before embarking on the subsequent steps. Inthis case, members from the problem solving team observed the current process first-hand and saw its




10/12


shortcomings. As a result, many biases and misconceptions were removed before moving to the subse-quent steps of problem-solving. Additionally, observation of a dysfunctional process provided the neces-sary motivation for change and allowed the lead problem-solver and others to switch from a passivemindset to an active mindset.

TQM is viewed by many as a collection of seven classical process-control tools (Check sheet, Scatter plot, Pareto chart, Histogram, Control chart, Flow chart and Cause-and-effect diagram). Many scholarsdocument limited use of TQM tools in many TQM programmes (Hackman and Wageman 1995; Kano1993; Rigby 2001; Zbaracki 1998). Zbaracki observes from his field study of 69 TQM programmes infive sectors (defence, government, health care, hospitality and manufacturing) that one of the primaryreasons members were hesitant to use the tools was because they found them difficult to understand andapply. The frequency of the usage declined as the tools became more technical. The problem was foundto be more acute with employees from service sectors such as hospitals and hospitality. Similarly, Kano,in his field study, finds that organizational members failed to take any action even when the controlcharts showed out-of-control situations. These findings seem to suggest that the tools were not veryeffective as boundary objects (physical but flexible artifacts that provide a common language and pro-

mote shared understanding about a problem or a situation among a group of individuals to reach a mutu-ally satisfactory resolution) as the organizational members faced road-blocks in validating their tacitunderstanding using them, discussing with others, and taking appropriate actions in their respectivedepartments to resolve the problem. The A3 Report that contains the A3 Process is a simple tool thatrequires an A3 size paper, a pencil and basic literacy to write. It does not require any sophisticated math-ematical or technical training. The team members, by observing the problem first-hand, discussing withothers, and documenting it on the A3 Report, were able to jointly validate their current understanding ofthe problem. As the iconic sketches were hand-drawn with pencil, the members had the liberty to fine-tune their individual understanding of the problem and were also able to accommodate the view of oth-ers. This deeper contextualized understanding helped the members to jointly transform knowledge anddevise a single way (electronic) of sending X-ray reports.

Conducting follow-up experiments after a new process has been implemented is critical to validatingnewly created shared knowledge. It demonstrates whether a new process is working satisfactorily or not.Though experimentation is advocated in TQM, scholars report that users often abandon it (Hackman andWageman 1995; Ovretveit 1997) or do not use it rigorously (Walley and Gowland 2004). One plausibleexplanation for this disregard for experimentation is the superficial understanding of the problem-solversthe managers. Since they did not always validate their current understanding by objectivemeans upfront, they lacked deep contextualized understanding of work practices and how it impacted

performance. Therefore, there was no individually felt compulsion to test whether the new knowledgefaltered or not. In this study, almost all the team members were frontline employees who had consider-able stake in the success of the project. They encountered the problem almost on a daily basis, and there-fore, wanted to resolve the issue. The team collected follow-up data over a fairly long period of time

(four months) and ensured that the agreed-upon process was indeed in place and was working satisfac-torily without any glitches.An interesting point to note in the study was, who initiated the process-improvement effort. It was a

not a senior employee of the hospital, but a transporter, a front-line staff member, who knew her work best, and had real stake in the outcome of the process. She and other stake-holders did a detailed analysisof the process, observed its deficiencies first-hand, saw the need for change, created an improved pro-cess, and supported it wholeheartedly for its sustenance. In fact, most of the problem-solving efforts that




11/12

10 Manimay Ghosh

the author observed in the hospital were initiated by frontline individuals. This is in stark contrast to con-ventional problem solving by a middle or senior level executive in a non-TPS organization. In mostcases, they failed to fructify due to the lack of support from the front-line staff, who were rarely allowedto participate in such problem-solving efforts.

Another noteworthy finding of this case is that the lead transporter did not belong to the Radiology orany particular clinical department. But she was able to see and show others how disintegrated the activ-ities between two departments for a simple process of delivering X-ray reports were. It was possible

because she, as a transporter, saw the missing linkages for effective accomplishment of work at the func-tional boundaries, which others could not and what the consequences for poor accomplishment were. AsDeming (1986) once said: A system cannot understand itself, and to bring about transformation, a viewfrom outside in is needed.

The task of redesigning an old process, though simple and short, was pretty daunting for her as shewas just a front-line worker and had limited authority. Moreover, the change involved dealing with care-givers from disparate disciplines who were experts in their own field of specialization but had silo men-tality. Yet, by observing and drawing the current state, and collecting objective data over an extended

period of time, the lead transporter and other team members were able to see themselves and show othersthe drawbacks of the old process and how it negatively affected the patient-care process. Without suchmutually agreed understanding of the old process, its redesigning by all individuals through consensuswould not have been possible.

Finally, health care work processes are generally human intensive and involves numerous hand-offs.These hand-offs cause ambiguities, unnecessary delays and drive up costs. The lead problem-solver,along with her colleagues, realized the shortcomings of the process and immediately switched to anautomated process that completely eliminated the hand-offs.

Conclusion

Continuous improvement is the order of the day and many health care organizations are continuouslystriving to improve their performance. Given the fact that health care costs are increasing by leaps and

bounds, and that care-givers have little time for problem-solving; it makes logical sense to adopt a lesstime-consuming, low cost, pragmatic, and yet disciplined approach such as the A3 Process to continu-ously improve health care work systems. It prevents management from committing huge organizationalresources (money and time) and, at the same time, it helps develop competencies of care-givers toacknowledge and manage interdependencies, ambiguities, and uncertainties across functional bounda-ries through creation of new processes or change of existing ones. Organizational members are able tomove from the silo mentality to system thinking, which is essential to effective process improvement inhealth care.

ReferencesAssaf, A.F., L.J. Bumpus, D. Carter & S. Brown (2003). Preventing errors in healthcare: A call for action. Hospital

Topics , 81(3), 513.Begun, J.W. & A.A. Kaissi (2004). Uncertainty in healthcare environments: Myth or reality. Healthcare Management

Review , 29(1), 3139.




12/12

journal of health management 2012 ghosh 1 11

Documents