I recently invited questions for Michael Balle, the author of the Shingo Prize winning book The Gold Mine: A Novel of Lean Turnaround. He has a new book (published by LEI, my employer), recently published, called “The Lean Manager.”
Here is the fourth Q&A. If you have a question for Michael, click here for more info on how to submit them. If you have a question in response to this post, please the comments feature. For previous Q&A, click the “Balle” link at the bottom of the post. Michael also has a new blog at the LEI website.
Q: A3 thinking seems like the latest buzzword in the lean world. It’s just a single 11×17 paper, what’s the magic in that?
Answer from Michael Balle:
It’s kind of puzzling why some tools become fashionable at some time or not. A3s have been around a long time, and certainly, this is one of the lean tools which are not TPS specific – many Japanese companies have been using them over time, and I remember seeing A3s from Japanese automakers and suppliers as far back as fifteen years ago. I have no clue why suddenly it’s become such a buzzword, other than it is a critical lean tool in a very specific way. Most TPS tools are all about the front line worker, the team leader – because we’re collectively not very good at this lean stuff, this is a point easy to miss, and indeed, I’ve stood corrected and humbled many times on the gemba showing off to the sensei something we’ve done only to be asked: “what’s the mission of the operator with this ___ tool (fill in the blank)?” Over the years, I’ve learned the hard way that tool ownership must pass from lean officers to operations managers, to supervisors, to team leaders and finally to team members themselves.
On the other hand, TPS has very few tools for middle-managers such as supervisors and beyond, and indeed, many of these people feel rightly ignored of by-passed by the lean initiatives – which creates difficult problems of involvement and teamwork when you go beyond the obvious stuff on the shop floor, and one of the reasons companies have trouble breaking out of tool kaizens (5S, SMED, Flow and layout, etc.) and into system and budget level results. There is no “magic” that I know of in the A3 other than it fills in a critical gap as it addresses middle-management and knowledge development for critical staff at that level.
Everyone has a different path of discovery of the lean tools and I can only describe how I ended up relying on A3s in hospitals about a decade ago. In that respect I recommend Cindy Jimmerson’s book A3 Problem Solving for Healthcare: A Practical Method for Eliminating Waste. Here’s how we got to using A3s :
Like on the factory shop floor, the hardest barrier to lean in hospital wards was to get ward managers to accept that 1) all was not well in their ward, and 2) they could do something about it – they mostly had accepted they were only a cog in the machine and solutions always belonged to some other staff service. In socio terms this is called learned helplessness: good people are convinced they can’t do anything about the mess they’re in, which, in the end, either makes them angry or depressed – and neither is good for them or for the patients (try being stuck in a hospital bed with an angry, depressed, or both nurse of doctor). So, working with the Nursing Directors of a number of hospitals we decided to try to address this first.
At the time, in the mid-nineties, no one had heard of “lean” in healthcare and we were very careful not to mention automotive OEMs and Toyota, for reasons you’ll easily understand. What we did was walk around – we’d walk with the nursing director in every ward in about twenty minutes with the ward manager and highlight obvious problems such as:
- Trolleys, beds, bins in the corridors (safety hazard)
- Basic cleaning (check out those corners and those skirting boards)
- Unmarked bio waste disposal bins (Yuck!)
- Out-of-date drugs and materials (check those fridges – find the food as well)
- Trolleys stored with all the bits and pieces still on when stored away (have they been sterilized?)
- Clean/dirty circuit for laundry, blouses, etc.
Nothing earth shattering, just very visible stuff.
The good point about this is that the nursing manager didn’t like it, but they couldn’t disagree they had a problem; They would then argue they couldn’t do anything about it: how can we take the laundry bags out of the corridor? We don’t have enough storage room and what we’ve got is full of diapers!”
“Look,” we told them. “let’s pick one of those issues. Then you’ll gather your team, explain why it’s a problem, and work with them to find a local solution to this.” You’ve got zero budget, so don’t come and ask for money or help from support structures – you’ll get neither. Think of something.
It sounds harsh, but in many, many cases we had astonishing immediate results. What also appeared is that some ward managers were much better than others at getting their teams to think creatively and pragmatically to solve small problems. Some just went through the motions with very indifferent results, and a few people invented a weird solution that totally defeated the purpose, but that’s humans for you.
In any case, once this got started and established, the next step was to get each ward manager to start measuring very simply adverse events for patients and staff and to review this weekly with their teams, and monthly with the Nursing Director.
By having both activities running in parallel, many basic issues got solved but the more advanced ward managers got, by themselves into actual care problems – problems of things they did to patients, and then the issue became incredibly complex for an number of reasons, including the pre-existing quality assurance initiatives and the whole issue of “protocols.” On the one hand there was no issue of ignoring centrally devised protocols, on the other, these were not well known at staff level, and sometimes difficult to apply locally (this is a difficult and entire other debate, central, I believe, to lean in the wards).
What we then decided to do is have the nursing team come up with a checklist of how they actually performed the care act – based on their practice not on the protocol – and then observe a minimum of twenty patients being cared for (the ward manager would do the observations with the checklist in hand). They would then do two things:
- Measure what was done and what was not (did we wash hands every time?)
- How did the checklist differ from the protocol
These two questions largely clarified the problem, and it then struck me that this was close enough to the two first boxes of the A3s I had seen in the auto industry: “what is the problem?” And “Grasp the situation.”
The deeper problem we were facing at the time with the Nursing Directors is that we had low confidence in the ward managers ability to come up with the correct solutions to the problems. On the one hand, we realized that the concrete problems they faced WERE DIFFICULT, and actually we couldn’t think any top of the head sensible solution in their local situation (terminal cancer patients in a XIXth century building with a splendid view on the Fort-de-France bay in the West Indies – how do you keep the wind and dust out?), second, protocols were far too generic to solve the problem in concrete terms, and most importantly, we didn’t trust the ward managers to come up with acceptable solutions, quality-wise (yeah, so, this is the real world, right?)
Which is about when we started using the A3 (okay: A4s), as a communication tool between the ward manager’s proposals and the Nursing Director. Before implementing anything, the ward manager had to detail her understanding of the problem and the solution she wanted to apply. After the first initial cycles, we even managed to get the best ward managers to propose two or three different solution to the problem.
In this manner, we tackled all sorts of previously intractable problems, such as:
- Reinfection on bandaging wounds
- Cannula maintenance in tracheotomy
- Bedsore development in bed bound patients
- Dealing with families in emergency wards
And so on.
So where’s the magic of the A3. Not the size of the paper, certainly (A3 was the largest piece of paper that could be faxed, back in the day – now, with e-mail, size don’t matter much in excel, although it does in PowerPoint or Word). The magic is in the back-and-forth between the middle-manager and the senior manager, and then other specialists, such as, for instance, getting the opinion of the hospital’s hygiene expert and other experts.
So here’s the thing: A3 is an incredible powerful tool IF the work is being done at the gemba. A3 without “zone control” will, in most likelihood, lead you astray. In the same way, A3 as a “problem-solving” methodology, done by people in isolation, will get you to paint yourself in a corner. The key point is that we don’t know what we don’t know. First we have to face what we don’t know, and this happens by Go and See on the gemba and asking why? Why? Why?, second we have to realize many things can be solved without A3s, just by getting the team to chew on the issue, try things and reflect. Finally, when the twin practices of accepting the Gemba as the greatest teacher, and standardizing work through kaizen have been accepted by the teams themselves, A3 is a great way to develop the ward managers in tackling more complex technical problems. On the other hand, I would urge practitioners to be wary of A3s before having done the foundation work at Go and See, Standardized Work and Kaizen levels with the teams. You’ll get to solutions all right, but you won’t have a handle on the check mechanism of the PDCA – so we have no idea whether we’re getting into the right kind of solution.
Sorry to be a curmudgeon, but I know of no magic in lean. It’s all about the two main tools: your legs and your eyes, and a lot of hard work. The power of A3s is in the giving management a tool to develop middle managers and include them in creating a lean culture. But it’s hard work, and more hard work. On the other hand, you should see the pride and motivation of ward managers and their teams when they’ve managed to reduce reinfections on specific bandage techniques by half. Or when they succeed in caring for patients after tracheotomy so that the cannula does not clog up so badly. No one has ever accused me of being soft, but I’ve rarely felt so moved in a working situation. Even with the jaundiced view of doing lean every day on the shop floor (everybody says “no” all the time – when they say “yes” it’s a good day), seeing improvement of care at the patient is the greatest payoff I can thing of. In industry, you get to a point where kaizen becomes fun (yes, yes, you do), but in the wards, solving A3 problems with ward managers and their teams can be, indeed, pure magic.
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