TOC and A3 - tocico

TOCICO 2009 Conference

TOCICO CONFERENCE 2009

TOC and A3 Facilitating a Path Through The Layers of Resistance Presented By: Tim Sullivan Focus! FollowFollow-through! Feedback! Date: June 8, 2009

© 2009 TOCICO. All rights reserved.

1

Attendee Benefits TOCICO 2009 Conference

• For Consultants: Using A3 is a way to increase acceptance in markets where Lean is king • For Practitioners: A3 A3, a socially constructed mechanism that f t fosters th thoroughness, h individual i di id l development and organizational learning, is ideal for CI teams. 2 © 2009 TOCICO. All rights reserved.

Brief PRT TOCICO 2009 Conference 1. Attendees Use A3

2. Attendees Understand A3 5. Attendees Understand A3 is rigorous, thorough, and flexible. flexible 9. Attendees Understand A3 is Socially Constructed. 11. Attendees Understand A3 is a Dynamic Mechanism that Aligns Responsibility and Authority JIT.

3. Attendees Believe A3 is Effective

6. Attendees Believe A3 will Help S/he Grow/Develop.

4. Attendees Believe Clients or Colleagues will Accept A3

7. Attendees Believe A3 is compatible with favored/dominant methodology.

10. Attendees Believe A3 will Help p Client or Colleagues Improve/ Solve Problems.

12. Attendees Understand A3 Communicates Effectively Horizontally and Vertically – Promoting Alignment & Organizational Learning. 3 © 2009 TOCICO. All rights reserved.

8. Attendees Believe A3 is “accessible” ((Client or Colleagues g will actually use it.)

A3 – What Is It? TOCICO 2009 Conference

• A3 Report • A3 Process • A3 Thinking • A3 Learning • A3 Management 4 © 2009 TOCICO. All rights reserved.

A3 Report as “Hub”? TOCICO 2009 Conference

A3 Process

A3 Learning

A3 Report

A3 Mgmt 5 © 2009 TOCICO. All rights reserved.

A3 Thinking

Beyond the A3 Report TOCICO 2009 Conference

“However, However, in all cases, the tools [A3 Report] are effective only to the extent they engender a style of thinking that is rigorous and thorough, a style of communication that focuses on hard data and vital information and (cont information, (cont.)) 6 © 2009 TOCICO. All rights reserved.

Beyond the A3 Report

(cont.)


….and a style of problem solving that is collaborative and objective. objective Understanding A3 Thinking by Sobek and Smalley, CRC Press, 2008.

7 © 2009 TOCICO. All rights reserved.

A3 Report

Durward K. Sobek, PhD Dept. of Mechanical and Industrial Engineering Montana State University http://www.coe.montana.edu/ie/faculty/sobek/a3/steps.htm TOCICO 2009 Conference

Title: Reduce Diagnostic Dept Patient Transport Time BACKGROUND: 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 i delays d l in i treatment andd patient i waits, i andd they h bl blamedd the h transporters for f the h delays. d l Many M thought h h 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.

TARGET CONDITION:

CURRENT CONDITION:

11 inches

Countermeasures:  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 Expected results:  The transportation manager set the target time from request to delivery at 30 minutes. IMPLEMENTATION PLAN:

ROOT CAUSE ANALYSIS: Problem: P bl Backups B k in i diagnostic di ti departments d t t 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? h ? Nurses unaware off prescribed ib d test Why? No mechanism to inform RN of scheduled procedure

FOLLOW-UP: Plan 



Note the plan to measure the effectiveness of the proposed change. Indicate when it will be measured, and by whom.

17 inches 8


Actual March, 2003

14.7

April, 2004

11

September, 2004

11.5

May, 2005

9.15

A3 Report Overview TOCICO 2009 Conference

• Targeted to an audience • Storyboard y of p project j (PDCA) ( ) −As visual as possible

• Has structure yet is flexible −A3 variations: problem solving; proposal; p p ; status. 9 © 2009 TOCICO. All rights reserved.

6 Layers of Resistance TOCICO 2009 Conference

0. I/We don’t don t have a problem. 1. You don’t understand my/our y problem 2. We don’t agree on the direction of the solution 3. Your solution can’t p possibly y deliver the results you state 10 © 2009 TOCICO. All rights reserved.

6 Layers

(continued) TOCICO 2009 Conference

4. There are obstacles (OBS) to implementing your solution 5. Your good solution will cause bad effects (PUNCs) 6. Unverbalized fear


A3 Report Sections TOCICO 2009 Conference

SECTIONS • [ Title ] • Background


A3: Title (aka Theme) TOCICO 2009 Conference

• Objective description of the content of the A3 • Include key words that you would use to search for solutions other teams may h have derived d i d on a similar i il problem/opportunity 13 © 2009 TOCICO. All rights reserved.

Title

Example from: Managing to Learn by John Shook, LEI, 2008 TOCICO 2009 Conference

• “Create Create Robust Process for Translating Documents” • “Deliver Perfect Translations” • “Support Launch Objectives with Accurate, Timely Document Translation” 14 © 2009 TOCICO. All rights reserved.

A3: Background TOCICO 2009 Conference

• Why are you spending precious time and resources on this Problem or Opportunity? • State the Business case case. • Tie to organizational goals • Be g graphic p 15 © 2009 TOCICO. All rights reserved.

Background: Example 1

From Managing g g to Learn by y Shook


• Acme plant to double capacity! • Much document translation required. • Poor English translations of Japanese documents caused many problems at original plant startup. • Expansion plans call for aggressive l launch h timeline ti li and d costt reduction. d ti problems could • Document translation p impede plant launch. 16 © 2009 TOCICO. All rights reserved.

Background: Example 2 TOCICO 2009 Conference

“It is common practice for patients to show up at or after their scheduled appointment time which means that even if the doctor is ready to see the patient ‘on time’ s/he cannot cannot. Too often when a patient is late for the first pp of the morning g or afternoon,, the appointment doctor is behind for the remainder of that ½ day (unless there is a no show). This results i too in t many tasks t k being b i completed l t d late l t in i the th day or after 5PM. Too often, then, the nurse is unable to get back to the patient in a timely manner.” 17 © 2009 TOCICO. All rights reserved.

P1 8 :4 0 A M

P2 P3

P2 P3 P4 P4 P5 P6

P5 P6

Patient late P7 P7


18

P8 P8

Minutes Doc is behind at Noon: Minutes Doc is behind at 5PM: P9 P9

Doctor behind

18 18

P10 P10

1 1 :3 0 A M

1 1 :2 0 A M

1 1 :1 0 A M

1 1 :0 0 A M

1 0 :5 0 A M

1 0 :4 0 A M

1 0 :3 0 A M

1 0 :2 0 A M

1 0 :1 0 A M

1 0 :0 0 A M

9 :5 0 A M

9 :4 0 A M

9 :3 0 A M

9 :2 0 A M

9 :1 0 A M

9 :0 0 A M

8 :5 0 A M

8 :3 0 A M

P1 8 :2 0 A M

8 :1 0 A M

8 :0 0 A M

Background: Example 2 TOCICO 2009 Conference

Summary TOCICO 2009 Conference

• Layers 0, “I/We I/We don’t don t have a problem” is addressed by the -Title, Title and -Background sections of the A3 Report.


A3 Report Sections TOCICO 2009 Conference

• Initial Conditions (Current State)


A3: Initial Conditions (Current State)


• Communicate the problem or opportunity −Include data the audience needs

• Be B graphic hi when h possible ibl • Walk the gemba


Initial Conditions (Current State)


Example 1: Sobek, Montana St. U. http://www.coe.montana.edu/ie/faculty/sobek/a3/steps.htm 22 © 2009 TOCICO. All rights reserved.

Initial Conditions

(Current ( State))

TOCICO 2009 Conference 2. Phones roll over at 8:00.

1. Clinic opens doors at 8:00.

3. PSRs answer phones.

4. Phone calls usually take priority over

5. Walk-ins can begin checking in at 8:00. 6. Staf f arrives bef ore 8:00 in order to be ready

9. Sometimes patients arrive f or check-in @ their appt time..

12. Sometimes patients arrive af ter their appt

8. Sometimes 8 S ti PSR d does not get SCHD patient checked in by appt time.

7. PSRs check in walk in patients.

10. It takes time to check-in and room patients.

11. Many times patients are not ready to see the Doc at their Appt time.

20. There is no time in the 20 schedule to complete tasks (other than lunch time)

16. Of ten Doc cannot dictate between visits.

26. Of ten identical annotations must be typed into EHR. 28. Doc is a slow typist compared to hand writing.

Example 2: Healthcare

29. EHR requires typing record in

18. Of ten Doc dictates during l lunch hb break. k

23


39. Nurse has many demands on her time.

41. Nurse can't always get tasks sent to Doc in time f or him to process in open slots during the day.

42. Nurse spends time af ter 5PM completing her tasks.

19. Sometimes Doc is behind on the rest of the patients th t morning. that i

22. Doc has [too many] tasks to do af ter 5PM.

24. It is easy f or a large number of tasks to build up bef ore the Doc realizes.

25. Doc spends [too much] time completing tasks af ter 5PM.

27. "Quick' tasks that in the past were completed between appts are not getting done now.

30. It is not easy to identif y tasks that quickly. y can be done q

31. Many days Doc has small amounts of time between appts in which 'quick' tasks could be

32. In EHR it is not easy to see quickly see what a task involves.

33. The EHR gives a very small window f or viewing.

40. Nurse has to do some processing on many of Doc's tasks bef ore he can complete them.

38. Nurse gets buzzed on her pager.

17. Sometimes Doc is behind on f irst patient of the

21. 50% of Labs to be verif ied come between 2 and 5 PM. 23. In EHR it is not easy to see how many tasks have built up.

37. Nurse gets paged overhead.

13. First SCHD appointment is 8:10. 14. Sometimes the f irst patient of the day is not ready f or Doc at 8:10.

15. Doc must dictate details of each patient visit.

36. Nurse gets assigned many electonic tasks.

34. One bucket is dif f icult to f ind in the system.

35. Doc has 2 task buckets: tasks needing to be done bef ore going home; tasks that can be done af ter hours of f premisis.

43. Doc is not able to get tasks to Nurse in a timely f ashion.

44. Nurse cannot get back to the patient in a timely f ashion.

Initial Conditions

(Current ( State)) 1. Patient makes initial call.


8. Patient makes 126/week incoming call-back. 9. Nurse leaves message.

7. Clinic answers immediately.

2. Clinic unable to answer immediately.

3. Nurse 3 N calls ll patient back.

5. Patient P i iis not reached.

Example 3: Simplified CRT 24 © 2009 TOCICO. All rights reserved.


• Layers 1, “You You don’t don t understand our problem” is addressed by the -Initial Conditions (Current State) sections of the A3 Report.


A3 Report (continued) TOCICO 2009 Conference

Sections • Objective(s)/Target(s) j ( ) g ( ) • Analysis


A3: Objective(s)/Target(s) TOCICO 2009 Conference

• How will you know the project is successful • Include ‘balancing’ measures when appropriate (PUNCs) • Be graphic when possible


Objective(s)/Target(s)

Example p 1: Healthcare


By December 1 we will redesign Dr. X’s schedule so th t att noon and that d att the th end d off the th day d there th is, i on average, 50% improvement in the number of tasks for Dr. X, and will have a 50% improvement in the number of minutes Dr. X must work at the end of the work day to complete his tasks. Balancing measures will check that there is no decrease in the average g number of patients seen, nor an increase in the average number of minutes behind at midday and days end, nor an increase in the average number of minutes of work Nurse Z has to do at the end of the work day to complete her tasks.


Objective(s)/Target(s) Example 2: Healthcare


• By December 1, Clinic will reduce the number of incoming patient call backs by at least 50%. Measures will be reduction in number of call backs and reduction in overtime. 29 © 2009 TOCICO. All rights reserved.

Objective(s)/Target(s) Example 3: Manufacturing

Curent

April 1st

Curent


April 1st

66%

F. G G. Invv.

OTIF @Peak @

50%


OTIFF

100%

Finished Goods Invventory

100%

A3: Analysis TOCICO 2009 Conference

• Find root cause(s) • Establish solid cause-effect • Walk the gemba • May require experimentation


Analysis – 5 Whys

Example p 1: Healthcare


101. Phone number bad.

5. Patient is not reached.

2. Why?

1. Why? 101. Phone number bad.

102. Call rolled to voicemail at patients of f ice. 103. patient moves to dif f erent number bef ore call back.

201. Number not verif ied at time of call.

3. Why?

202. No f ield in GPMS f or cell phone #.

203. Number incorrectly entered.

(FOL)

(See next page)

902. Staf f take short cuts.

4. Why?

301. Person answering phone (PAP) is too busy.

403. Clinic not f ully staf f ed.

902. Short cuts become S.O.P.

5 Why? 5. 501. Takes time to hire.

104. no instruction on which number to call. 302. Not all people answering phones (PAP) understand the importance of verif ying phone # every time.

502. Takes time f or new staf f to get up to speed.

503. Vacations.

6. Why?

4. Why? 404. PAP doesn't understand the work it can cause.

601. True capacity not known - no protective capacity.

5. Why?


505. Some have no experience working in the back.

506. Clinic has not explained or trained properly.

504. Too f ew f loat staf f .

6. Why? 602. EHR "go live" is priority f or f loat staff.

Analysis

Example 2: Healthcare


Four Root Causes why Dr X is behind on the rest of the patients that morning/afternoon. 1. Clinic opens doors at 8:00. 12. Sometimes patients arrive after their pp time. appt 13. First SCHD appointment is 8:10. 20 Th 20. There is i no time ti in i the th schedule h d l to t complete tasks (other than lunch time).



• Layer 2, “We We don’t don t agree on the direction of the solution” is addressed by the -Objective(s)/Target(s), and the -Analysis sections of the A3 Report. p



Sections • Proposed p Injection(s)/Future j ( ) State


A3: Proposed Injections (‘Countermeasures’) ( Countermeasures )


• Exploit, subordinate, and elevate (if/where necessary) • Socially S i ll constructed t t d −Initially Initially include all injections considered

• TOC strength: OBS & PUNCs • Include predicted results 36 © 2009 TOCICO. All rights reserved.

Example 1: Healthcare TOCICO 2009 Conference

10. Clinic uses new process f or inf orming of test results. 11. Clinic 11 ef f ectively manages patients expectations f or receiving test results results.

12. Clinic uses new process to direct calls to appropriate staf f .

8 Patients make f ar 8. f ewer incoming call-backs.

1. Fewer patients make initial calls.

9. Nurse seldom leaves message.

7. Clinic 7 answers more calls immediately.

2. Clinic unable to answer some calls immediately.

13. Clinic uses new process f or recording call back numbers.

3. Nurse calls patient back. back 14. Clinic uses new process f or prioritizing call backs.


5. Patient usually is reached.

Example: Sobek,

Montana St U

http://www.coe.montana.edu/ie/faculty/sobek/a3/steps.htm p y p

TOCICO 2009 Conference Countermeasures: Diagnostic departments will beep the charge RN and the transporter at the same time The page will include specific information, and a reference card Th charge The h RN (or ( a person designated d i t d by b the th charge h RN) and d the th transporter t t will ill attend tt d the th patient, ti t with ith specific responsibilities Make the patient aware of the ensuing procedure



• Layer 3, “Your Your solution can can’tt possibly deliver the results you state” is addressed by the state - Proposed Injections (Future State) section of the A3 Report.



Sections • Follow-through g Plan


A3: FollowFollow-through Plan TOCICO 2009 Conference

• Must overcome OBS • Identify y Who,, What,, When • D in PDCA


Example: Healthcare TOCICO 2009 Conference

1 Build new schedule in 1. system. Staff A 10-Oct Build 2-15 min appt slots in schedule in a test environment environment. Staff A 12-Sep Build 2-30 min daily Task slots, on in AM, one in PM in a test environment. Staff A 12-Sep Build 2 Pre Pre-Op Op slots to be held on Tue and Thu at 3:30. Staff A 12-Sep Users test new schedule procedure. Staff A 19-Sep Enter new appts manually in new schedule with paper back-up. Staff B 26-Sep

2 Two staff arrive before 2. 7:45 in order to be ready at 7:45. Staff A&Staff B 13-Oct Assign staff.

Staff A

13-Sep Provide keys.

Staff A 10-Oct Arrange for float nurse to arrive at 7:45 (as emergency cover). Staff A 13-Sep Ensure when a nurse covers for Nurse that they know to be here at 7:45 7:45. Staff A 13-Sep

3 Clinic opens doors at 3. 7:45. Staff A&Staff B 13-Oct Identify responsible person(s). Staff A 13-Sep Devise back-up plan for when responsible person doesn't show. Staff A 13-Sep


4 Scheduled Patients are 4. given priority check-in before 8AM. Staff A&Staff B 13-Oct Devise signage.

Staff A 23-Sep Define process for giving priority to scheduled Patients. [need writen] Staff A 23-Sep Train staff on the process for giving priority to scheduled Patients. Staff A 3-Oct

5 Clinic effectively 5. communicates changes to all effected. Staff A 10-Oct Develop message to Patients regarding when to arrive [need writen] arrive. Staff A 14-Sep Prepare explanation of Patient benefits of wave scheduling.[need writen] Staff A 14-Sep Communicate changes to clinic staff. Staff A

10-Oct

Example: Sobek,

Montana St. U

http://www.coe.montana.edu/ie/faculty/sobek/a3/steps.htm p y p


What Who Develop a “group page” whereby two or more people could designated transporter and a be paged simultaneously by the diagnostic departments. staff from communications in CMC Develop p a patient p tracking g sheet (a ( log g sheet for the floor transportation p manager g and the staff to sign off when the patient is transported) charge RNs Develop a reference card that contains the pager transportation manager and numbers of the charge RNs of each clinical department the designated transporter (Obstetrics, Medical Surgical Floor, Intensive Care Unit Orthopedic, Unit, Orthopedic Rehab Nursing Unit, Unit etc.), etc ) and the transport pager number that the diagnostic departments should page.


When 1/17/2003

1/17/2003 1/24/2003

Follow--through Plan Follow TOCICO 2009 Conference

• Can be a simplified version of a complex project plan or Gantt chart



• Layer 4, “There There are obstacles (OBS) to implementing your solution” were identified in the solution -Proposed Injections section and are addressed in the -Follow-through Follow through Plan section of the A3 report 45 © 2009 TOCICO. All rights reserved.


Sections • Feedback Plan


A3: Feedback Plan TOCICO 2009 Conference

Project Feedback • TOC Strength: g buffer mgmt g • Immediate & Visual • Monitor predicted results


Feedback Plan


System Feedback • Tweak as required q • Standardize new process • Share system learning


Feedback Plan Example TOCICO 2009 Conference

FEEDBACK PLAN: List Mechanism(s), Mechanism(s) date/frequency used, used expected, expected and actual measures. measures MECHANISM DATE/FREQ EXPECTED ACTUAL All staff meeting 12/3/2008 Call back data Quarterly sample Reduce >50% Overtime data Monthly Reduce



• Layer y 5, “Your g good solution will cause bad effects” (PUNCs) is addressed by the -Proposed Injections, and -Follow-through F ll th h Plan Pl and monitored by the -Feedback Plan section of the A3 Report. Report 50 © 2009 TOCICO. All rights reserved.

A3 TOCICO 2009 Conference

• F3 (A3) Process


F3 Process TOCICO 2009 Conference

FOCUS • 0: Identify y target g problem p or opportunity −TOC OC strength

• 1: Create Title state Background


F3 Process (continued) TOCICO 2009 Conference

Focus (continued) • 2: Show (graphically if possible) th IInitial the iti l Condition C diti • 3: Define the Objective(s) • 4: Discuss Steps 5-8 w/affected parties (social construction) −OBS & PUNCs

53


F3 Process


Focus (continued) • 5: Do Root Cause Analysis y • 6: Show (graphically if possible) the Target Conditions • 7: 7 D Devise i aF Follow-through ll th h Plan Pl 54 © 2009 TOCICO. All rights reserved.

F3 Process


Focus (continued) • 8: Devise a Feedback Plan • 9: Obtain approval(s)/ permission(s) if necessary


F3 Process


Follow through Follow-through • 10: Execute Follow-through g Plan • 11: Execute the Feedback Plan


F3 Process


Feedback • 12: Evaluate the Feedback • 13: Improve/Tweak • 14: Codify System Learning • 15: If necessary, start a new A3 Process with DMADV Cycle 57 © 2009 TOCICO. All rights reserved.


• Layer 6, “Unverbalized Unverbalized Fear” Fear is addressed in the “A3 Process”, which is: -Rigorous -Thorough -Data driven -Socially constructed -Iterative 58 © 2009 TOCICO. All rights reserved.

A3 Report: other benefits TOCICO 2009 Conference

• Flexible • Aligns g Responsibility p y and Authority JIT • Communicates Horizontally & Vertically – promoting alignment and organizational learning 59 © 2009 TOCICO. All rights reserved.

A3: Flexible during project TOCICO 2009 Conference

Title: BACKGROUND:

ANALYSIS (continued)

INITIAL CONDITIONS (Current State): INITIAL CONDITIONS (Current State):

OBJECTIVE(S)/TARGET(S): OBJECTIVE(S)/TARGET(S)

ANALYSIS:


A3 Flexibility


Title: BACKGROUND:

PROPOSED INJECTIONS: List and evaluate…

INITIAL CONDITIONS (Current State):

OBJECTIVE(S)/TARGET(S):

ANALYSIS:

Target Condition (FRT or Future State)


A3: Flexible projectproject- project TOCICO 2009 Conference

• Generic 7-part 7 part structure is NOT cast in stone • Different generic structures −Problem solving A3 3 −Proposal A3 −Status A3 62 © 2009 TOCICO. All rights reserved.

A3: Align Resp’&Auth Resp’&Auth’’ JIT TOCICO 2009 Conference

• A3 ‘owner’ owner has the responsibility but usually no formal authority • Pull Based Authority • Just-In-Time Decision Making −When When shared understanding exists

• “Kanban Kanban Democracy Democracy” 63 © 2009 TOCICO. All rights reserved.

Communicates Horiz&Vert TOCICO 2009 Conference

• Provides consistent platform for multiple C. I. teams • Accelerates organizational learning −Team Team to team −Across leadership 64 © 2009 TOCICO. All rights reserved.

A3… TOCICO 2009 Conference

• Thinking −A3 Thinking by Sobek and Smalley

• Learning • Management −Socratic tool for mentoring TOC gy methodology 65 © 2009 TOCICO. All rights reserved.

Questions TOCICO 2009 Conference


About Tim Sullivan TOCICO 2009 Conference

Tim is an experienced consultant, lt t educator, d t facilitator and conference speaker. He has combined his experiences as a coach coach, corporate trainer, and manager in the private and public sectors with his training in the concepts and tools from TOC, Lean, and Six Sigma to produce a unique approach to problem solving. (Tim is also the current chair of the TOCICO Dictionary ct o a y Committee.) Co ttee )

[Color Photo of Presenter]
