Discussion Questions

The A3 Report

Problems are dealt with in superficial ways. Very few people and organizations actually arrive at the root cause

of their problems. At Toyota and many other many other enterprises that apply lean principles, they employ

Root Cause analysis in almost everything they do. One problem solving approach they employ is the A3

Process. The A3 provides a framework for leading teams through Lean Kaizen events (a 1-3 day event aimed at

the elimination of waste). The A3 framework is so name for the paper size (A3) used to lead the team and

provide visuals of the Kaizen event progression. The A3 Framework follows these steps:

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.

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 process first hand, and document observations  Create a diagram that shows how the work is done – a value stream map will be helpful here.  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.

Root Cause Analysis

Once you have a good understanding of how the process (i.e., the one that needs to be fixed) currently works,

it’s 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 haven’t reached the root cause until you’ve asked “why?” at least five times in series.

Countermeasures

Once the current situation is fully understood and the root cause(s) for the main problem(s) has been unveiled,

it’s 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 Bowen 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

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.

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.

A3 Example

Below is an example from an A3 project. The context for the A3 Report below is around the question “Why

was the end-of-shift clean-up (5s) not being completed?” This question drove the team to follow the A3 method

and subsequent root cause analysis to arrive at the root causes and implement solutions. Note that the A3 below

follows a PDCA (Plan-Do-Check-Act) scheme. This is a common sequence to test and validate improvements.

This activity below was done proactively done by the team with full support from management.

VALUABLE FEATURES OF THE A3:

There is tremendous power in having one problem solving method in which management and staff

members develop confidence.

When staff and management have been involved with the A3 process and an issue arises for which the A3

approach is suggested, everyone knows the steps that will be employed, believes that they will be either

involved or represented in the work redesign and that there will be a timeline and accountability for completion

developed. They believe that the experimental environment will be safe. They know that when problem solving

is reported, it will be easy to understand and consistent. When management says, “I think we should do an A3

on this”, everyone knows what that means.

The A3 is done on the front side only of an 11x17” (thus the name, A3) sheet of paper.

With only a small area for problem analysis, the A3 forces the problem solver to choose issues that are specific

enough to complete on one sheet. This assures that the work is of a scope that can be realistically completed,

quickly demonstrating successful change and motivating workers to do even more problem solving.

A3 problem solving occurs in the course of work.

Large numbers of staff do not have to be gathered for extended times to do speculative problem solving.

Coaches can be recognized and easily trained to help staff validate and participate in the A3 process without

leaving their work site.

A3 problem solving is intuitive and easy to learn and remember.

Healthcare workers did not enter the profession to become management engineers or spend all their time

improving processes; they came to this work to take care of people. The A3 process is logical thinking based on

the familiar scientific method of problem solving that is easy to learn and teach and requires no technical

training.

A3 Thinking can be used to create better and fewer meetings.

Conducting a lean meeting using the A3 process can greatly reduce the time and numbers of meetings required

to achieve the work of the agenda. A3's are ideally done by a focus group of 2-3 people who represent the

affected parties and can procure validation of the current condition and the target condition from their peers, in

the course of work.

Measurement of the cost of implementation and the cost benefit is documented on each A3.

The cost of the implementation plan is documented on every A3 and can then be compared to the benefit, which

may be measured in hard or soft dollars saved, or in a measure of quality of service. This information creates

objective information for leadership to use in authorizing the implementation plan presented on the A3

document.

The A3 form is both a template for problem solving and documentation of the efforts.

When the A3 document is stored in a 3-ring binder on the work unit and logged on the Improvement Marquee

©, real activities can be reviewed by regulatory groups (OHSA, JCAHO, etc.), governing board members,

physicians and senior leaders, as well as staff from other departments. This allows cross departmental sharing of

process changes and generates even more problem solving ideas.

Last, but certainly not least, the A3 process is satisfying to everyone who uses it, particularly frontline

workers.

The A3 is an easy to learn and easy to teach method that staff can use to remove the frustrations of their daily

work that are created by weak and un-supportive processes. This ability to be involved with creating a better

way to work has been exceptionally well received by frontline workers, who Toyota recognizes as the resident

experts in any industry. It involves them in improving work that is meaningful to them, at a level at which they

can see and appreciate the changes they have participated in creating. In this era of current and impending

healthcare worker shortage, this satisfaction is essential to retaining good workers.

One responsibility of a lean coach (facilitator) is to make sure that problem-solvers do not short-circuit the A3

process. There seems to be a fairly strong temptation to skip steps in the process (probably because it’s hard

work!), particularly not doing observation to establish the current condition, and not soliciting input and buy-in

from affected parties. Short-circuiting the A3 process renders it ineffective, so it’s important that deviations

from the basic process be avoided.

Conclusion

The A3 problem-solving report, adapted from Toyota, is a potentially useful tool for organization-wide

continuous improvement. It simultaneously documents the key results of problem-solving efforts in a concise

manner and embodies a thorough problem-solving methodology that begins with a deep understanding of the

way the work is currently done. When implemented properly, the approach pushes the organization toward

system-wide rather than local optimization as the problem-solver seeks input and ultimately consensus from all

parties affected by the proposed change. In taking as many system issues into consideration as possible, the

problem-solver attempts to propose countermeasures that help the organization move one step closer toward

ideal.