A3 thinking nhsiq 2014

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A3 Thinking:
A3 thinking is a structured technique of working through problems or opportunities for improvement. The ‘A3’ itself is literally just that: a piece of A3 paper summarising the logical thought processes that have been agreed by the team in defining the opportunity for improvement or solving the problem they face.

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A3 thinking nhsiq 2014

  1. 1. © NHS Improving Quality 2014 A3 Thinking Patient Safety Team Lisa.smith@nhsiq.nhs.uk
  2. 2. © NHS Improving Quality 2014 A3 Thinking • What do we mean by A3 Thinking? • Why do we use it? • How do we use it?
  3. 3. © NHS Improving Quality 2014 What is A3 Thinking? • Structured thinking way - thinking deeply • Follows a series of standard steps • Rigorous application of PDSA cycle • Output is a concise, consensed document - A3 Report (11 x 17 inch paper)
  4. 4. © NHS Improving Quality 2014 PLAN DOSTUDY ACT 1. Is the problem statement CLEAR and ACCURATE? 2. Has the SYSTEMIC root cause(s) been identified for all parts of process? 3. Has IRREVERSIBLE CORRECTIVE ACTION(s) been implemented for ALL root causes? 4. Has a plan been identified to verify the EFFECTIVENESS of all corrective actions? 5. Has a plan been identified to STANDARDIZE and take all lessons learned across products, processes, functional areas, etc.? Understand the problem Execute the PlanFollow-up Standardize
  5. 5. © NHS Improving Quality 2014 Why do we use A3 Thinking? • Problem solving methodology: – Visual – Simple – Logical – Countermeasure, not containment (“Band aid”) – Move towards Ideal System • Document & share the learning • Standardise new method
  6. 6. © NHS Improving Quality 2014 How do we use A3 Thinking? • Consensus on initial problem perception….. • A guide for: – Understanding the problem – Identifying the root cause – Developing countermeasures – Creating an action plan • Good A3 report should convey the problem & analysis of it without any explanation
  7. 7. © NHS Improving Quality 2014 Format Title: Problem: Version: Date: Author: Current condition: Target condition: Root cause analysis: Responsible: Team members: Proposed countermeasures: Plan: Follow up: Agreed by: Date:
  8. 8. © NHS Improving Quality 2014 Format Title: Problem: Version: Date: Author: Current condition: Target condition: Root cause analysis: Responsible: Team members: Proposed countermeasures: Plan: Follow up: Agreed by: Date: • Customer/patient value • Basic problem • What is happening? (data/graphs, photos, current state value stream map) • Set SMART Goal • Investigate why problem is happening
  9. 9. © NHS Improving Quality 2014 Fishbone / Cause & Effect Checked possible Not cause of Cause 1 problem Checked possible Direct cause Cause 2 Checked possible Contributory Cause 3 cause IDEA INVESTIGATIONS RESULT idea idea idea Investigate possible causes further (data collection) Identify possible causes
  10. 10. © NHS Improving Quality 2014 5 Whys Analysis Problem Root Cause Countermeasure Why? Why? Why? Why? Why? Reason Reason Reason Reason
  11. 11. © NHS Improving Quality 2014 Format Title: Problem: Version: Date: Author: Current condition: Target condition: Root cause analysis: Responsible: Team members: Proposed countermeasures: Plan: Follow up: Agreed by: Date: • Investigate how to solve root cause(s) • Agree action plan − What − How − Who − When • Is the problem solved? • Has the goal been met?
  12. 12. © NHS Improving Quality 2014
  13. 13. © NHS Improving Quality 2014

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