The document outlines an A3 approach used by 4 South at SJMO to improve hand hygiene compliance, which was baseline at 67% in April. The team aligned their work with organizational goals and chose hand hygiene as their focus area, with the goal of completing the A3 process within 2 months to develop solutions to increase compliance above 90%. Metrics and progress are tracked on a scorecard to monitor the impact of their problem solving efforts.

1. A3 Thinking & Problem Solving
St Joseph Mercy Oakland
Presented By: Dave Follis
Performance Excellence Leader
Date: August 12th , 2016

2. Education & Training Plan
2©2015
A3 Deployment: Training 2nd week of each month (1 hr.)
• Wave 1: June, 16th
− Target Areas: EVS, ED, CDU, 4G, 7S
• Wave 2: July, 14th
− Target: Areas: Food Services, OR
Transport, 2S, 3E
• Wave 3: August, 11th
− Target Areas: Pharmacy, Radiology,
3S, 4E, 5W / 5E
• Wave 4: September 15th
− Target Areas: ASC-OR, Cath. Lab,
4N, 5N, 6E
…continued for balance of 2015!
Share & Spread Learning Experience's and Best Practices
Wave 4
Wave 3
Wave 2
Wave 1
Pilot

3. A3 Deployment Plan
3©2015
Project: A3 Deployment Plan
Update Date: 12/22/15 Left-side Right-side
#
Target Area
(Unit)
Service Line Phase Responsible Owner A3 Start Date
Training
(Session 1)
Training
(Session 2)
Kata Coaching
(Weekly)
Px
Support
Performance Measure
(KPI)
Baseline
Metric
Target
Metric
Financial
Benefit
1 2G Med Surg Pilot Tara Hegwood Dave
2 3G Med Surg Pilot Laura Keoppen Dave
3 4S Med Surg Pilot Patty Kerin Dave
4 6S Med Surg Pilot Daniel Broders Dave
5 Lab Lab Pilot Nancy Pelowski 02/16/15 Christie AMDraws
6 ED ED Wave 1 James Beck 06/16/15 Katie Culture of Safety (COS)
7 CDU ED Wave 1 Crista Walsh 06/16/15 Katie Culture of Safety (COS)
8
Food Services
(Nutrition)
Facilities/Services Wave 1
Jim Donnellon
Sonya Stanley
06/16/15 Katie Tray Delivery (Time & Accuracy)
9 4G Med Surg Wave 1 Linda Borucki-Urban 06/16/15 Dave
10 7S Ortho/Rehab Wave 1 Sarah Simon 06/16/15 Dave
11 4E Ortho/Rehab Wave 1 Sarah Simon 08/11/15 Dave I's & Os'
12 Central Transport Ops Wave 2 Mehul Naik 07/14/15 Dave Cancelled Tranports
13 OR (Main) Surgery Wave 2 Trudy Lentini 07/14/15 Christie Pre-op Hand Off's
14 2S Med Surg Wave 2 Rebecca Trammel 07/14/15 Dave Bed Fall Alarms 85% 100%
15 Ethics Admin Wave 2 Beverly Beltramo 07/14/15 Dave Ethics Consultation Process
16 Respiratory Respiratory Wave 2 Paulo Fantin 07/14/15 Christie Hand Hygiene Compliance 65% 70%
17 Pharmacy (Retail) Pharmacy Wave 3 Phil Wein 08/11/15 Katie TBD
Status Key: Training
1 Not Started Completion 82.5% 78.9%
2 Barriers / Delayed / no progress
3 Scheduled / some progress
4 On-track
5 Complete
1 Pilot +7 Waves of Training for 58 Leaders from March to December’2015

4. Coaching & Mentoring
4©2015
Knowledge Transfer through Mentoring

5. Daily Management (Standard Work)
5©2015
Huddles, Gemba, & A3 Coaching Support

6. Tracking & Reporting
6©2015
#
Target Area
(Unit)
Service Line Responsible Owner A3 Start Date SLT Gemba?
Px
Support
A3 Title Leading Indicator Lagging Indicator
Baseline
Metric
Target
Metric
% improvement
End Date
(Target Met)
PX Comments
1 2G Med Surg Tara Hegwood 01/20/16 Yes Andy
Improve flow from PACU to 2G (Joint
A3 with PACU)
Depends on Root Cause of Delay
(dirty beds, delayed discharges,
lack of notification)
Patient Transfer Time from PACU
(RTMto Arrival)
1 hr 44 min
(median time)
<90min
4/19: Data analysis shows systemic issue (41% pts assigned to dirty beds,
no prompt in system for when bed clean based on the way tracker is used)
that may mean this is out of scope for unit level A3. Need to engage
logistics, PACU, and EVS to understand causes of delay.
2 2G Med Surg Tara Hegwood Yes Andy Staff Brainstorming New A3 4/19: Staff brainstorming next A3 at huddle (1 week).
3 3G Med Surg
Stephany Powell-Bedell
Laura Keoppen
02/01/16 Yes Dave Improve Shift Handoff % Overtime Budget Variance # of Instance w/OvertimeZero Overtime Nice progress & engagement of staff
13 4N (GYN, PEDs) OB/GYN Patty Tracy 09/15/15 Yes Christie ED report to Peds
RN availablity for report and
critical report components
present
Patient satisfaction. Patient
Safety
95%
4n and ED staff are trialing the ED summary report sheet to give and
receive input from each other, starting 3/21/16 . ED will try to have same
RN who is caring for pt give report
15 4S Med Surg Leisa Krieger 01/16/16 Yes Andy Improve Hourly Rounding Patient Call Light Usage Pt PG Satisfaction Scores 56% 90% 34%
4/15: PG scores have improved for February, but while call light usage has
dropped from January, it is at baseline. Need to continue to work on
"purposeful" part of rounding. Many theories from staff regarding usage
of HillRom & RTLS. Will gather data to help drive testing of potential
ideas.
22 7S Ortho/Rehab
Sarah Simon
Brad Neideck
04/05/16 Yes Dave
1. JCC Patient Luggage Transportation
2. RN Patient Rounding
Parking Lot: Stocking Med Rooms
1. Define Standard Proces
2. Often Nurses checked on you
1. Patient Experience
2. Patient Perception of Rounding
1. SOME Belonging to
Room
2. 67.8 (2/1/16)
All Pt belongings
brought to Room
1. Create a process of moving JCC patient luggage from pre-op to post-op
rooms without asking family to transport luggage
2. Increase use of phrase I'm checking on you" during hourly rounds to
help change patient's perception of the overall experience of care.
23
Accred. &
Regulatory
Quality Carol Bosch 01/29/16 Andy Joint Commission Preparedness
Environment of Care / Mock
Survey Results
SJMO Joint Commission Survey
Results
TBD TBD TBD
1/29: PX met with owner and participated on EOC for two units. Owner
would like for departments to incorporate EOC in A3 priorities.
24 Cath Lab Cardiology Karen Bratton 03/11/16 Yes Andy
Standardize post procedure handoff
from Cath Lab.
3S Satisfaction with Handoff Tool
Cath Lab Utilization of Handoff
Tool
0 90% TBD
4/18: Team decided to pursue standard handoff tool as iniatial solutions.
Draft handoff tool circulated to 3S for trial. Will utilize for 2 weeks and
gather feedback for improvement and % compliance to tool.
25 CDU ED Crista Walsh 01/14/16 Yes Dave
Staffs pulls to ED
Nurse Communication
RTMto Occupied ED ALOS 64 min. 30 min. Last Update: 2/19 - Processing time for patients from ED to CDU
26
Central Supply
Process
Surgery Stephanie Glover 01/08/16 Yes Christie OB equipment turnover Dept efficiencies
Improved physician satisfier- and
improved teamwork between
both depts Scoping
27 ED ED Sharon Silk 01/01/16 Yes Dave
Sepsis
EKG
Stretchers
4N Handoffs-Joint A3 with 4N
# notification of time 0
# EKG order deficencies
# shifts stretchers available
% bundle compliance
# EKG deficiencies
NA
14%
TBD
TBD
Discussed during CIC committee that preference would be to have no
more than 2 Active A3 at a time. Per Denise/Dave
1. Columns H through N are to be completed by the Process Owner. The PX support will help to coach and mentor the process owner in completing the
noted sections.
2. Pictures of the A3s are located in the SJMO A3 "picture" folder.
3. Comments in column "O" will be documented by the PX Coach.
4. Process owners are encouraged to schedule time with their designated PX coach to review their A3
8/10/2016
SJMO A3 Plans
A3 Deployment Scorecard

7. Strategy Deployment - Cascading Alignment
7©2015
Ensure alignment of A3 work with Team’s Strategic Goals

8. Leadership Audits - Gemba Walks
8©2015
Area
Process Owner
(Lead Support)
SLT Sponsor
TH Action
Planning
Group
Rounding frequency per
month
SLT Report Out
12/2015
Facilities (B&G) Aric Alexander Ken LePage 3 4
Highlights: A3 is moving along - length of open work orders.
Successes:
Barriers/Challenges:
4E Brad Neideck Kathy Brodbeck 3 4
Highlights:
Successes:
Barriers/Challenges: some are passive and not as engaged;
Need PX support on A3. Katie will take back to her team.
7S Brad Neideck Michael Smith 3 4
Highlights: handoff to MS from FF
Successes:
Barriers/Challenges:
Cath Lab Cathy Porwoll
Shannon
Striebich
3 4
Highlights: lots of turnover. Various reasons - no patterns.
Using as opportunity to refresh staff structure (i.e. board runner)
Successes: going to set up Q breakfasts to have informal
discussions with the staff
Barriers/Challenges:
2S
Dawn Hanson
(Nick
Nickolopolous)
Michael Smith 2 2
Highlights: meeting today. Report out next session
Successes:
Barriers/Challenges:
SLT Sponsors:
GEMBA walks will be scheduled with the individual Process Owners/Leaders.
Frequency is listed below.
The goal is to review the unit/department A3, along with their Hoshin Kanri and
Huddle Boards, provide support as needed, then report back to the SLT group with
a summary of the improvement activities.

9. Leadership Audits - Visual Management
9©2015
Daily Huddle w/ A3 Problem-solving

10. Standard Method Hardwired into Culture
10©2015
3G Score Card
CAHPS Summary Information
2015-2016 as of 8-1-16 BL
TRINITY FOCUS DOMAINS
July August September October November December January February March April May June July
Rate Hospital 0-10 80.6 54.3 70.6 61 78.3 65 55.3 56.5 70.3 69.2 79.2
Communication with Nurses 81.6 74.7 75.5 78.6 82.6 74 76.9 66.7 84.5 74.9 76
Communication with Doctors 81.6 63.8 64.7 62.9 75.4 70.7 65.8 63.9 65.2 74.1 70.7
Pain Management 69.2 68.8 70.8 62.5 83.3 60 44.4 59.4 88.5 67.9 71.2
Discharge Information 87.1 75.8 76.7 87.6 88.6 90.8 85.9 81.2 80.1 85 81.3
GPA EP 2 0 0 0.4 EP 3 0.8 0 0 1.8 0 1.2
N size 30 35 34 41 23 40 40 24 38 26 25
A3-Improve Shift Handoffs
A3-Cleanliness & Rounding with Leaders
Overall Pain MD Comm RN Comm D/C
Except Perf 82% 78% 89% 86% 91%
Target 76%-81.9% 74%-77.9% 85%-88.9% 82%-85.9% 89%-90.9%
Better than Median 71%-75.9% 71%-73.9% 81%-84.9% 79%-81.9% 87%-88.9%
Median <71% <71% 81% <79% <87%
Focused A3 Problem-solving to Key Performance Measures
Focus & Engagement

11. A3 Sharing - 4 South
SJMO Manager’s & Director’s Meeting
Presented By: Leisa Krieger (Clinical Leader)
Date: August 24th, 2016

12. A3 Approach
12
• Align with Hoshin Kanri (How)
• People Centered P7-Hand Hygiene
greater than 90%
• Choosing an A3 topic (What)
• Base line hand hygiene compliance
April 67%
• Timeframe (When)
• Goal was to complete A3 within 2
months
# Metric Status Exec # Strategic Initiative Status Exec
TOP 5 STRENGTHS X-FACTOR
P1 # of Attributed Lives (increase attributed lives by 5%) Weiner P9 Bundled Payment for Care Improvement $19k M. Smith
P2 Hospital BCBS collaboratives participation Weiner P10 Achieve PCHM neighborhood designation in specialty practices Cobb
P3 Uninsured Medicaid eligible individuals in SJMO's market (increase 1-2%) Weiner P11 Technology to support patient care improv (PRISM, Sotera, RSVP…) Fregoli
P4 UEM Clinical Indicator Scorecard (3.2 or greater) 2.6 Fregoli P12 Reduce observation admissions by 5% M. Smith
P5 Mortality Index (< 0.66) 0.77 Fregoli P13 Expand the network by 10% Cobb
INTENTION P6 Patient Experience index (target: 76% Overall Rating) 71.1% Striebich / Weiner P14 Continue integration of IT plan Fregoli
P7 Hand Hygiene (90%) 76.7% Brodbeck P15 Implement initiatives from CIN / ACO Weiner
P8 Readmissions (Reduction in avoidable readmissions by 20% of baseline) 16.00% Fregoli P16 Deploy Athena Cobb
PLAYGROUND
EC1
Colleague Engagement score (No baseline set for 2015/ 2016 target 4.09) TH
2015 3.98
4.01 Davis EC6 Implement Work Day Davis
TOP 5 WEAKNESSES EC2 Annual Total Turnover % 11.70% Davis EC7 Implement Kronos Work Analytics Samyn/Davis
EC3 Participation in Promoting Catholic Identity (PCI) Beltramo EC8 Leadership Gemba Walks Striebich
EC4 Culture of Safety (Target FY16 69% OPS) 62.9% Davis EC9 Enhanced Department level A3 Striebich
EC5 First Year Turnover % 19.3 Davis EC10 Pursuit of Magnet Designation in collaboration with Regional partners Brodbeck
O1 Operating cash flow margin (12.3%) 9.8% Samyn O6 Transforming Operations Striebich
BRAND PROMISE O2 Case Mix ALOS (Target 3.00) 2.96 M. Smith O7 Outcomes Logistics Redesign Project LePage
TOP 5 OPPORTUNITIES O3 ED throughput (10% improvement) T/R 145 Striebich O8 Implement RTLS for asset management and patient logistical tracking Jones
O4 ED throughput (10% improvement) Admit 275 Striebich O9 Support regional deployment of electronic management operations (iDashboard) Fregoli
O5 CMI (1.575) 1.66 M. Smith
PC1 P4P Collaborative Performance (>95% for each) Fregoli PC4 Redefine the peer review redesign and alignment process M Smith
VALUES & CULTURAL THRUSTS PC2 Expand FQHC Clinics / relationships Weiner PC5 Enhancement of Physician Leadership Development - +2 groups through HS M Smith
PC3 Medical staff development (recruitment to fill) Weiner PC6 Educate physicians on bundled payment and next generation ACO Cobb
PC7 Complete implementation of centralized verification office Cobb
L1 Achieve FY16 Community Benefit Goals Beltramo L5 Complete Master Facility Plan Striebich
L2 Maintain Regulatory Compliance (achieve certifications) Bosch L6 Develop Hybrid OR & expand structural heart program Striebich
L3 Leapfrog (Maintain Group Hospital Safety Grade "A") B Fregoli L7 Expand Telemedicine network Weiner
TOP 5 THREATS L4 Community Health & Wellness Striebich L8 Expand and enhance Oncology Striebich
L9 Develop Expanded Neurology service line Striebich
L10 Develop expanded cardiac EP program Striebich
L11 Reevaluate behavioral medicine programming Striebich
ES1 ICD10 (implementation) Samyn ES5 ICD10 implemetation Samyn
ES2 Total Cost of Care / Member Cobb ES6 Paid Hrs/CMAED (79.9) 81.1 Striebich
ES3 Network Financial Performance - achieve budgeted net income for the network Cobb ES7 Supply Expense/CMAED ($1,203) Striebich
ES4 Market share Weiner ES8 Implement Growth Program Weiner
Next Scheduled Plan Review:
Comments:
Updated: 2/25/16
People Centered
Engaged Colleagues
Operations Excellence
Physician & Clinician Engagement
Leadership Nationally
Effective Stewardship
SJMO Organizational Objective Alignment (Hoshin Kanri) - SLT/Board
Planning Document (FY16)
BUSINESS THRUSTS
Competencies/Processes
- High quality
- Low cost
- High Satisfaction
- Ease of use
- Population Health (patient centric)
KPI - Key Performance Indicators KSI - Key Strategic Initiatives
Faith based heritage, member of the 2nd largest
Catholic healthcare system in the country,
community hospital, exceptional quality outcomes
leveraging the latest available technology.
MISSION
We, Trinity Health, serve together in the spirit of the Gospel as a compassionate and
transforming healing presence within our communities.
VISION
As a mission-driven innovative health organization, we will become the national leader in
improving the health of our communities and each person we serve. We will be the most
trusted health partner for life.
PDACO
Master Facility plan - campus refinement
Development of new relationships for service
delivery (Beaumont,
.Havenwick,…Ascension.)
Strong physician alignment
Physical Plant
Top decile clinical performance
World class clinical program
Strong nursing team
Technology
Emergency preparedness
Community engagement / EMS
Marketing program - media relationships
Total cost per member per month
Payer Audits
Poor Medical Records Documentation
Insurance Benefits Realignments
Unknowns in Healthcare Reform
Market Realignment
Be the premier healthcare provider in the region
Development of large multi-specialty group practices
Significant reduction in healthcare utilization
Key Product or Service Lines: Orthopedics,
Oncology, Cardiology, Neurology, Surgical Services,
Neonatology
Primary Competitors: Beaumont, Crittenton,
McLaren, Henry Ford
Strong revenue management
Operations / Performance Management
Growth & Innovation
Quality & Safety Competencies
Regulatory & Compliance
Financial Management
Technological Superiority
Information Transparency
Excel at SJMHS Tiple Aims
Respect, Social Justice, Compassion, Care of
the poor and underserved, Excellence
Process Excellence
Personal, Connected Journey
Culture of Safety & Employee Engagement
Physician Relationships
Just Culture
Personal Accountability
Professional Growth
Diversity & Inclusion
Regionalization

13. A3 Strategy
13
Structure
• A3 work part of daily huddle
• Posted hand hygiene RTLS
metrics
• Engaged all team members in
the process.
• Individual hand hygiene metrics
to help identify root cause
• Recognition for staff with 90%
compliance
• Staff assisted in investigation
once root cause identified

14. A3 Outcome
14
• Week One/Two
• Hand hygiene compliance
daily monitoring, root cause
analysis and investigation
(rooms identified as not
including data)
• Week Three/Four
• Team reached out to Robert
Jones. IT team evaluated
RTLS system and determined
“dimmer replacement needed
• Standard work developed for
system maintenance
• Lessons Learned:
• What went well
• Staff collaboration/Increased
morale
• Data accuracy
• Support from IT
• Decreased Infections
Who? When?
Leisa Huddle
Leisa Huddle
Leisa May
Leisa June
Leisa June
Leisa July
Leisa TBD
Leisa TBD
A3: Workout Process Summary
1.) Information
6.) Containment Actions (short term): What must happen
immediately to contain the problem or minimize the impact?
Improvement Theme/Title: Hand Hygiene Improvement 1) Bad batteries in RTLS badges:
- Staff performed battery checks at huddle; unit replaced all low
or dead batteries.
2) Wall dispenser sensors not capturing badges:
- Nurse Manager contacted HillRom who came onsite 6/6/2016
to replace batteries in dispensers (problem not fixed).
- Nurse Manager contacted IT for assistance.
- Nurse Manager & IT contacted EcoLab who came onsite
6/9/2016 to investigate wall dispensers.
• EcoLab really only provides the soap for the dispensers.
• EcoLab representative utilized measured grid and testing to
determine dispensers WERE capturing badges, but location
tracking sensors in ceiling were NOTcapturing badges.
3) Ceiling tracking sensors not capturing badges:
- Nurse Manager & IT contacted Centrak who came onsite
6/15/2016 to fix dimmers in ceiling censors.
Department/Unit: Four South Date: May 2016
Champion: Leisa Krieger Update date: 8/10/2016
2.) Background/Problem Statement
• HillRom system in place to monitor hand hygiene since move to
new south tower in 2014.
• HillRom generated Hand Hygiene scores are noted to be very low
on 4S despite staff efforts to improve. - 67% Compliant April
• In early 2016, most staff members experienced dead or dying
batteries in their RTLS tracking badges (batteries replaced by unit
manager).
• Known high performers are experiencing large fluctuations in
scores depending on room assignments. 7.) Corrective Actions (Permanent): Process changes for
sustainable improvements
1) Standard Work: Nurse manager posts hand hygiene scores to
huddle board daily (monitoring for low scores indicating badge or
room failures).
2) Standard Work: Nurse manager to monitor HillRom data by
room weekly (monitoring for low scores indicating failure).
3) Preventative Maintenance: Reccomend Nursing & IT to
develop ongoing ownership, monitoring, and maintenance (i.e.
process / structure) for HillRom system for the entire hospital (task
for Clinical Technology Team?).
3.) Current Condition
• System uses RTLS staff badges, sensors in the soap & alcohol
dispensers on walls (EcoLab = vendor), and location tracking
sensors on ceiling (Centrak = vendor). Information is collected
and patient room entry & exit hand hygien is calculated by HillRom
software.
• Unit focus on improving hand hygiene in daily huddle, especially
since May 2016. Staff report issues with ceiling sensors not
capturing their badges and automatically turning off call lights.
• Room by room investigation of sensors. Discovered non-
functioning rooms: 4901, 4904, 4905, 4907, 4920, 4928, 4929,
4931 & 4932 (confirmed by IT).
8.) Implementation Plan: Major milestones
4.) Goals & Targets What? (Key deliverables) Outcome
1) Hand Hygiene compliance % greater than 90%.
2) All staff RTLS badges fully functional.
3) All sensors (wall dispenser, ceiling tracker) functional in all
rooms and hallways.
Badge Battery Replacement April 67% / May 72%
Meet w/IT Scheduled Vendors
Meet w/Vendors
New batteries &
dimmers June 82%
Posting Daily Scores April 67% / May 72%
Analyze broken rooms.
Bring A3 to Clinical Technology Team for
prevenative maintenance
5.) Analysis/Root Cause(s) - 5 Why's
Low hand hygiene scores in rooms 4901, 4904, 4905, 4907, 4920,
4928, 4929, 4931 & 4932.
WHY? Badges not interacting with wall / ceiling censors in the
above rooms.
WHY? Bad batteries in RTLS badges.
WHY? Wall dispenser sensors not capturing badges.
WHY? Bad batteries in wall dispensers.
WHY? Bad sensors in wall dispensers.
WHY? Ceiling tracking sensors not capturing badges
WHY? Bad censors/dimmers in trackers.
WHY? No preventative maintenance!
WHY? No owner of system, no process for monitoring.
9.) Performance Measure(s)
Measure/Metric Before After
10.) Yokoten - Best Practice sharing (application in other
depts/units)
Share A3 with Med/Surge Pod, CNO, at Nurse
Leadership Council, and with clinical technology
team.
May 72%
July 84%
Hand Hygiene Compliance April 67%
June 82%
Monitoring HillRom Weekly July 84%
Bring A3 to POD, NLC

15. A3 Sharing - 3 South
SJMO Manager’s & Director’s Meeting
Presented By: Carolyn Maher (Manager CCU)
Date: September 28th, 2016

16. Our Approach on 3S
16
Structure:
• Huddle Daily @ 8:30
• See huddle board 
• “Cuddle” board with
weekly updates 
• Staff Ownership
• “Ideas in Motion”
• Staff project owner
listed on board.
©2015

17. 3S Approach Cont.
17
A3 Work:
• Choosing A3 topics
• Staff driven.
• Staff owned.
• Worked on independently.
• Shared at Huddle.
• “Knowledge Nook”
• A3s in process on wall. 
• Binder for completed A3s.

18. Successful A3s
18
Top 10 Drawer
Improvements:
Alicia
Kanban Improvement: Paul
PST to RN
Standard Work &
Communication:
Khara & Mandi

19. Questions / Comments
19©2015