When A3 Problem Solving Fails:

Practical Advice for Improvers

Much has been published about the reasons why improvement projects fail. Sixsigmadaily.com describes the top 5 reasons for failure[i], the Harvard Business Review the top three reasons[ii], and the Juran Institute sums it up into one reason: lack of management support[iii]. But what specific actions can an improvement team take to mitigate these failure modes? This post will expound upon the top reasons for project failure according to the Juran Institute and suggest practical approaches to mitigate these risks.


Failure to Select the Right Project

Two criteria must be met for optimal project selection. First, the benefit it will provide to the organization must outweigh the resources required to complete it. All organizations have a finite capacity to improve, therefore, careful stewardship of improvement resources is key. Second, those working on the project must be motivated to do so. Improvers are generally motivated to solve problems that exist locally because they experience them frequently. However, when improvers are asked to solve an organizational problem that they don’t necessarily experience themselves, it can be challenging to remain motivated. Ideally, all projects would always be selected to satisfy both criteria. However, in complex organizations this does not always happen.

Remedy: Balance Local & Organizational Needs

The first criteria can be satisfied by performing data analysis on the proposed problem to understand how much opportunity exists. Next, consult a team member with improvement experience to weigh the opportunity against an estimate of the resources it will take to solve it. The second criteria is commonly compromised by an imbalance in project selection. The improvement team leader and their sponsor(s) should discuss the proposed project in the context of all projects: past, present, and future. If the portfolio of projects appears skewed towards those with significant organizational benefit but minimal local benefit, perhaps a project in the latter category would be a better choice. Alternatively, if most the projects have been of great local benefit but less impactful overall, perhaps it’s time to tackle an organizational goal. There is no formula for the perfect project mix, but it is important that the balance between local and organizational priorities be considered to keep all stakeholders motivated.

Failure to Assemble a Team of the Right People

Once the problem and why it needs to be solved are clear, the next step is to assemble a team. This is done by considering the various process experts that will be needed to fully understand the problem and the current state surrounding it. When teams have inadequate representation from essential stakeholders, the quality of the current state analysis may be compromised. The less thorough the current state analysis, the less likely hypothesized tests of change will achieve the predicted effect. Without a robust current state analysis to fall back on, the team may find themselves stuck without a clear path forward.

Remedy: Start Current State Mapping Early

One reason that teams fail to include the right people is because they are assembled before the discovery process begins and are not re-evaluated once the project is underway. To mitigate this risk, create a rough process map(s) for your project while considering who should be on the team. By making the problem visual, it is less likely that a key stakeholder will be omitted from future discussion. Also, take time to reflect on your team’s composition throughout the project and resist the urge to proceed when it is clear a stakeholder is missing from the discussion! Often, this will create more work in the future.

 Failure to Apply Improvement Methods Effectively

Though “A3 Thinking” is often described as common sense, the effective application of the methodology requires practice and experience. For example, consider the first step in A3 problem solving: Defining the Problem. How does a team develop a problem statement? How will they know when it’s satisfactory? There aren’t necessarily right or wrong answers to these questions but some will serve the team better than others. If there is no one on the team to guide them through their chosen method and offer helpful tools and techniques along the way, projects can easily go astray.

Remedy: Seek Improvement Expertise

When assembling the improvement team, consider including someone who has experience applying improvement methods. Many organizations have dedicated Improvement Teams of specialists who can assist when tackling high-complexity problems. Not all improvement projects require improvement experts, however. For many projects, it is sufficient to include someone on the team that has experience applying the chosen method for improvement. Identify someone who has done more improvement projects than anyone else on the team and invite them to join in that capacity.

Failure to Define Roles & Responsibilities

Clearly articulated roles and responsibilities for physicians, nurses, medical assistants, and other disciplines are crucial for optimal care delivery. To improve effectively, however, the necessary job functions are different. Who will decide when the team meets? Who sets the agenda? Who takes notes? Who manages time? Who knows how to work with data? The team will naturally assume that these activities are everyone’s responsibility. But what’s everyone’s responsibility can easily become no one’s responsibility, which means these crucial activities will not happen reliably.

Remedy: Match Needs with Interest & Ability

In the first few team meetings, consult the improvement-methods expert and create a list of all activities that will need to be conducted during the improvement project. Next, match the individuals on the team with the necessary activities according to their interest in and ability to perform that task. It is incumbent upon the team leader to empower team members in their respective roles by respecting their function on the team throughout the project.

Failure to Effectively Communicate Project Progress

Well-chosen projects will have several individuals who are vested in the project’s success even though they are not attending team meetings on a regular basis. Consider the project’s primary sponsor as an example. How often should they receive communication from the team? Which mode of communication should be used? What do they want to know? Improvement teams can easily get carried away with problem solving and fail to answer these questions satisfactorily. If an effective communication plan is not in place, teams may find themselves having to work backwards when barrier removal or course corrections are needed later in the project.

Remedy: Tailor Communication to your Audience

In a similar way that the project’s necessary activities were mapped to team members, list all parties that may want to be updated somehow on the project’s progress. Next, confer with each stakeholder starting with those who will be most instrumental to your success and determine the best communication process. Lastly, consult your improvement-methods expert to ensure that the content of the communication is the most relevant for its audience.

Failure to Adequately Support Education and Training

As previously mentioned, the effective application of improvement methods requires practice and experience. In other words, it requires time spent not performing one’s usual job functions. This author estimates that it takes an inexperienced improvement team approximately 20-30 hours to solve a medium complexity healthcare problem. If steps are not taken by leadership to ensure that each team member is afforded the time necessary to learn and do improvement work, the team will likely experience frequent absenteeism or worse, burnout.

Remedy: Protect Time for Learning by Doing

Once it is clear who needs to be on the improvement team, make sure there is a plan in place (endorsed by each member’s chain of command) to accommodate their presence in team meetings and at team activities. For hourly employees, this might mean allocating non-productive hours to their schedule. For physicians, this may mean reducing RVU targets or adjusting call schedules. Whatever the chosen mechanism for protecting time for improvement activity, a plan must be in place.

Failure to Create Visibility to Leadership

Completed improvement projects must be made visible for team recognition and organizational learning. Team recognition is important because the significant number of hours of intellectually and emotionally challenging work deserve acknowledgement. For the organization, a significant portion of the return on investment for improvement work is the increased organizational knowledge about problems and how to solve them effectively. Furthermore, mature learning organizations should not only have a process to capture local knowledge, but to spread generalizable improvement knowledge to the improvement community at large in the form of publication. If plans are not set in place to ensure this recognition and knowledge sharing happens, it can easily be lost in the ebbs and flows of daily operations.

Remedy: Plan to Celebrate & Share Knowledge

At the outset of the improvement project, team leaders and sponsors should discuss how the project will be celebrated at its conclusion. Some examples include formal report-outs, poster presentations, graduation ceremonies, and organization-wide assemblies. In addition, the team should also consider where their work could be published and what the guidelines for publication are. There are many journals that publish improvement work submitted using the SQUIRE guidelines.[iv] Whatever the chosen venue, ensure it is well attended and that it includes leaders in the same chain of command of those on the improvement team.

Conclusion

Improving complex systems is challenging. Over time, improvers have developed and continue to develop methodologies like A3 Thinking to guide teams through these challenges; however, they are note fail-proof. Consequently, it is incumbent upon all improvers to not only study the common failure modes of improvement work, but also to share their collective knowledge of how they can be mitigated. Only by our collective efforts will we be able to expand our human improvement capability in our quest to become better at getting better.

Written by Hurley Smith

 

 

[i] “What Causes Improvement Projects to Fail.” Six Sigma Daily, 21 May 2020, www.sixsigmadaily.com/what-causes-process-improvement-projects-to-fail.

[ii] “Avoiding Catastrophic Failures in Process Improvement.” Harvard Business Review, 23 July 2014, hbr.org/2011/04/avoiding-a-catastrophic-failur.

[iii] Juran Global. “The No. 1 Reason Why Performance Improvement Programs Fail.” Www.Juran.Com, 3 Jan. 2017, www.juran.com/wp-content/uploads/2017/01/The-No.-1-Reason-Why-Performance-Improvement-Programs-Fail.pdf.

[iv] “SQUIRE | QI Journals.” Squire-Statement.Org, 3 Jan. 2017, squires-tatement.org/index.cfm?fuseaction=Page.ViewPage&pageId=513.

Karen Frush, MD, is the former Chief Quality Officer at Stanford Health Care. She is a Clinical Professor of Emergency Medicine and Pediatrics. She also serves as a member of the Stanford Medicine Center for Improvement Advisory Committee.

Dr. Frush has been an MCHB funded researcher and helped lead an effort funded by the CMS Innovation Center to improve patient safety and quality across 70 small community and rural hospitals through the LifePoint Hospital Engagement Network. LifePoint was recognized with the John M Eisenberg Patient Safety and Quality Award in 2017 for this work. Dr. Frush has published peer review manuscripts in the areas of pediatric emergency care, patient safety and quality, teamwork, safety culture, interprofessional care, and quality improvement, and she has authored multiple books on these subjects, including Improving Patient Safety through Teamwork and Team Training, with Eduardo Salasin 2012. She is a Team STEPPS Master Trainer and served on the Department of Defense, Team STEPPS Technical Expert Panel (2008-2010). She is an alumnus of the AHA-NPSF Patient Safety Leadership Fellowship program, served on the American Academy of Pediatrics Steering Committee for Quality Improvement in Pediatrics(2006-2011), and has been named one of 50 experts leading the field of patient safety by Becker’s for the past five years. She served on the Board of Advisors and the Board of Directors for the National Patient Safety Foundation and currently serves as Chair of the Institute for Healthcare Improvement (IHI)Certification Board for Professionals in Patient Safety.

Former Leadership positions include Chief Patient Safety Officer of the Duke University Health System (2004-2018); member of the Board of Trustees, North Carolina Center for Hospital Quality and Patient Safety (2005-2012), and Vice President for Quality, LifePoint Health and Duke-LifePoint Healthcare (2011-2018). Dr. Frush received a BSN from the University of Pittsburgh School of Nursing and then attended the Duke University School of Medicine where she earned her MD.

Alice R. Georgitso, MPH, joins the SMCI Advisory Committee as our first Patient Partner. Alice has served as a Patient Partner with the Stanford Health Care (SHC) Patient & Family Partner Program for over 4 years and was appointed Chairperson of the Adult Congenital Heart Program Patient & Family Advisory Council in January 2020. She assisted in developing the Stanford Adult Congenital Heart Program’s Peer-to-Peer Program and serves as a Mentor to ACHD patients pre-and-post-organ transplantation. Alice has presented Stanford Health Care’s C-I-CARE framework for structuring best practice communications and developing relationship-based care approaches with patients and colleagues to 500+ Stanford Medicine Directors, Managers and Clinical Staff.

Alice is a Patient Relations Manager at Stanford Health Care. Within her role, she provides a channel for problem resolution to promote the highest quality of care and service excellence. Alice has also worked as an Unrelated Donor Search Coordinator with the Blood & Marrow Transplant at Stanford Health Care to coordinate allogeneic hematopoietic stem cell transplants through collaborative planning and partnership with the National Marrow Donor Program and SHC clinicians. Prior to her work with SHC, she was the Community Service Foundation Director at San Mateo County Medical Association where she partnered with local stakeholders and clinicians to expand county-wide community health programs to diverse populations. She has also delivered invaluable community health services through her work with the American Heart Association.

Alice earned her Bachelor of Arts in Sociology and Biology at Saint Bonaventure University in Olean, NY and her Master of Public Health from SUNY Buffalo in Buffalo, NY. Alice is a member of The Beryl Institute and Adult Congenital Heart Association professional associations, Donor Network West partner advocating for organ, eye, tissue, and blood donation, and remains an active volunteer with SHC. Alice continues to promote patient-and-family-centered care in both hospital and community settings to support precision health and improve the healthcare experience for patients, families, and clinicians.

John Shook learned about lean management while working for Toyota for 11 years in Japan and the U.S., helping it transfer production, engineering, and management systems from Japan to NUMMI and other operations around the world. While at Toyota's headquarters, he became the company's first American kacho (manager) in Japan. In the U.S., Shook joined Toyota’s North American engineering, research and development center in Ann Arbor, Michigan as general manager of administration and planning. His last position with Toyota was as senior American manager with the Toyota Supplier Support Center in Lexington, Kentucky, assisting North American companies adopt the Toyota Production System. Shook co-authored Learning to See, the book that introduced the world to value-stream mapping. He also co-authored Kaizen Express, a bi-lingual manual of the essential concepts and tools of the Toyota Production System. With Managing to Learn, Shook revealed the deeper workings of the A3 management process that is at the heart of Toyota’s management and leadership.
Shook is an industrial anthropologist with a master’s degree from the University of Hawaii, a bachelor’s degree from the University of Tennessee, and is a graduate of the Japan-America Institute of Management Science. At the University of Michigan, he was director of the Japan Technological Management Program and faculty member of the Department of Industrial and Operations Engineering.
Shook is the author of numerous articles, including "How to Change a Culture: Lessons from NUMMI"; Sloan Management Review, January 2010, which won Sloan’s Richard Beckhard Memorial Prize for outstanding article in the field of organizational development.

The Stanford Medicine Center for Improvement benefits from the diversity of its members and the richness of the experiences that they bring. Although the program continues to evolve from when it first launched in October 2019, we continue to reach out to improvers across Stanford Medicine in the School of Medicine, Stanford Health Care, Stanford Children’s Health, Stanford ValleyCare, UHA and PCHA. We welcome everyone from every discipline and recognize that we are stronger together as we value the contributions of every member of our teams.

Dr. Paul Maggio is the Chief Quality Officer of Stanford Health Care. Prior to being appointed the SHC CQO, he was Vice Chair of Surgery for Clinical Affairs, Associate Chief Medical Officer of Operational Effectiveness, and Associate Director of the Adult Intensive Care Unit. He trained in General Surgery at Brown University and obtained advanced training in Adult Surgical Critical Care and Trauma at the University of Michigan. He holds a Masters of Business Administration from the University of Michigan and is triple board certified in General Surgery, Critical Care, and Medical Informatics. In addition to being a clinician and surgeon, Dr. Maggio participates in the National Committee on Healthcare Engineering for the American College of Surgeons, and his research interests are focused on the delivery of high-value care.

Dr. Maggio received the SHC Board of Hospital Director’s Denise O’Leary Award for Clinical Excellence in 2013

Micah Duchesne joined Stanford Medicine in 2020 as a Principal Consultant project managing the deployment and operations of the Hospital Incident Command System (HICS) for COVID-19. He is now the Administrative Director of Performance Improvement at Stanford Health Care where he leads annual operations planning, improvement consulting, and capability development. Micah is also a Fellow at the Stanford Medicine Center for Improvement.

Before joining Stanford, Micah was an independent consultant for his company Silicon Valley Strategy Group, which partnered with Novartis and the Perelman School of Medicine at the University of Pennsylvania to commercialize cellular therapies. He led a team of clinicians from Europe, Japan, and Australia in designing a global logistics model and quality management system for Kymriah, the world's first approved CAR-T therapy, and helped create an international advisory board aimed at improving global capacity.

Prior to independent consulting, Micah was the Director of Performance Improvement at Kaiser's Santa Clara Medical Center, and he previously held improvement roles of increasing complexity within other health systems. Micah has both a Bachelor of Science in Accounting and Master of Health Services Administration from Mississippi College. He also holds certifications as a Lean Six Sigma Master Black Belt and Project Management Professional.

As a professional, Micah enjoys organizing complex stakeholder ecosystems, clarifying ambiguous goals, aligning visions, and driving high-stakes change. As a human, Micah just enjoys breaking a sweat. While he's not at work, he's at his very own gym in San Jose, CrossFit Moxie. You can find him there coaching olympic weightlifting or working out with his wife. He has a daughter in elementary school and two gym dogs.