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Preoccupation with Failure: Root Cause Problem Solving: “A3” Thinking
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Problem Cause Solution Action Measurement
A3 Process Follows
Scientific Method
Similar To Healthcare
Familiar PDCA
Presenter
Presentation Notes
The A3 process is based upon scientific method. (PCSAM). The form supports this method in its organization and flow. Problem Cause Solution Action Measurement This is very consistant with the PDCA cycle most hospitals are familiar with and use in some form.
Purpose Show a healthcare application of a visual control board that show status on a unit. (Public knowledge as relates to the previous slide.) Key Points By looking at this board we can see: How many rooms are used Which rooms have been setup for Inpatient or patients to be admitted. Pt & Dr name and scheduled procedure time (First Initial and 3 letters of Last name to meet HIPAA requirements.) At a glance you can see what patients are In procedure (Red arrow) Prepped (Blue dot) Being Prepped (No symbol by name) Add-on procedures are also shown in pink How many more procedures there are for the day. (above line) Floor is currently caught up. There are patients prepped and ready to go to each active procedure block. Note: In this unit a “BLOCK” is a procedure room and crew. Not a block of time as in “block scheduling.”
Extra Pt Lift keeps coming back to this floor 1 2 Clean Pain pump not available from Central Equipment 3 Weekend shift not putting equipment back
Presenter
Presentation Notes
Purpose: Show an example of History/ Pareto/ Problem Solving on a data wall. Key Points: The data wall is a communication tool. Continuous Improvement flows from What is the Current State (History) What are your biggest problems (Pareto) What are you going to do about it? (Problem Solving)
“We are Leaders in an industry that we are not sure we understand” Timothy Porter O’Grady
Healthcare has become so complex that “command and control” no longer works.
We have the most educated staff of all industry yet we do not take advantage of their wisdom. – Timothy Porter-O’Grady
Leaders must develop those for whom they are responsible so that the organizational capacity to be self-correcting, self-improving, and self-innovating is distributed and practiced widely and consistently – Steven Spear