Often, there are many perspectives that we need to consider before we have a complete picture. 'The Blind Men and the Elephant', and earlier versions of this parable, show us the limits of perception and the importance of complete context. This also applies when we are facing a difficult or complex issue in relation to patient safety.
As part of the Patient First programme at Brighton and Sussex University Hospitals NHS Trust, we used A3 problem solving. Many others do too. It’s a structured problem-solving tool, first employed at Toyota and typically used by 'lean' manufacturing practitioners. Flexible and succinct, it captures everything you need on a single piece of paper – A3 in size, hence the name. It also brings together some widely used improvement tools – cause and effect diagrams (fishbone diagrams) the 5 whys and small change cycles (Plan, Do ,Study, Act).
Most recently, I've had the pleasure of using it with teams wanting to improve elements of their services such as time to triage, discharge or wanting to minimise avoidable harm (e.g. patient falls). I have also used it with families and clinical teams wanting to take forward a key service change.
Its’ real power is that, rather than jumping in with solutions in hand (which are, more often than not, shopping lists of resources required), you don’t move forward until you have absolute clarity on what the ‘problem’ is you are trying to solve. Plus, this is a team activity. It is rare we know everything about our issue and the power of an A3 derives not from the report itself, but from the development of the culture and mindset required for its successful implementation.
There are several formats around – just google A3 problem solving. I have summarised the first 4 steps below:
Step 1: Problem Statement
Set out why this is important? A couple of sentences about the size of the issue, how long it has been going on, impact on patients, their families and staff.
Over the last 4 months we've seen a reduction in patients triaged from X% to Y%. There was a near miss event last week that would have been averted had triage been in place on that shift and staff are concerned that there is no single process for them to follow.
Our surveys over the last 6 months indicate that only X% of our clients are fully engaged in the development of their care plans. We need to address this urgently in order to ensure best outcomes for our clients and support family members and carers who are willing and able to participate.
This is your call to action – if it isn’t making your staff and clients sit up and want to engage then it needs more work.
Step 2: Current Situation
What you know about the issues, what staff are saying, what patients and their families are saying (small surveys are great), what the data is telling you, any protocols or algorithms, and anything else that you need to know.
Step 3: Vision & Goals
Vision: A softer statement of quality AND
Goal(s) : Measurable goal(s) and when you are aiming to deliver, for example:
From June 2020:
‘X% of patients to be triaged within Y minutes of arrival‘
‘Y % of patients triaged to the correct clinical pathway’
Step 4: Analysis: Top Contributors & Root Causes
Use a cause and effect (fishbone) diagram to ensure you are capturing the many causes For example, the methods in place that may not be working quite so well, things to do with the environment, equipment and the people, both patients and staff. Once these are all out on the table then you can use root cause analysis to get underneath them.
It’s only at steps five and six that you start to think about the actions that you will take forward and how you might fix some of these big issues. The full A3 is pasted below:
And finally, it goes without saying that step nine, ‘insights’, is key. In my experience, people get best benefit if they complete this as they go along. There is always learning, for example people you might have engaged sooner, early identification of others who are already on top of the issue and able to share their work with you so you can adapt for your own use – we used to call it ‘assisted wheel re-invention’ when I worked for the NHS Modernisation Agency.
Please leave a comment below or message me through the hub @Sally Howard if you want to know more. I'm very happy to talk further about this approach.