Standardization

Quality
A3 PROBLEM SOLVING
An Introduction
Root Cause

A P Check
Value-Added
Theme:

Background

Current Condition
Act
Prepared By:

Target Condition
Date:

CD Planning
Implementation Plan
Action Item Resp Due Date

Cause Analysis
Cost:

Follow-Up
Planned Results Actual Results

Improvement
BILL GIAMBRA
Continuous Improvement
Building a Culture of Excellence
AP
Operational Improvements
Process Owner Development
Team-building
CD
Training
Quality Manager – Fidelity National Information Services
Lean Certification: Toyota sponsored Lean program at the
University of Kentucky.
Applied Lean in Production, Sales, Customer Service, and
Administration functions.
Experience in plastic embossing, plastic injection molding,
fabrication, machining, and assembly industries.
AGENDA

Introduction
Overview of A3 Problem Solving
Using A3 Problem Solving
Conclusion
AGENDA

Introduction
Overview of A3 Problem Solving
Using A3 Problem Solving
Conclusion
THE HOTEL

 New high-rise hotel

receives complaints that
the elevators are too
slow.
 The manager instructs his
people:
“Find a way to speed up the
elevators”
THE HOTEL

 Elevator company:
“cannot go any faster.”

 Manager gives new

orders:
“Find a location and design a
shaft to install another
elevator.”
THE HOTEL

 Fortunately, solution
prevented because REAL
problem discovered:
The guests were bored while
they were waiting.
 The manager then gave
his final command:
Find a way to take customers‟
minds off of their waiting.
RAINFOREST CRUNCH

 A store was having

difficulty selling the
health food mix called
Rainforest Crunch,
which was a hot selling
item in other stores.
RAINFOREST CRUNCH
 The instructions given by the
store manager:
"Lower the price of the item to
increase sales."
 It still did not sell.
 The manager lowered the
price further. Still no sales.
 After lowering the price two
more times to a level that was
well below the competitors',
the item still did not sell.
RAINFOREST CRUNCH

 Manager walked around

store, saw the real cause
of the problem.
 Cause
 NOT high cost of the item
 real cause item not
prominently positioned in
store.
 Once moved, sales shot
up.
EXAMPLES

 How are these examples alike?

 How are these examples different?

RELATIONSHIP OF
PROBLEMS, SYMPTOMS, AND CAUSES.

Analysis Results of
ROOT CAUSES PROBLEM SYMPTOMS
Leads to the problem

Root Causes are A Problem is Symptoms are

the specific when a what we first
circumstances condition varies become aware of.
that are the from ideal and is They are
underlying not acceptable. indicators and
source of the results that tell us
problem. about the current
condition.
RELATIONSHIP OF
PROBLEMS, SYMPTOMS, AND CAUSES.

Analysis Results of
ROOT CAUSES PROBLEM SYMPTOMS
Leads to the problem

We must clearly understand the

current condition through the
assessment of all symptoms.
RELATIONSHIP OF
PROBLEMS, SYMPTOMS, AND CAUSES.

Analysis Results of
ROOT CAUSES PROBLEM SYMPTOMS
Leads to the problem

Once the current condition is fully

understood, we can begin to look
beyond the problem to uncover the root
cause.
ROOT CAUSES

 Root Causes are

usually hidden.
 Resist the
temptation to
conclude too
soon
ROOT CAUSES

Root Cause 1 Countermeasure 1

Root Cause 2 Countermeasure 2
Root Cause 3 Countermeasure 3
Root Cause 4 Countermeasure 4

For each root cause, countermeasures can be

identified to fix the root cause and, thus, prevent
the problem from recurring.
AGENDA

Introduction
Overview of A3 Problem Solving
Using A3 Problem Solving
Conclusion
THE PURPOSE OF A3 PROBLEM SOLVING IS:

To understand a problem fully

To uncover root causes of problems
To determine solutions to fix the problems at
their root cause
To develop a plan for effectively implementing
solutions
To verify that the solutions solved the problem.
 Mission:
Prepared By: Date:

Background Target Condition

Current Condition

Implementation Plan
Action Item Resp Due Date

Cause Analysis
Cost:

Follow-Up
Planned Results Actual Results

The A3 is done on the front side of an 11x17”

(thus the name, A3) sheet of paper.
 MISSION

Mission:
Prepared By: Date:

Define the problem in

Background Target Condition


a clear and concise Current Condition

way Implementation Plan

Action Item Resp Due Date

 Convey the symptoms

 Do NOT suggest a Cause Analysis
Cost:

Follow-Up

particular cause or
Planned Results Actual Results

solution.
 BACKGROUND

Describe any pertinent

Mission:


Prepared By: Date:

Background Target Condition

background
information Current Condition

 What is essential to Implementation Plan

Action Item Resp Due Date

understanding the
extent and
Cause Analysis
Cost:

Follow-Up

importance?
Planned Results Actual Results

Remember: do not suggest a particular cause or solution.

 CURRENT CONDITION

 Convey the current Mission:

Prepared By: Date:

state of the process Background Target Condition

 Collect reliable data on

process quality, cost,
Current Condition

Implementation Plan

and delivery
Action Item Resp Due Date

 Anything that can be Cause Analysis

Cost:

used to uncover the Follow-Up

Planned Results Actual Results

underlying causes of
the problem.
 CAUSE ANALYSIS

To dig down into the

Mission:


Prepared By: Date:

Background Target Condition

problem to identify its

root cause. Current Condition

 The root of the problem Implementation Plan

should relate to waste,

Action Item Resp Due Date

variation, or strain. Cause Analysis

Cost:

Follow-Up
Planned Results Actual Results
 TARGET CONDITION

Mission:

Define
Prepared By: Date:

 Background Target Condition

countermeasures to
eliminate root cause(s) Current Condition

 Create a diagram that Implementation Plan

Action Item Resp Due Date

represents the
condition we want to Cause Analysis
Cost:

create. Follow-Up
Planned Results Actual Results
 IMPLEMENTATION PLAN

Mission:
Prepared By: Date:

 Summarize the steps Background Target Condition

needed to achieve
target condition. Current Condition

Implementation Plan

 Include task, who is Action Item Resp Due Date

responsible, and due Cause Analysis

date.
Cost:

Follow-Up
Planned Results Actual Results
 FOLLOW-UP

Mission:
Prepared By: Date:

Background Target Condition

 Verify the improvement

was effective. Current Condition

 Follow-up later with Implementation Plan

Action Item Resp Due Date

appropriate
measurements Cause Analysis
Cost:

Follow-Up
Planned Results Actual Results
 EXAMPLE
Reducing Change-over time
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34
35
PROBLEM SOLVING TOOLS

 Pareto Chart  Brainstorming

 Flow Chart  Fishbone Diagram
 Identifying Waste  5 Whys
 Value Added Vs. Non-  Project Planning &
Value Added Implementing
WHY USE THE A3?
FLASHING PHRASES EXERCISE

In the following 3 slides, phrases will quickly

flash on the screen.
After each phrase flashes, write it down.

Are you ready?

 Paris
in the
the Spring
 Bird
in the
the Hand
 Jack
in the
the Box
WHY USE THE A3?
According to scientists at Johns
“Apple” Hopkins University…

…It takes about 550 to 750 milliseconds for

the mind to recognize and understand a
familiar situation.
WHY USE THE A3?

 Following the A3 format

slows down the mind
and helps to keep users
from jumping to
conclusions.
AGENDA

Introduction
Overview of A3 Problem Solving
Using A3 Problem Solving
Conclusion
USING A3 PROBLEM SOLVING

Mission and Background

Assessing the Current Condition
Determining Root Cause
Defining the Target Condition
Developing the Implementation Plan
Follow-up
FLOW METER
 A Flow meter was
installed at a chemical
plant to measure the
flow of a corrosive fluid.
 A few months later, the
flow meter began to
leak.
 Instruction: “Find a
material to make a flow
meter out of that will
not corrode.”
FLOW METER

 An extensive, time-
consuming search was
conducting to find such a
material that was still
cost-effective. None was
found.
FLOW METER

 Problem statement
should have been:
“Prevent to flow meter
from leaking.”
 Solution: a preventive
maintenance program
that replaced flow meter
on a regular basis
before leaking occurred.
MISSION

Define what your team is trying to

accomplish in a clear and concise way
Convey the symptoms of the problem
Avoid suggesting a particular cause or
solution.
If considering metric target, a good rule of
thumb is to reduce the pain by half.
BACKGROUND

Describe why we are trying to accomplish our

mission.
Include pertinent background information.
Convey the importance of the situation.
Do not suggest a particular cause or
solution.
IN THE BACKGROUND, CONSIDER
INCLUDING

how the problem was discovered

why the problem is important to the
organization's goals
the various parties involved
the problem symptoms, past performance or
experience
Metrics that may be used to measure the
success of your project.
“ISSUE” & BACKGROUND - EXAMPLE
USING A3 PROBLEM SOLVING

Mission and Background

Assessing the Current Condition
Determining Root Cause
Defining the Target Condition
Developing the Implementation Plan
Follow-up
WHERE IS THE OIL?

 A major oil company was

getting a lower than
expected production rate
out of a well.
 Instruction: “Find ways to
improve the oil
production rate.”
 WHERE IS THE OIL?
 They initiated studies
costing hundreds of
thousands of dollars over
a 20-year period.
 Finally, it was determined
that the original
estimation of how much
oil there was wrong due to
a miscalculation.
The company did NOT have adequate understanding
of the current condition.
ASSESSING THE CURRENT CONDITION

 When possible,
observe the
process first-hand
and document
your
observations.
BE CAREFUL…

 Sometimes, instead of
seeing things the way
they really are, we see
what we expect to see or
what we want to see…
 Be careful to observe
things as they are!
WHEN ASSESSING THE CURRENT
CONDITION

Illustrate the current condition of the process

Draw a diagram representing the flow of
material and/or information.
Simple stick figures and arrows will often do the
trick.
Show what is not ideal about the process.
Show the extent of the problems.
Include relevant information.
CURRENT CONDITION – EXAMPLE
DEFINITION OF A PROBLEM

Analysis Results of
ROOT CAUSES PROBLEM SYMPTOMS
Leads to the problem

A Problem is when a condition varies from ideal

and is not acceptable.
Therefore, to understand what a problem is, we
must understand what the ideal condition is.
GOAL OF ANY LEAN PROCESS:

Produce what the customer needs

In the quantity the customer needs it
When the customer needs it
The first time (i.e. no errors)
For a cost the customer is willing to pay
CURRENT CONDITION
Storm Storm
Burst Burst

Once your process is diagrammed to show its

flow, place storm-bursts on the diagram to
indicate issues with the process.
Storm
Storm
Burst
Storm Burst

Burst
CURRENT CONDITION – EXAMPLE
USING A3 PROBLEM SOLVING

Mission and Background

Assessing the Current Condition
Determining Root Cause
Defining the Target Condition
Developing the Implementation Plan
Follow-up
PRINTING MONEY

 In 1990, the Bureau of

Engraving and Printing set
out to improve the quality of
their paper money.
 As part of the project, new
printing machines were
installed.
 But the new process
produced money with ink
that smeared.
PRINTING MONEY

 After 1-1/2 years of

investigating this issue, it
was determined to
develop better ink.
 A budget was created for
this new development of
better ink.
 Before this new project
got underway, the real
cause was discovered:
PRINTING MONEY

 The presses were not

applying enough
pressure to drive the ink
far enough into the
paper.
 The budgeted money
went towards buying new
machines.
NOTE: HUMAN ERROR IS NATURAL

 Resist the temptation to

blame the operator.
 We encourage workers
to try harder to NOT
make mistakes.
 But the root cause of the
error is usually failure to
account for the
possibility of human
errors in the system.
TO UNCOVER ROOT CAUSES FOR
MISTAKES, WE MUST ASK:

“How does our

current system allow
operators to make
mistakes?”
HUMAN ERROR IS NATURAL
Before blaming the worker, consider the
following in this order:
Are methods/tools adequate?
Are expectations clearly defined?
Is worker properly trained?
Was worker effort inadequate?
Does worker have „spiritual‟ issue?
Does worker not care?
Is worker not capable?
WHEN DETERMINING ROOT CAUSE:

Identify sources
of waste,
Waste
variation, and
Strain
strain

Variation
ROOT CAUSE QUESTIONS:

Are work activities sufficiently specified according

to content, sequence, timing, and outcome?
Are connections between steps clear, direct, and
immediately comprehended?
Are the pathways along which products/services
travel simple, direct, and uninterrupted
Are all the steps value-added?
ROOT CAUSE EXAMPLE
FOR LARGER PROJECTS:

 Some root causes may

require validation.
 Experiment or analyze
existing data before
proceeding with the
Target Condition.
BEFORE PROCEEDING TO THE TARGET
CONDITION:

Consider if you want

to add any additional
storm bursts to the
Haven’t
current condition Maintained
diagram based upon Car
your root cause
analysis.
USING A3 PROBLEM SOLVING

Mission and Background

Assessing the Current Condition
Determining Root Cause
Defining the Target Condition
Developing the Implementation Plan
Follow-up
ARRIGATING LAND

 New South Wales,

Australia very arid.
 Gov‟t wanted to grow
crops.
 Dammed the Murray
River.
 No new vegetation
grew, existing
vegetation died.
ARRIGATING LAND

 Cause of new problem:

high concentration of
salts in soil
 Now looking at projects
for desalinating the soil.
PARADIGM PARALYSIS

 In 1968, Switzerland had 80%

of world market in watch sales.
 Today, they hold less than 10%.
 They invented the Quartz
Digital watch, but didn‟t see
the value in it.
 Swiss watch employment
dropped from 65,000 to about
15,000 in a little more than
three years.
STEPS FOR
DEFINING THE TARGET CONDITION

Create a list of possible solutions

Evaluate possible solutions – Screen out
impractical ideas or combine solutions
Evaluate ideas on simplicity, amount of
benefit, area of control, and timing
Develop Consensus
Prepare Target Condition Diagram
DIAGRAM TARGET CONDITION

The next step will be to redraw Process Diagram

on the A3 form, showing how the process will
run with your proposed solutions in place.
Kanban for
packing mat’ls

Show your solutions in puffy clouds.

TARGET CONDITION
BEFORE GOING FURTHER

 Your team will most

likely want to gain
Management
Approval
 This is best done by
presenting the
results of your A3
problem solving
activities thus far.
USING A3 PROBLEM SOLVING

Mission and Background

Assessing the Current Condition
Determining Root Cause
Defining the Target Condition
Developing the Implementation Plan
Follow-up
TWO TYPES OF COUNTERMEASURES

Short-Term Countermeasures Long-Term Countermeasures

 Temporary containment  Solutions that are either
solutions until Long-term permanent or long-term
solutions are implemented. and eliminate root
causes.
PROJECT PLANNING INCLUDES:
 Defining the Project‟s Scope
 Defining Project Steps, Stages, or Activities
 Defining Responsibilities & Due Dates
KEY IMPLEMENTATION POINTS:
If improvement is large, consider a pilot implementation.
If done, analyze pilot results thoroughly to verify
effectiveness
Make necessary adjustments before implementing on
a large scale.
Aspects of the implementation plan can be broken out on
separate action plans.
Contingency plans should be considered for solutions
that have not been tested.
Include plans to give final ownership to the appropriate
personnel.
Assess Cost of implementation.
Gain approval of Plan before proceeding.
IMPLEMENTATION PLAN SHOULD INCLUDE:

 A breakdown of major tasks  Creation or updating of SOPs

with due dates and assigned  Ways to involve workers in the
responsibility – (Action Plan) implementation
 Procurement of new materials  Plans for giving the
and equipment improvement project visibility
 Required Training and training and those involved, recognition
materials  Plans to help affected workers
 Milestones and update reviews deal with their changing
for large projects environment
 A measurement system for on-  Plans for follow-up to verify the
going assessment of effectiveness of the
performance of target state improvement
 Celebration upon successful
completion of project.
MANAGEMENT APPROVAL

 Once the Plan is

created, it is
another
opportunity to gain
management
approval
IMPLEMENTATION PLAN
USING A3 PROBLEM SOLVING

Mission and Background

Assessing the Current Condition
Determining Root Cause
Defining the Target Condition
Developing the Implementation Plan
Follow-up
FOLLOW-UP

 Was the implementation

executed as planned ?
 Was the target condition
realized?
 Were the expected results
achieved?
FOLLOW-UP

 Compare metrics
indicated in earlier
stages of the A3 form
as a before and after.
FOLLOW-UP
A3 PROBLEM SOLVING

More Examples
MISSION & BACKGROUND - EXAMPLE

Background
CURRENT CONDITION – EXAMPLE
ROOT CAUSE EXAMPLE

Travelers are not clear enough Too much variation in store packing requirements
Why? – Packer must decipher information on Why? - Packing requirements are not
traveler before knowing what to do. standardized
Why? - Traveler not designed for packing. Consolidation adds non-value added movement
Pick List missed or not available Why? – Packers must move tumblers from new
Why? – Packer missed that Order has Pick List orders aside while finishing another order
Why? - “Combined Order” is an unclear Why? - Packers receive tumblers from one order
reference to pick list before their previous order is completed
Routing guide orders need repacked in the EDI area Why? - Orders are split @ decorating
Why? – They were not packed correctly by the Wrong size Toppers are packed
packer Why? – Topper sizes are too difficult to
Why? – Packer not aware of RG requirements distinguish
Why? – RG indication on traveler does not Why? – They are too small and they look alike
stand out enough.
TARGET CONDITION
IMPLEMENTATION PLAN
FOLLOW-UP
As an alternative to listing improvement values, you may
wish to …
FOLLOW-UP
…Show your improvements
Follow-Up graphically

120 0.3 0.258

10
97 8.43
100 84 0.25 8
0.200
80 0.2 5.59
6
60 0.15
4 Before
40 0.1
2 After
20 0.05
0 0 0
Issues Issues/1,000 Issues/1,000
widgets orders
13.4% reduction 23.3% reduction 33.7% reduction
MISSION & BACKGROUND - EXAMPLE

Background
CURRENT CONDITION – EXAMPLE
ROOT CAUSE EXAMPLE
Cause Analysis
TARGET CONDITION
IMPLEMENTATION PLAN

Implementation Plan
Action Item Resp Due Date
Implement Group Page Bob 2/23
Coordinate with Charge RNs Manager 3/2
Implement Tracking Sheet Jane Doe 3/2
Cheat Sheet Manager 3/2

Cost:
FOLLOW-UP

Follow-Up
Planned Results Actual Results
Patient xsport time 30 min max March, 14.7 minutes
April, 11 minutes
May, 9.15 minutes
MISSION & BACKGROUND - EXAMPLE

Background
CURRENT CONDITION – EXAMPLE
ROOT CAUSE EXAMPLE
Cause Analysis
Transcriptionists take three to four hours a day matching paperwork to specimens.
Why? – They match them manually.
Why? - Paperwork and specimens are not presented in the same order.
Many specimens delayed in until the next day.
Why – Specimens are delivered to the Grossing room @ 6:00 pm which is when that
department closes.
Why - Slides get to pathologist from histology embedding 10:00 am @ the earliest
Why – Histology embedding did not begin until 5:00 am.
Final reports often delayed
Why - Transcription reports to the pathologists previously had a four- to five-hour
turnaround
Many labeling errors occurred causing further delayes
Why - Work processes throughout were inconsistent.
TARGET CONDITION
IMPLEMENTATION PLAN

Implementation Plan
Action Item Resp Due Date
Modify print order on report IT 2/2/07
Coordinate new Grossing Rm hrs. GR 2/9/07
Coordinate new Histology hrs. HD 2/9/07
Move transcriptionists area TM 2/9/07
Document & Standardize steps PM 2/9/07

Cost:
FOLLOW-UP

Follow-Up
Planned Results Actual Results
Two-day total turnaround All Specs Grossed by 10 pm
Transcription turnaround < 1 hr Average: 47 minutes
Labeling errors: 4/year 1 in first 3 months
AGENDA

Introduction
Overview of A3 Problem Solving
Using A3 Problem
Conclusion
BENEFITS OF THE A3 FORMAT

A3 problem solving is intuitive and easy to learn

and remember.
The A3 form is both a template for problem
solving and documentation of the efforts.
The A3 process is satisfying to everyone who
uses it, particularly frontline workers.
BENEFITS OF THE A3 FORMAT

The objective nature of the A3 creates safe and

acceptable problem solving; it is never critical
of an individual's work.
The graphic nature of the A3 contributes to
deep understanding of the current condition
and the target condition.
BENEFITS OF THE A3 FORMAT

Creating the Target Condition is easy because

we so deeply understand what‟s wrong with the
Current Condition.
Building accountability with a specific
Implementation Plan occurs naturally as we
outline the specifics of what needs to be done
to make the countermeasures a reality.
QUESTIONS?
THANK YOU …

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