QUERI – Quality Enhancement Research Initiative

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Quality Improvement Methods

1. A-3 worksheet

a. Definition: Communication and participation are key elements of quality improvement. Getting the important points of an improvement project across on a single page is a good way to assure needed information is communicated to everyone who needs it. The layout of such a page can vary but often a large paper size (hence the A3 term which is a paper size) is often used. On the A3 page are the goals, current status, role of participants and performance measures. The paper form may be posted in multiple accessible spaces for all to see as well as used as a working document by the team of people most involved. It can also serve as a structure for a quality improvement project since it highlights what aspects of a project must be developed.

Research projects benefit from having everyone who is involved knowing what changes are occurring. Broad participation is important in successful QI. Some organizations specify a standard format for the form's layout. Posting A3 forms in hospital or clinic work areas will increase the likelihood of a new practice or change being successful.

b. Literature: Design and use of the A3 is generally described in texts on the Lean Method (see Section 20). Also see:

  • Jimmerson, Cindy. A3 problem solving for healthcare: A practical method for eliminating waste. Productivity Press, 2007.
  • Bassuk, James A., and Ida M. Washington. "The A3 problem solving report: a 10-step scientific method to execute performance improvements in an academic research vivarium." PloS one 8.10 (2013): e76833.
  • Lee, Te-Shu, and Mu-Hsing Kuo. "Toyota A3 report: a tool for process improvement in healthcare." Stud Health Technol Inform 143 (2009): 235-240.
  • Visich, John K., Angela M. Wicks, and Faiza Zalila. "Practitioner perceptions of the A3 method for process improvement in health care." Decision Sciences Journal of Innovative Education 8.1 (2010): 191-213.

c. Example: A research project developed an intervention that impacted several provider departments in a hospital. The implementation team included people from various areas which were affected by the intervention. It was important that all areas implemented the changes as planned and with coordinated timing. The prior research results provided specific goals and an overall time schedule. As a way to organize the tasks to be done, as well as a way to keep everyone impacted by the project informed, an A3 form was prepared and updated as the team proceeded with the implementation. The form was posted for view by staff in the Emergency Department as well as in other departments such as radiology and pharmacy, and it was updated weekly as parts of the project were changed or completed. Because everyone was informed, participation was as needed. The A3 not only included objectives and plans but also responsibilities, results and conclusions or insights. The following is an example of a blank A3 form.

example of a blank A3 form

d. Steps:

1) Use of the A-3 requires selection of a consistent format so that readers find it easy to understand. There is no one standard universal format. Available literature presents a variety of possible formats if one format has not already been adopted by the organization.

2) The form is filled in and then used by posting it in work areas for all affected to see. It is also used as a working document for discussion and an organization structure for a Kaizen (see Section 18 in this handbook) or a research group.

3) As the change process proceeds, copies of the A-3 are updated and new versions posted.

4) At the end of the effort, the A-3 provides a historical record of the change process.