Tuesday, April 28, 2009

The A3 and evidence-based healthcare

At the Rona Consulting Group (see "sister sites" at the left), my partners and I help health care organizations transform themselves into quality-conscious institutions capable of making money by employing the principles of the Toyota Management System. Most of the activities we undertake involve teams chartered using Toyota's famous A3 knowledge management system (after which this humble blog is named).

What is an A3?

"A3" refers to a large European paper size (297 x 420 millimeters or 11.69 x 16.54 inches) that is functionally equivalent to the Imperial tabloid (11 x 17 inches). Toyota uses A3 size paper to document its myriad improvement projects and the various team charters and reports generated in the course of project management. These documents are all referred to as "A3s." (For more details, see my book, Hoshin kanri for the lean enterprise (Productivity Press, 2006) or visit my web site (again, see "sister sites" at left) of the same name.)

How does an A3 work?

Essentially, an A3 creates a team charter that is a framework for a collaborative, multidisciplinary, scientific investigation of a problem. Every A3 requires the team leader or "author" to specify a quantitative improvement target and to integrate that target into a succinct narrative that that inspires or compels others to participate in the improvement process. This target statement--and supporting database--provide the framework for gathering and communicating the data that supports analysis and corrective action.

So how is this relevant to health care?

It plunges us into the beating heart of evidence-based health care. Every A3 document rests upon the scientific logic of the Deming Cycle of Plan, Do, Check, and Act (or PDCA). PDCA refers to the planning, doing, checking of a scientific experiment to improve work processes; the "A = acting" bit of PDCA refers to the publication of a new standard based upon a successful, verified experiment.

Tell me again how this is relevant to health care...

So tell me again how this is relevant to health care in some way that is not relevant to other industries? You've got me there, because evidence-based improvement is capable of cutting through the defenses of all types of entrenched interests, including the considerable defenses of management and organized unions universal to industries of all persuasions, including manufacturing and service industries, which of course include the health care industry.

It becomes clear.

Now it becomes clear, at least to the economist in me--I am a trained economist and economic reasoning is a principle unifying thread in this blog--why health care is a "special case," so to speak. Health care is an industry that has the usual, conservative management hierarchy plus multiple unions of considerable power. Actually, I prefer to refer to unions as "guilds." All guilds tend to restrict economic freedom in order to enhance the financial power of their members. Health care's guilds wield very considerable power (for starters, who has not heard of the American Medical Association?), power more potent perhaps (?) than the guild of the United Autoworkers.... In this connection, see Sharon Begley's cheeky Newsweek article, "Why Doctors Hate Science" (http://www.newsweek.com/id/187006).

Moreover, this economically dire situation (dire, that is, from the perspective of a free-market-loving economist) is compounded by the fact that health care organizations tend to have very few competitors, domestic or foreign (although this is changing as the costs of health care rise and the relative costs of travel fall). Predictably, this exacerbates the traditionalist perspective of management and reinforces the monopolistic tendencies of health care's guilds.

At a stroke, we have a logical explanation for a) why health care is relatively (or abnormally) poor with respect to quality and cost, not to mention the ability to adapt to changes in its environment; and b) why the scientific, evidence-based approach of Toyota's A3 knowledge management process is so very very relevant.

An inconvenient truth.

As Jesus so very inconveniently once said, "The truth shall set you free." Toyota's A3 process of PDCA (plan, do, and check your experiment, and then act on the results by publishing new standards) is a rigorous, truth-telling process that any industry may benefit from. But with all of its noncompetitive limitations--entrenched bureaucracy, multiple and powerful guilds, and a pronounced lack of competition--health care will (as surely as night follows day) benefit more than most.

Tom Jackson
Portland, Oregon

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