methodology is beyond the scope of this lecture, we thought it would be helpful to present a framework to be used for both educating fellows on quality improvement methodology and for actually completing quality improvement projects. The table presented here is used for QI at the University of Pennsylvania and is called the A3 framework, named this because it is typically developed and printed on an A3 piece of paper. It was developed by Toyota while trying to improve manufacturing processes through the It incorporates several other quality improvement conceptual models, including the well-known plan, do, study, act model. One works through the A3 by starting at the top and working down, then moving to the right. The left side of the A3 corresponds to data gathering and the right side corresponds to QI intervention implementation. Now we will take a deeper dive into the A3, starting at the top left corner. In the top left corner, you will find the problem statement section. This is where fellows should clearly define the quality improvement problem that they are addressing. Moving down, you will find the current condition section, and this is the section where fellows will describe the data that informs that quality improvement problem. So here, data should be presented graphically using bar charts or data over time, which could be line graphs, or other advanced quality improvement tools such as statistical process control charts. There should be at least one process map in this section, and the metrics that are going to be addressed through the quality improvement project should be clearly identified in this section. Additionally, the stakeholders in the quality improvement projects should be identified in this section. Moving down in the A3, you will find the root cause analysis section, and this is where fellows should be applying a relevant root cause tool, such as a fishbone diagram, otherwise known as an Ishikawa diagram, that can be used for a deep analysis of a quality improvement problem and really what are the causes of that problem in your organization. This section is very important because the choice of the root cause of the quality improvement problem that will be tackled through the quality improvement project first must be supported by the data that you have, that your fellows have previously obtained, and that root cause is what will be addressed in the right side of the A3 diagram. Moving along to the top right corner of the A3 diagram, you will find the target condition section, and this is where fellows will be attempting to define the target condition they wish to achieve, which is based on all the work that was done on the left side of the A3, and this is really the condition that fellows would like to see if the quality improvement problem they outlined earlier in the A3 was addressed, and there must be a clear aim statement in this section, meaning what the fellows are trying to achieve with this quality improvement project. This will be addressed in a couple of slides in this module. Moving down the A3, there is a section here where fellows will be able to propose and test countermeasures, and countermeasures is another name for a quality improvement intervention. So this is where this gives fellows the opportunity to identify and define what kind of intervention they plan to undertake as part of this quality improvement project, and really that QI intervention should be clearly defined in the sense of what it is, what it will be done, and who will do it. Continuing to move down on the right side of the A3, you will find the metrics and results section, and this is where the goals of the project are restated and where the results after applying the QI intervention are described as data, and again, data should be described over time. Finally, the last section of the A3 is dedicated to thinking about how to sustain any gains made earlier in the project, meaning once the project is complete, once a successful QI intervention is identified, how does one take that intervention and make it part of standard work, of routine work in a healthcare organization, and this should be thought about really from the beginning of the project as well. So here's the A3 framework presented in a different way. You'll see that the A3 again is divided into the left side and the right side, where the left side is dedicated to really understanding the current problem, the current condition, and the right side is dedicated to action. So you'll see on the left side, there's an acronym FOCUS that's used, and what FOCUS stands for is really finding out what the problem is, what is the QI problem, and clearly defining it. The second part, the O and the C, are dedicated to really understanding what is going on in current work, what is the current condition, how does that inform the problem that is occurring. Then you will see that U will stand for root cause tools, and S will stand for selecting root cause tools, and that's really, as we had mentioned earlier, trying to think about what tools can be used, such as a fishbone diagram, to get to the root of what is causing the QI problem so that one can develop an appropriate intervention that's tightly matched to that root cause of the problem. Moving on to the right side, you can see this is where the classic plan, do, study, act, or PDSA framework comes in. This gets to really the action part of the QI project, and you'll see here this starts with planning the first test of change, and test of change can be called a number of different things, including a countermeasure as well as a QI intervention. Once that test of change is planned, the next step is to actually do and execute the QI intervention. While the QI intervention is underway, metrics that are identified earlier should be tracked and studied, and they should be trended over time and compared with what your fellows both predict and what the previous state was. Then, once the QI intervention initial period is complete, the last section of PDSA is act and really reflecting on what the results of the test were and deciding what to do next, which means either another test of change, which is an iteration of the first test of change, or was that test of change, that intervention, that countermeasure successful, and now are steps needed to make that into the standard culture, the standard work of an organization. This slide again summarizes the A3 framework, where you move from the top left of the A3, starting with defining the problem, moving down on the left side, then moving over to the top of the right side and moving down again until you end in taking a QI intervention and making it into standard work of an organization.

A3 framework

quality improvement projects

data gathering

root cause analysis

quality improvement intervention