A Case Study in A3 Problem-Solving

Long Patient Transportation Times

The Context
At Community Medical Center (CMC), two types of patients are sent to the diagnostic
departments for the procedures: outpatients and inpatients. The outpatients come to the hospital,
register, complete the procedure, and leave on the same day. The inpatients reside in the clinical
departments overnight and are sent to the diagnostic departments for various procedures
depending on the medical necessity. Once the procedure is complete, s/he is returned to the
clinical department.

Some of the outpatients who come for the procedures are old and frail and therefore unable to
walk to the diagnostic department. It is the responsibility of the transportation department to
provide a transporter to transport the patient to the appropriate department for procedures.
Similarly, it is the responsibility of the transporter to transport the inpatients to the diagnostic
department from the clinical departments as and when they are scheduled for a procedure.

The diagnostic departments (Operating Room, Radiology, Nuclear Medicine, Cardiology,

Endoscopy, and Emergency Room) in CMC regularly complained that patient transporters took
an exceedingly long time causing delays in treatment and patient waits, and they blamed the
transporters for the delays. Many thought that the transporters were having long coffee breaks
and did not transport. They sometimes called the manager of transportation and complained,
“We called 35 minutes ago and the patient is not here…” The transportation manager became
exasperated with the influx of complaints and decided to address the issue with an A3 process
and report.

The A3 Process
A group of individuals representing the diagnostic departments (Radiology, Endoscopy, Special
Procedures, Cardiology), Nursing, Transportation, and Quality Risk Management met to discuss
the issue and initiate the A3 problem solving method. These individuals formed the core A3
problem solving team.

To understand the problem first hand, the transportation manager and four transporters observed
the current process. They observed the patient request to transportation process as it unfolded
every day for10 hours for 10 days. He also contacted and interviewed different individuals in the
diagnostic departments and the clinical departments to get first hand information about the
process. The transportation manager said, “We observed all nursing stations and procedure
areas, and noted a process full of miscommunications. For example, I observed the ward
secretary… She said she would call [a transporter] right away. She actually made the call 37
minutes later, 3 minutes before the procedure. This happened frequently. The procedure
department and the nursing station never communicated as to the expected patient transport
times or procedure times. The patient’s nurse often did not even know the patient was going to a
procedure so the patient medications were not always met for the procedure….”

In addition, using a self-devised form, the manager of transportation completed a patient

transportation survey. In his survey, he measured the time difference between the transporters
receiving a beep (a request from the diagnostic department) to the time the patient was
transported (delivered) to the diagnostic department or the procedure area. The results of 23
patients surveyed over a three-day period (1/15/03- 1/17/03) showed an average request to
delivery time of 56 minutes. The actual patient transport time was only 5 minutes and the rest
was preparation time and delays in communication. The communication delays caused delays in
timely procedures, resulting in unhappy patients, clinical workers, and physicians.

In the current state, somebody from the diagnostic department, usually a technician called or
paged the transporter. At other times, somebody from the diagnostic department called the ward
secretary on the floors who then called the RN and the transporter. The transporter did not know
who was paging. Sometimes the message the transporter received said, “Bring down John Doe
to Radiology.” There was no information on the room number, bed number, floor, or area. The
transporter did not know from where the person was paging and did not always know whom to
call to clarify. She only knew a patient needed to be transported. A great deal of time was thus
expended by the transporter on patient search.

If the information was complete and the patient was ready for the procedure, the transporter
reached the patient and transported him or her to the diagnostic department. However, in many
situations when the transporter reached the patient (usually inpatients), s/he was not ready and
was in need of medications, Magnetic Resonance Imaging (MRI) screen, bathroom, IV change or
other needs. In those situations, as the patient was not ready for transport, the transporter
contacted the nurse. The transporter left the room and waited for the call from the nurse when
the patient was ready for the procedure.

The transportation manager drew the current state (patient ready for transport) drawing on the A3
Report with appropriate icons and arrows to indicate the flow of information and patient through
the system (see diagram below). On the current state drawing, he recorded the shortest (9
minutes), longest (177 minutes), and average transportation time (56 minutes) from the data
collected earlier. The problems he identified were no written message to request a transporter
and late arrival by the patients at the diagnostic departments. These are depicted as storm clouds
on the current state diagram.
The A3 problem solving team brainstormed the root causes to the problems using the “5-Whys”
approach. The analysis of the first storm cloud revealed that the staff members calling from the
diagnostic department were often too busy to send written messages to the transporter or to the
floors and therefore the message lacked complete information causing delays. The analysis of
the second storm cloud revealed that as the RNs or the ward secretaries were sometimes not
aware that a patient needed a procedure, and therefore, they failed to prepare the patient on time
which eventually led to late arrival of the patient at the diagnostic department.

Based on the understanding of the current state and the associated root causes, the team
embarked on devising the target state. The transportation manager termed the problem solving
as “Road to Recovery”. In the target state, the staff in the diagnostic department (usually a
technician in Radiology or Endoscopy, or ward secretary in Surgery) will page both the charge
RN and the transporter at the same time. The information included in the page is complete
information for effective transport of the patient to the diagnostic department (i.e. patients first
and last name, medical record number, room number, destination, etc.). The charge RN will
attend to the nursing care needs of the patient and the transporter will attend to the comforts
during transport such as shoes, blankets, chairs/stretcher etc. If everything is found in order, the
patient will be transported to the diagnostic department for the procedure. On completion of the
procedure, the diagnostic department will page the transporter who will return the patient back to
his/her room.

The transportation manager drew the target state drawing on the A3 report as illustrated below:
The specific countermeasures to achieve the target state, then, were:

 Diagnostic departments will beep the charge RN and the transporter at the same time;

 The page will include specific information, and a reference card;

 The charge RN (or a person designated by the charge RN) and the transporter will attend
the patient, with specific responsibilities; and,

 Make the patient aware of the ensuing procedure; and

As part of the implementation plan, the team created a specific action plan. First a designated
transporter and a staff responsible for communications in CMC developed a “group page”
whereby two or more people could be paged simultaneously by the diagnostic departments.
Second, the transportation manager and the charge RNs met and developed a patient tracking
sheet (a log sheet for the floor staff to sign off when the patient is transported). Third, the
transportation manager and the designated transporter developed a reference card that contains
the pager numbers of the charge RNs of each clinical department (Obstetrics, Medical Surgical
Floor, Intensive Care Unit, Orthopedic, Rehab Nursing Unit, etc.), and the transport pager
number that the diagnostic departments should page. It contains the information that needs to be
paged by the diagnostic department when asking for a patient transport. This information
includes:

 Name of the department from where the message is paged

  First and last name of the patient

 Patient’s Medical Record #

 Room #

 Patient’s destination

 Preferred mode of transport (chair, stretcher).

The reference card also contains the step-by-step procedure for requesting a transporter by the
diagnostic departments. The transportation manager sent copies of the cheat sheet to every
department to ensure safe, accurate, and efficient transport of patients.

To ensure smooth implementation of the improved process, the transportation manager met with
key individuals in all clinical departments on a one-on-one basis, explained to them about the
necessity of the new process and got their feedback on the new process and how it could be
improved. He also had couple of meetings with the house supervisors to get them on board with
the new process. The transportation manager mentioned that the ward secretaries were tough to
deal with initially. But the house supervisors were very supportive. “They hit the nail. They
made the ward secretaries conform to the policies,” said the transportation manager. The
procedural departments were very supportive as well.

The transportation manager set the target time from request to delivery at 30 minutes. When
asked about the rationale for setting such a high time, he responded, “The procedural
departments were happy with 30 minutes. They were tickled to death. Moreover, most
procedure departments schedule in 30 minutes increments.” He carried out follow-up surveys at
regular intervals to continue to assess transport time. The following table presents the collected
data:

Survey Date Time (In Mins)

March, 2003 14.7

April, 2004 11

September, 2004 11.5

May, 2005 9.15

Reactions to the A3 Process

The transportation manager felt the A3 process was every effective for problem solving in
healthcare. He wrote, “I find the [A3 Process] a very important tool for evaluating problems
and/or processes. It allows a person or team to look at how a process flows and where the
problem or work around area may be. It promotes team work on solving problems by giving a
global and unbiased look into procedures. It involves a positive thought process and invigorates
the mind to think in alternative ways of problem solving by including all aspects of a process. It
gives all parties involved a way to express and present their perceptions, fact or data on a
process/problem. The end result is a quantitative measure if there is an improvement and if it
can be sustained. On a scale of 1-10, ten being the highest, I would rate the [A3 Process] at a 10.
In my case it has given me the tool for myself and staff to become involved in a data driven
process that can prove perceived outcomes. Without TPS process it would be very difficult to
outline how an improvement plan will really be effective.”