INTERVIEW – We are used to thinking of A3s mainly as a tool for problem solving. In this Q&A, you will learn about the experience of a San Francisco hospital using it for personal development.

Interviewees: Margie Hagene and William Huen

Roberto Priolo: The A3 is an incredible versatile tool. It may be generally used for problem solving, but it has many other uses. You two specialize in using the A3 for personal development. What’s the best way to describe this approach?

Margie Hagene: I keep learning new ways to think about this, but the best way to describe A3 thinking that I have come across is Zuckerberg San Francisco General Hospital CEO Susan Ehrlich’s: improvement chartering. I think that's brilliant. If I think about that relative to my personal improvement, then the framework becomes a tool for rigorous thinking that results in an improvement charter for myself.

I know of no organization in the US that has dug in as deeply on personal improvement through A3 thinking and started to think of it at an organizational level as Zuckerberg San Francisco General Hospital. They use the very same framework you can see in Managing to Learn. We anchor people with what is already familiar to them from John Shook's book and then, through some different thought starter questions, we encourage them to apply this to self-improvement rather than just problem solving.

RP: Lean is a socio-technical system, so it’s only natural that leaders should also think about the “social” dimension of it. Yet, they typically tend to focus more on the technical one. Why is that?

MH: It is unfamiliar to them. Leaders typically came to be recognized in their field because of their technical accomplishments, what they went to school to learn about, what they've practiced being better and better at over time. It is highly uncommon for someone to have been encouraged to give any thought to the social components of the work. They have learned to feel highly confident in their technical practices, and it can almost feel like a step backwards to look at the social side of things because it normally makes them feel wobbly (something they haven't experienced in a long time) and they've never been asked to focus on it. Unfamiliar content and requirements is not necessarily what any accomplished person is drawn to.

William Huen: In healthcare, there is a little bit more balance between the social and technical side of management, because there is an increased focus on the relationship with patients as well as with the larger team. But there is a tendency still to focus on tasks and less on the organizational vision, the relationships within the organization and even with patients. Too often, we make the person a technical system. We tend to list problems in a compartmentalized way – by “system” (as in, neurological, respiratory, cardiovascular, and so on) and make it overly technical. Every now and then, we have to pull ourselves back and ask what the patient is actually experiencing, what condition they are in, how the system as a whole can work together to help them. Because of the specialization of the medical profession, the technical side of the work is generally more appealing – it’s clearer, black-and-white, and measurable. What I like about lean is that it pulls people back to the social side.

RP: How did you come to think of A3 thinking as a tool for personal development?

MH: My formal schooling is College of Education, where I was taught that it's important to create the conditions for learning – something that Lean Thinking and continuous improvement certainly align with. Approachable frameworks, like the A3, help people to make their way forward with whatever is in front of them.

When John Shook wrote Managing to Learn, he and I both lived in Ann Arbor. Some of his early experiments with workshops were happening at the University of Michigan. He invited me to sit in the room to provide him with feedback and learn about the framework. That’s how I came to learn more about A3 thinking and deepened my own practice. Then I would do workshops with and for LEI, during which we’d introduce people to a range of lean practices. Towards the end of the workshop, you’d tell people to go back and practice… but nothing happened. We were teaching them new ways but asking for next steps in old ways.

I just kept staring at the A3 framework and wondered why it wasn’t working for some of the people I coached. It occurred to me that, if you accept the hypothesis that each of us as a leader is a condition in the workplace that could also benefit from improvement, there is no reason why an improvement framework like the A3 shouldn’t work when applied to personal development. So, I dabbled with it with individuals and started asking some thought starter questions about it that aligned with the different elements of the framework. It was useful to people: when it comes to self-improvement or my own leadership development, there often isn't a framework for doing it.

WH: For us, it was an evolution. We started by teaching tons of people tools and problem solving, until we realized that the leaders themselves had to change their behaviors. A lot of leaders find this challenging, but once they turn the corner and start to see their leadership role more clearly, they understand that other people’s leadership behaviors are dependent on their own.

As far as the A3 framework goes, many healthcare people appreciate it. They like the data driven side of it, the scientific method behind it, the ability to be messy. I don’t necessarily see it as a simple framework, but rather as a complex framework that can be applied simply to complex problems.

RP: How do you find people react to the A3 framework? To them, is it simple or not?

MH: A3 thinking is an incredibly rigorous practice. On the surface, it presents as not overwhelming, and most people can connect with the logic in the flow of the story. So, initially, it's not off-putting. They are often surprised and uncomfortable, however, about what is uncovered by digging into it deeply. I will say that the framework helps them navigate what it is they need to learn, whether it is for problem-solving purposes or self-examination and improvement.

WH: For many of our leaders, the A3 framework allows for deeply thinking about challenging and complex problems, using a shared language. As they develop an understanding of the organization, their teams, and their units, they gain clarity and start to see what’s needed as a place to start. How can I show up to contribute differently to the achievement of our goals? What are my strengths? How do I use them in a way that is in the service of my followers or my peers?

RP: From a practical standpoint, how do people go about using the framework for self-improvement purposes? Starting with giving their A3 a title…

MH: We present the A3 to them as an “improvement story about yourself”. Every story has a title, and we ask them what a good name for their story could be at this moment, knowing it will very likely evolve as they think more deeply about it.

WH: In our organization, we like to think of A3s and strategic deployment as top down and bottom up. For example, within the context of a new  strategic direction, as a leader you're sharing ownership around alignment and realignment of complex systems and then operationalizing strategic problem solving at the departmental or unit level. There can be a deployment of personal development as well.  A supervisor may invite a leader to begin a personal development plan A3 around specific feedback. We have invited our expanded executive team to practice personal development plan A3s in response to 360 surveys or concerning trends in our staff engagement data. And more recently, our CEO, Susan Ehrlich, challenged our Executive team to have an equity goal in our personal development plans. Not an exact title, but a direction for us to move in.

RP: What parts of the A3 framework do people find most challenging?

MH: People typically struggle with current state, just like they do when they use the A3 for problem solving. They tend to speak in generalities and often look at the people they lead versus holding up the mirror to themselves. Also, their problem/opportunity statements are often countermeasure statements.

As coaches, our role is to get our coachees to focus on themselves and get very specific about their behaviors and the outcomes they produce in the rest of the organization. We see them getting uncomfortable with this level of self-examination, but that’s how self-learning and improvement happen.

WH: I agree. Just as in any other improvement work, I think that self-reflection and identifying real problems is always the hardest part. As a coach, you also need to be prepared for conversations that get very personal and often unearth organizational trauma that’s been around for decades. It is our job to create a safe space where people can then move to the right side of the A3 and feel like they can find the next step.

RP: Something you often hear in healthcare is that the professional group that’s harder to “convince” to participate in lean improvement work is the physicians. Do you agree?

WH: I get the stereotype. Many physicians have incredible expertise and grueling schedules and can often come across as distant and uninterested in the improvement work, and that can lead people to fear them and make them into villains. That’s a problem, though, because you're never going to win over a villain. You have to think of physicians in a totally different way and consider how you might involve them in identifying and solving problems around a shared purpose. They are people like everyone else, with their own feelings and vulnerabilities. And they are incredibly passionate, and super mission driven. They just speak a different language and most medical training programs are still very early in integrating formal concepts like interdisciplinary teamwork and quality improvement.

MH: This goes back to creating the conditions for learning. It is disrespectful to not meet the learner where they are, to not try and speak their language, to not try and understand their practice. To engage them, I for one strive to speak their same language, and speak to what’s important to them. I learned this from Dr. Jack Billi at University of Michigan: he taught me that the scientific approach physicians follow to diagnose and treat a patient is intended as a framework for complete and rigorous thinking, just like the A3. It just has some different labeling. So, with clinical healthcare leaders, I don’t ask them what the opportunity for personal improvement in their problem statement is, but what their “differential diagnosis” for themselves is. And then they get it.

RP: How does the practice of A3 as personal development link to leader standard work?

WH: We use leader standard work as a follow-up tool, but also as a continuous study and adjust tool. Those targets or goals that we'll have will often be measured through leader standard work, especially daily behaviors. We try to get people to experiment at the level of specificity of a daily behavior that's measurable. We encourage people to think about how they show up every single day, about their specific daily behaviors, and then we'll use the standard work.

It is less about what boxes I check and more about how I am leading and in service of others. Asking open-ended questions is a common one people will put in their A3s.

RP: Who would typically be the coach challenging people in the development of their personal A3? Is it a peer? Is it their manager?

WH: From the beginning, we relied on a peer approach and transitioned over time to the manager. It was the most feasible way to do it, and it worked well for us. We have a ton of experienced leaders, but they often don’t have the bandwidth and capacity to do this on a regular basis. At a later stage, we brought the practice into our expanded executive team agendas, where we would build time into our monthly meetings to have people share their improvements and leader standard work – it’s how we measure its effectiveness across the organization.

MH: When we introduce this, we immediately introduce catchball and the asking of effective questions, which is in service to the A3/improvement/problem owner. Whether the presentations of the A3s happen in a one-on-one setting or in a room full of colleagues or strangers presenting to each other, the first interaction is universally uncomfortable. People often feel a sense of disappointment for what's on the paper (which is not at all the intent), and we often have to insist they write down their strengths – not just their limitations. In my experience, after that first time, they realize they've survived, that they have learned, that they are supported by the team, that they will leverage their strengths. Then, it becomes easier.

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