A3 Methodology

The A3 problem-solving assessment tool and self-instruction package for teachers was published in the peer-reviewed journal BMJ Quality and Safety in 2021. Please cite this paper if you use the materials in future research.

Myers JS, Kin J, Billi J, Burke KG, Harrison RV. Development and Validation of an A3 Problem-Solving Assessment Tool and Self-Instructional Package for Teachers of Quality Improvement in Healthcare. BMJ Quality and Safety.  2021.

Purpose A3 problem solving is part of the Lean management approach to quality improvement (QI). However, few tools are available to assess A3 problem-solving skills. The authors sought to develop an assessment tool for problem-solving A3s with an accompanying self-instruction package and to test agreement in assessments made by individuals who teach A3 problem solving.

Methods After reviewing relevant literature, the authors developed an A3 assessment tool and self-instruction package over five improvement cycles. Lean experts and individuals from two institutions with QI proficiency and experience teaching QI provided iterative feedback on the materials. Tests of inter-rater agreement were conducted in cycles 3, 4 and 5. The final assessment tool was tested in a study involving 12 raters assessing 23 items on six A3s that were modified to enable testing a range of scores.

Results The intraclass correlation coefficient (ICC) for overall assessment of an A3 (rater’s mean on 23 items per A3 compared across 12 raters and 6 A3s) was 0.89 (95% CI 0.75 to 0.98), indicating excellent reliability. For the 20 items with appreciable variation in scores across A3s, ICCs ranged from 0.41 to 0.97, indicating fair to excellent reliability. Raters from two institutions scored items similarly (mean ratings of 2.10 and 2.13, p=0.57). Physicians provided marginally higher ratings than QI professionals (mean ratings of 2.17 and 2.00, p=0.003). Raters averaged completing the self-instruction package in 1.5 hours, then rated six A3s in 2.0 hours.

Conclusion This study provides evidence of the reliability of a tool to assess healthcare QI project proposals that use the A3 problem-solving approach. The tool also demonstrated evidence of measurement, content and construct validity. QI educators and practitioners can use the free online materials to assess learners’ A3s, provide formative and summative feedback on QI project proposals and enhance their teaching.