Gemba A3 v2.6 — David Clark About & Licence

A3:
🔍 Systems Lens Explore People, Systems, Design and Risk perspectives
A3 Details
1
Problem Statement
Why are we talking about this?
Draft
📷 Tap to add photo from gemba
Checkpoint Questions

✦ What is your reason for choosing this project?

✦ What has been tried so far to resolve this problem?

✦ How will it impact staff in the department?

✦ What is it that makes it important? Who is it important to?

✦ Does it fit your purpose, vision and values?

🔍 Systems Lens
People

Who experiences this problem, and who else is affected that isn't mentioned? Are there staff, patients, or other services bearing consequences that aren't visible from this workstation?

Systems

Is this problem contained within one process, or does it cross organisational, departmental, or system boundaries? Where does the problem sit in the wider value stream?

Design

Was this problem designed in? Is it an inevitable consequence of how the process, workspace, or technology was originally set up?

Risk

What is the patient safety risk if this problem continues? What is the risk of unintended consequences from intervening?

2
Current State
What happens now? Evidence from the gemba.
Draft
Checkpoint Questions

✦ Does your baseline data fully explain the performance of the process and the problem?

✦ What do your customers say about the problem?

✦ Who owns the process?

✦ How does the problem relate to the pathway it sits within?

✦ How do staff perceive this problem or feel about it?

🔍 Systems Lens
People

Whose knowledge about how the work actually happens hasn't been captured yet? Have you gone to the gemba and spoken to the people doing the work?

Systems

What upstream inputs and downstream dependencies does this process have? If you fix this process, what happens to the processes it feeds into and receives from?

Design

Was this process deliberately designed, or did it evolve by accident? Are the physical layout, equipment, and information systems helping or hindering the work?

Risk

What workarounds are people using to cope with the current state? What risks do those workarounds create that aren't being measured?

3
Goal / Target
SMART goal based on current state data.
Draft
🎯 SMART Check (coaching use)
Checkpoint Questions

✦ Is the goal based on data from your current state analysis?

✦ Is it achievable within your circle of influence?

✦ Does achieving this goal resolve the problem?

🔍 Systems Lens
People

Who needs to agree that this is the right goal? Are the people who do the work involved in setting the target, or was it set for them?

Systems

Does this goal optimise the whole system, or could it improve one part while making another worse? Have you checked for sub-optimisation?

Design

Does achieving this goal require redesigning the process, or just improving execution of the current design? If the design is the problem, an execution target won't fix it.

Risk

What could go wrong if you hit this target? Are there unintended consequences of success that you haven't considered?

4
Waste Identified
DOWNTIME categories with evidence.
Draft
Checkpoint Questions

✦ Have you identified waste through direct observation at the gemba?

✦ Can you link each waste category to specific evidence?

✦ Which are the vital few? (Pareto principle)

📊 Pareto Analysis — Identify the Vital Few

Enter defect or waste categories with observed frequencies to prioritise which problems this A3 should focus on.

5
Root Cause Analysis
Why is this happening? Evidence-based analysis.
Draft
⚠ Root Cause Validation

If you remove your root cause(s), does the problem completely disappear? If not, keep digging.

📷 Tap to add photo from gemba
Checkpoint Questions

✦ Have you identified the real problem?

✦ Did you go to the gemba, observe, and talk to the people who do the work?

✦ Do your results explain the gap between the target and the current condition?

✦ Check back — if you remove your root cause(s), does the problem completely disappear?

✦ Check back — is your current state analysis in-depth enough?

🔍 Systems Lens
People

Human error is not a root cause. What factors in the system guide behaviour — selection, training, instructions, environment, workload? Is the individual adequately prepared and supervised for the work required by the system and process?

Systems

Do any of the root causes originate outside your span of control — in another department, organisation, or regulatory requirement? If so, who owns that part of the system?

Design

Are any root causes traceable to decisions made when this process was originally designed or last changed? What assumptions were built into the design that are no longer valid?

Risk

Which root cause, if left unaddressed, poses the greatest risk of harm? Are you prioritising by frequency or by severity?

6
Future State / Countermeasures
What conditions need to exist?
Locked

📝 Quick Notes (memo pad — jot thoughts while left side is in progress)

7
Action Plan
Specific actions, named owners, timescales.
Locked

📝 Quick Notes

8
Results & Measures
What happened? Before/after evidence.
Locked

📝 Quick Notes

9
Next Steps
Remaining problems, follow-up, handover.
Locked

📝 Quick Notes

A3 Information

Nemawashi — Stakeholder Consultation

Record who has been consulted about this A3. Building consensus is how authority to act emerges.

Export & Sharing

Full Record exports a Word document (.docx) containing the complete A3 evidence trail — all section content, revision history, memos, nemawashi log, action items, and standardisation checklist. Suitable for NHS M365 workflows and audit purposes.

Type 1 — Troubleshooting 4C Rapid Response (Art Smalley)

1 Concern (Containment)

Immediately address the abnormal condition. What happened? Take swift containment action to protect the patient/customer or downstream process.
📷 Photo evidence

2 Cause (Direct Cause)

What is the most obvious, direct reason for the failure? Focus on the point of cause — what happened right here? Not a deep root cause analysis.

3 Countermeasure (Correction)

Implement a quick fix to restore the status quo. This may be a temporary fix to stabilise the situation.

4 Check (Confirmation)

Verify the fix worked. Monitor for a short period to ensure the concern is mitigated and no secondary problems are created.
⚠ Recurring problem? If this issue keeps happening, it should be escalated to a Type 2 (Gap-from-Standard) A3 for deeper root cause analysis.