A LEAN principle is that front line staff provide value as defined by the customer (the patient). Within a LEAN framework, an A3 is both a way to understand your problem and a tool to organize multiple PDSA cycles into one cohesive and visible structure. While the literature cites many examples of PDSA cycles that improved the functioning of Code Blue teams, A3 thinking is rarely mentioned.


To create standard work for Code Blue events that reinforces multidisciplinary communication.


Our hospital currently has suboptimal multidisciplinary communication during Code Blues, as evidenced by staff surveys showing only 48% of residents, nurses and pharmacists (N=47) agreed with the statement they “felt comfortable being a member of the code blue team.” Additionally, only 51% of respondents agreed with the statement “the other members of the Code Blue team value my input during Code Blue events.”

A multidisciplinary team formed to address this issue and create an A3. Focus groups consisting of front line staff identified two root causes of the current state of poor multidisciplinary communication during Code Blue events – insufficient role identification of team members and poor crowd control. These root causes arose from various criticisms that were voiced, including bedside nurses feeling “excluded” during Code Blue events, residents struggling to identify themselves as code leaders, and the lack of a standardized way to provide feedback to the Code Blue team.

Initial PDSA cycles employed blue glow sticks to provide visual cues to identify the code leader, incorporated role identification and crowd control training into Code Blue simulation sessions, and created a standardized code leader script to facilitate code leader identification and crowd control. We prioritized the order of interventions in this way as front line staff stated that debriefs were felt to be impractical if team members did not know with whom they should be debriefing (role identification) or if the environment was too chaotic to foster a productive debrief (crowd control). Upcoming PDSA cycles will include the initiation of a standardized debrief, followed by the staff being re-surveyed.


By utilizing A3 thinking with a multidisciplinary team, we identified several root causes and prioritized our interventions. LEAN provides a practical framework to empower front line staff to evaluate the current state and implement positive change in their daily routines. A traditional approach to quality improvement (QI) would have been to find a QI champion to address the most frequently stated need and then institute change. This top-down approach championed by a single motivated individual runs counter to LEAN principles in which multidisciplinary, bottom-up leadership is favored. Our use of A3 thinking addressed the root causes at play and resulted in the front line staff owning the process themselves.