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Thursday, June 8, 2017

Lean and Veterinary Medicine: Like a Glove



After reading, studying and thinking about Lean over the past seven years, I am convinced that Veterinary practice and Lean are destined for each other. As veterinarians and systematic problem solvers, we already know and are familiar with over eighty percent of Lean; we just don’t know it. Lean promotes greater value for the customer (from the customer’s perspective), with higher quality, better utilization of all resources  (especially our human resources), less expense and increased engagement of staff. I think most veterinarians want the same things.

Lean is the Western name for the Toyota Production System (TPS). Coined for its ability to remove the “fat” (wastes or muda) from processes.  Toyota developed TPS in an effort to rise out of war torn Japan, with its limited resources, to be able to go beyond truck manufacturing for the small, Japanese economy to complete with the American auto giants in a global economy. Since then, most other industries have found successes with Lean, including human healthcare. Can it do for veterinary medicine what it has done for many hospitals and healthcare system around the world? I think it can and that we need to try.



We’re Not That Different, Really

First of all, Lean takes a systems approach to problems. Problems are examined from a systems breakdown perspective before people are blamed. Lean asks “Why did this happen?”, or “How did this happen?” as opposed to “Who is responsible?” As doctors, we work with systems in our patients every day. We understand inputs, outputs, delays and feedback loops, both positive and negative. We know what can happen when one system is changed and how it can affect other systems for the better or the worse.

In order to identify the abnormal, we must first understand what is normal; what is ideal for this species, breed or animal. In veterinary school, we learned normal anatomy and physiology before we studied pathology. The same concept is true for Lean. We must have a very clear idea of what our ideal practice would look and function like. Notice, that I did not say an ideal practice. Lean is not trying to make your practice some management guru’s idea of the perfect “cookie cutter” practice. Lean understands that your practice is unique. The doctors are different. Their biases, philosophies and perspective are unique. The neighborhood where your practice is located is different than other neighborhoods. The mix of your employees is one of a kind. The Lean objective is to make your practice the best “your” practice it can be, now and into the future.

In the Lean mindset, this ideal is called our “True North.”  What would your practice look like if it was perfect? How would your practice perfectly relate to your clients? What would your ideal staff look and function like? How would your practice benefit your neighborhood and community if it is was perfect? It’s totally up to you. What ever you decide your True North is, Lean is designed to get you there. Forget, what a “Top 100 Best Practice” says you should be. What is important from the Lean perspective is that you are closer to your True North today than yesterday; closer this month than last month.  The perpetual destination of the Lean journey is perfection, knowing full well, of course, that this is impossible. The Lean journey never ends. As Vincent Lombardi said, we pursue perfection, knowing we will never get there, in order to reach excellence.


We Know This

As veterinarians, we are already quite familiar with eighty percent, or more, of the Lean methodology. We just don’t know it. Both mindsets are based on the scientific method of problem solving.

When a sick pet comes into our practice, health is our goal, our ideal state. The first step in diagnosing that pet is to understand fully the current state of that patient. We start with the primary client complaint. Regardless of whatever else we discover, we want to make sure we address this problem. Next, we collect a complete history; vaccinations, diet, current medications, symptoms and their progression, etc.

The second step is to perform a complete “tip of the nose to tip the tail” physical exam, paying particular attention to the client’s primary complaint. Can you imagine trying to make a diagnosis without performing a physical exam on the patient?

Next, we might perform diagnostic tests, such as a complete blood count, a general organ profile, urinalysis, radiography, and specific serology tests. We are attempting to explain why the patient is having the symptoms it is having. Medicine is based on facts, objective data, not fantasy.

At this point, we should have a reasonable understanding of the pet’s current state of health. Now, because we know what the ideal state of health is for this species, breed, gender and age, we can identify the problems; the gaps between our patient’s current state and the ideal state.

Based on our problems list, we formulate a treatment plan. This is an experiment. We don’t know if our treatments will work, but we decide, maybe with consultation with colleagues and specialists, what we are going to do. Later, we will follow up with the client and pet in order to analyze if we were successful  at reaching our ideal state of health. If we were successful, we will set a time for the next review, maybe in six months or a year. Remember the 3Rs; Recall, Re-examine or Reminder? If we were not successful, we reflect on what went wrong and start the process over again with additional history, another, possibly more in depth, physical exam, additional tests, a second, adjusted round of treatments (another experiment) and another analysis of the outcome.

As I said, the Lean methodology of management problem solving is also based on the scientific method. The process is almost identical to the one described above for diagnosing and treating sick pets. So how do we know we have problems? Because we have not reached our ideal state in one form or another.

The first step in Lean problem solving is to thoroughly define and understand our current state, just as it was with our patient. This step might include past and current metrics; key performance indicators. What is our story? “The facts, ma’am, only the facts!”

Defining the current state also includes an essential “physical exam.” In Lean, this is called “going to gemba.” Gemba is the Japanese word for the work floor, the place where the work (and problem) actually occurs. For instance, if the problem has to do with surgery, then the surgery room is the gemba. Lean emphasizes the importance of physically observing the flows and processes (the “value stream”) in real time in order to deeply understand the current state as it really is. A big difference in the Lean mindset, however, is that this observation (physical exam) should take place with the staff that are there on the floor, because they know better than anyone what the real issues are. They deal with it every minute of every day. They are an organization’s most valuable asset and resource, especially for helping to identify and provide solutions to problems. Lean promotes partnering with employees in this effort. Our staff wants to be part of the process of finding solutions, rather than always being seen as the cause of problems. This is a big part of what engages them.

Now, as in the diagnostic process, we can identify the gaps between our current state (disease) and our True North (health). However, many problems can appear to be caused by a particular cause when, in fact, it is caused by something much deeper; something more basic. Just as not diagnosing and treating the real problem versus treating symptoms will probably not yield a cure for or patients, not solving problems at their root cause will not provide a permanent solution to the problem at hand.


So, in Lean there is a “diagnostic” called “5 Whys.” This is the idea that one should ask “why” five times to insure the root cause has been identified. A fix for anything less will not solve the problem once and for all. The number five is somewhat arbitrary. It could be four or it could be seven. The idea is to ask enough times that the root (absolute) cause has been identified.

Does it ever seem like you are having to deal with the same problems over and over again? As if you are constantly playing the game “Whack-A-Mole?” As soon as you think a problem has been squashed in one place, it “pops up” again somewhere else? One of the main reasons for this could be the fact that the root cause (the definitive diagnosis) has not been found (another reason could be that your unique, valuable and knowledgeable staff played no part in the process). That it has always only been handled with “Band-Aids.” And, all of this effort is found to be just a waste of time and effort.

Once we know the gaps between our current state and our ideal state, we, in dialogue with our staff,  can devise the counter measures (treatments) we feel are indicated. This is an experiment, also, since we don’t know if it will work. It will give us an idea of what the future state should look like. Since our True North, or ideal state, is perfection, and we know that is impossible,  then the best we can do is aim for the next, improved, future state. Lean is a journey that never reaches its final destination of perfection. It is the process of continuous improvement toward ever better future states. We can never reach our True North, but with constant effort, we can get really, really close!

The final step, as with our patients, is to study the results of our tiny experiments. If the results are positive, then we institute it as the new, best method or standardized work and the staff is trained to this new current state. We will continually, from time to time revisit this process in order to improve it  even more down the road. If our “treatments” does not turn out well, then we (along with staff) will make adjustments and start the whole process over again with different countermeasures and experiments.
I hope it is evident, now, how much diagnosis and treating patients in our veterinary practices is similar to the Lean methodology of management and problem solving. I told you that you knew more about Lean than you realized!





SOAP vs PDSA

We are all familiar with the SOAP format for writing medical record. “S” stands for “Subjective, “O” stands for “Objective”, “A” stands for “Assessment” and “P” stands for “Plan.” The Subjective and Objective parts define the current state of the patient. Assessment delineates our tentative diagnosis. Plan communicates our, hopefully, successful treatment. It is not the medical record that is so important. It is the diagnostic thought process that is important. We could write medical records with a different format, but the thought process is the same, regardless.

In Lean, the written document is called an A3 report because it was written on an A3 sized (approximately 11 inches by 17 inches) piece of paper which was the largest paper that would fit in a fax machine at the time. It is based on the Deming (named for the American, W. Edwards Deming, one of the first to use statistics for quality control and improvement) or PDSA cycle that is the thought process.


“P” stand for “Plan.” In this part of the report (which typically occupies about 50% of the entire report), we provide a statement of the problem, any 5 Why analyses, the necessary information (e.g. data, charts, graphs, Value Stream maps, etc.) to describe our current state, possibly a Future State map, and any cost estimates relevant to the experiment . 

Following is the “D” or “Do” section. This section delineates the proposed countermeasures we will experiment with. 

Next is the "C" or "Check" (some use “S” or “Study”) portion of the report. Here, we explain and study the results of the experiment. 

The final section is the “A” section which stands for “Act” or “Adjust.” Here, we reflect (hansei) on the results of our experiment. If it was successful,  then we act on the results by instituting them within the practice. If not, we adjust, come up with new countermeasures and experiments in a new PDSA cycle and A3 report. Again, it is not the format of the report that is important (although the idea that everything should be concise enough to fit on one A3 sized paper is an important aspect), it is the process (called A3 thinking) that is.

Because the diagnostic process and Lean problem solving are both based on the scientific mindset, both reports are similar. More that we didn’t know that we know!


Thanks for visiting. Tell your friends about the blog!



Saturday, May 13, 2017

This Kanban System Works

Several months ago, I helped a practice set up a small, experimental kanban system for drug inventory. This particular system uses a kanban card as the signal to re-order.

The other common system utilizes two bins to hold a predetermined amount of product. When the first bin is empty, it is  removed and placed in a specified place known as a kanban post. From here, someone routinely (determined by standardized work) collects the empty bins and refills them from a central supply area. These bins are then returned and placed under (behind) the bin currently in use. The cycle repeats. This type of system is most often utilized in work areas, such as exam rooms, treatment areas or the lab to manage syringes, blood tubes, gauze squares, microscope slides, etc.



This was the “system” that was used previously. Excess drugs were stored throughout the hospital wherever there was room, such as this exam room cabinet. Notice the somewhat haphazard way the bottles are arranged.  Nothing is labeled. There are two empty slots on the second shelf. What is missing and needs to be ordered? And, how many? How long has this shortage been going on?

This “system” requires a staff member to go to all the the different “nooks and crannies” in order to create a complete drug order. In addition, this person would need to be experienced enough to “know” what belongs in empty spaces and how many to order. Inventory must be taken daily in order to identify depleted drugs, and get them ordered and delivered, hopefully, before a doctor needs to prescribed them. There is no reserved supply to cover the time necessary to get a new order in. Fortunately, for this hospital, orders placed by 10:00a.m. would be delivered by 3:00p.m. Not horrible, but still a gap before anyone can use the drug. For many hospitals, the lead time is days, not hours. Daily ordering also means daily receiving, daily invoice reconciliation, and daily restocking of shelves. That’s a lot of muda (waste)!!



In the new system, a place was found to install a couple of shelf units to experiment with. The drugs and supplies chosen were arranged in alphabetical order, with a few spaces left open for future additions.



The front of the shelves were labeled for each item. A place for everything, and everything in its place!
Even at this point, a missing item would be noticeable and identifiable.




The final step was making and placing the kanban cards (the signals). In order to keep this experiment as inexpensive as possible and to allow for quick, easy changes, I used pink index cards. The cards were bent in an “L” shape so they would stand up and be more visible.

On the front of the cards, I wrote the name of the drug, its size (e.g. milligrams), the unit size (e.g. tablets per bottle), the number of units to order and the number of units to keep behind the card. Our goal with this system was to only need to order once weekly. We wanted no more than two months supply up front, if possible, and, at least, one week's worth behind the card. When a new order comes in, the inventory is rotated by placing the items behind the card in front and replacing the reserve stock behind; a FIFO ( First In, First Out) system.

Now, once a week, a staff member (any staff member, because the system makes this possible) looks at the shelves and records the item, size and quantity to order. Ba-da-bing, ba-da-boom!

An improvement experiment might be to place a bar code on the card and read it with a smartphone or tablet into a form to be faxed or transmitted directly into a vendor's ordering software.

There are several Lean concepts here.

  1. It is visual. With a single glance and one can see what is needed and what is not.
  2. Just-In-Time. Item are only ordered when they are needed and in the amount needed, but before they run out completely.
  3. Elimination of waste (muda). Wasted time in ordering, receiving, reconciling  and shelving, i.e. once weekly vs once daily. Wasted space in warehousing large amounts of inventory. Wasted use of capital that might be needed for other situations. And, wasted transportation and motion by the vendor. Increased workload on the rest of the staff to “cover” for an employee to handle inventory on a daily basis.
  4. Use of  small, inexpensive, manual systems to experiment with and work out the “bugs” before investing in and expanding the system to include all other drugs or supplies, such as office supplies, or implementing more advanced technology, such as expensive and cumbersome software.

I had the opportunity to speak with the doctors and staff last month. They are still using the system and admitted that it has resulted in near zero shortages of these drugs. They were planning to expand it to other areas in the very near future.

Thanks for visiting? Comments and questions always welcome.

Saturday, April 29, 2017

Leanvets.com Surpasses 10, 000 Pageviews


This milestone may not seem like a big deal, especially compared to other big name websites that probably get 10, 000 hits a minute. But, for me, it is astonishing, especially given the fact that my only promotion has been through my LinkedIn connections.

I went "live" with leanvets.com in late February of 2015. I populated the site with the different subjects Mark Graban and I presented to the Texas Veterinary Medical Association's Convention and Expo that year in San Marcos, Texas.

When Mark and I first collaborated, it was for an article for an online veterinary magazine. After publication, we were told that there had been no interest from the readership. I believe there are good reasons for this, but that is a different rant. They were not interested in anything more about Lean and veterinary medicine. 

So, to see this level of interest gives me hope (and a lot of satisfaction) that there is interest.

The other things that have been surprising are the countries from all over the world that have logged on and the posts that got the highest number of views.

I expected that I would reach viewers from the United States,  especially since I only promote to my connections on LinkedIn.com. That there is an audience world wide proves to me that Lean in veterinary medicine has possibilities.


These would not have been my guesses for posts with the most hits. Very curious.

None of this would have been possible and come to fruition without the friendship and mentoring of Mark Graban. Mark has been there every step of my journey and continues to this day. He would never call himself a Lean sensei, but he has been mine in every way.

Thanks, also, to all you for reading the posts and for considering the possibility that veterinary practice could actually benefit from a Lean discussion and experiment.

So, where from here? From my perspective, it is to spread the word beyond this blog, but I need your help. I have had some difficulty in securing invitations to speak at any of the major conferences. If any of you have any connections or influence with AVMA, NAVC, AAHA, WVC, SWVS, CVC or the like, please mention us. If you know or work for a veterinary related company or organization that would be interested in sponsoring us at one of these conventions, please let me know. I think we have shown that veterinarians and staff are interested. And, I feel more are out there given the opportunity to present the concepts.

Also, please let me know what you see as the strengths of Lean for veterinarians and veterinary management. What are the weaknesses?  Do you feel the use of the Japanese terms are helpful or a hindrance?  How could I improve the way the leanvets.com message is delivered?

If you would be interested in exploring the opportunity of taking your practice through a Lean transformation, please contact me. These past two years have been the "Plan" stage of the PDSA cycle. It is time for the "Do" stage so that we can move on to the "Study" and "Adjust" stages.

Again, thanks for participating.  Comments always welcome!

Saturday, February 25, 2017

Preparing the Soil

In the Japanese culture, it is considered “poor form” to introduce a topic for discussion at a business meeting without giving the other attendees prior notice in order to allow them time to prepare. This is called nemawashi, and it  literally means “preparing to soil for planting.”

In a less literal context, it is defined as consensus building or “playing catchball.” It is one of the major differences (and advantages!) between Lean management and Western management ideology or Taylorism. Taylorism is completely top-down management. Employees are not paid to think, they are paid to do what they are told. It is “command and control.”

In a Lean culture, there is deep respect for the workers. This is manifested by such concepts as “going to gemba” to fix problems where they occur with front line personnel, or having staff write standardized work because they know better what that should look like on the front lines.

Principle 13 of “The Toyota Way” by Jeffrey Liker states:

Make decisions slowly by consensus, thoroughly considering all options; implement decisions rapidly (nemawashi).

It is a means to engage staff and eliminate the wastes associated with implementing a plan only to find out at the end there are errors in root cause discovery, problems not identified or disagreements between the different levels of management and workers (stakeholders), thus necessitating “trashing”  most, if not all, of the project and starting from the beginning again. If consensus is nurtured along the way, then the only thing to do at the end is implementation.  Everyone is already on board. Differences have been worked out along the way.

Consensus building permeates all aspects of Lean thinking, from 5 Why to 5S to Standardized Work mentioned above to, especially, kaizen

I blogged earlier about the “True North” statement. This is  management's way of defining the future state at the highest levels. The focus areas for the period are then given to the staff through the concept of strategy deployment or hoshin kanri. It is the staff that determines how those focus areas will look like and be implemented in their areas (gembas). But, they are not given carte blanche in these efforts. Dialog is maintained between all levels. It is this back and forth interaction, discussion, input and respect that defines consensus building and hoshin kanri, and is one of the major differences (and advantages!) between Lean and traditional Western management.

Remember the game we played as children called “catch ball?” Two or more kids would separate themselves by some arbitrary distance and toss a ball back and forth in no particular order. Everyone was included and everyone was equal. Nemawashi or consensus building is the same thing, except that ideas and potential solutions are “tossed around” instead of a ball and the participants are the stakeholders. Everyone is included and everyone is equal in that all opinions are valid and respected. Management has their place and input, but so do the employees. In "corporate speak" it is "bubbling down" and "bubbling up."

What kind of management system does your organization utilize? What would be the outcome if your organization utilized consensus building more? How many correct root causes, new ideas or solutions would come out of this concept? How would engagement amongst staff be affected? How would a practice that has adopted this mindset compare and compete versus one that hasn't? 

Thanks for stopping by. If you enjoy and learn from leanvets.com, please consider sharing this site with your friends and encouraging them to 'follow' it. And, please share your thoughts. We are all part of this 'organization' and, we are all intelligent, valuable and respected!

Sunday, January 29, 2017

10 Lean Alternatives to Blanket Fee Increases

Well, as I was recently reminded by one of the practice management ‘gurus,’ it is the beginning of the first quarter of 2017 and we all know what that means:

A quarterly, blanket increase in fees! 

But, not all fees, of course. Just those fees clients don’t typically shop. And, by what justifiable, rational amount? 

I remember years ago, the "gurus" recommending the "postage stamp" exam fee. The idea was that whenever the U.S. Postal Service raised the price of a regular stamp, we should raise our office call/exam fee to the same number, but in dollars. For example, when stamps went from 25 cents to 27 cents, we should increase our fee from $25.00 to $27.00. Of all things to tie a fee increase to, the U.S.P.S. was probably (or obviously) not the best choice. 

Why do we not realize that prices are set by the market, not our costs? Lean teaches us that we're not entitled to increase prices just because we feel like it's "necessary." This only works in the short term. Over time, our customers will find alternatives (like Dr. Google) or they'll just stop coming to us as much.

Instead of just raising prices, what have we done to improve our practices in order to not need those increases? What have we done to eliminate waste and improve flow in order to provide greater value to our patients and clients so these increases are not needed in the future? What have we done to train our staff to be more multifunctional across different job positions in order to keep payroll down? What have we done to get Lean?

Below are ten ideas for improvement, instead of increasing fees. Some of these ideas may not seem like they will give the same financial boost as a fee increase, but as Jeff Liker states in Principle 1, of his book The Toyota Way: 
”Base your management decisions on a long-term philosophy, even at the expense of short-term goals.”
My 10 ideas:

  1. Set up a kaizen board to involve staff in daily problem solving.
Allow your staff the opportunity to partner with you in solving problems, rather than, too often, feeling they are the source of problems. They are intelligent, creative assets to the practice. Taking on these small improvement projects teaches them about problem solving and engages them in the hospital. Staff is one of the few assets within your practice with the potential to appreciate in value over time, rather than depreciate, the way equipment, furnishings, inventory and supplies do. Invest in your people now. It will reap big benefits for your business.

Here is an example of a kaizen board, courtesy of Mark Graban and his book Healthcare Kaizen:




  1. Run a 5S project somewhere in the hospital.
There is probably at least one area of your hospital that could use some reorganization in order to allow better flow and less confusion. Get rid of unused materials. Organize what is left into specific places. Bring in supplies or instruments that you seem to always need, but are never there. Use drawer organizers or small bins. Find a place for everything (the right place!) and put everything in its place. The more frequently used objects should be closest at hand. Clean. Label drawers and cabinets with their contents. Where appropriate, such as the different exam rooms, make similar spaces the same, so there is less confusion between similar areas. Run routine maintenance on any instruments and equipment. Set up a schedule of maintenance for the future. Have staff write the new standard work. Train to the new standard. Sustain the gains.

Photo courtesy of Mark Graban

  1. Train your staff in a new procedure or skill.
Add a new service or, better yet, cross train staff so flow can be maintained or improved, especially at busy times of the day, week, month or year.

  1. Start scheduling gemba walks (or stands) for everyone in the practice.
Sometime during the week, schedule an hour for each staff member and doctor to just watch what goes on in a particular area of your practice. Have them watch the flow and the process. Follow a patient and customer from arrival to departure. What wastes do you observe? What do you learn that you didn’t know before? What problems do you see? What improvements would you and your staff recommend? Then, and this is the most important part, spend time afterwards discussing what you saw and learned. These are sources for improvement projects.

  1. Set up a kanban system to improve inventory or other resource utilization.

A kanban is a signal. It is part of the Just-In-Time and visual management concepts. The pink kanban card visually signals that this drug needs to be ordered before it runs out. But, only a certain amount.


This illustrates a kanban signaling the need for another resource,  a doctor in a specific exam room.


  1. Decrease confusion in some area by working with staff writing Standardized Work.
The first step in improvement is to get everyone on the same page. This is one of the purposes of Standardized Work. Once everyone is “pointed” in the same direction, then improvement can start. It is staff that writes Standardized Work because they know better than anyone what that should look like at the place of work (gemba).

  1. Hold a kaizen event to map and eliminate waste in a value stream.
Photo courtesy of Mark Graban

  1. Set up a whiteboard to improve visual management in some area of the practice.

  1. Start a Lean “book club” with staff. Start learning, discussing and experimenting with Lean methodologies and mindsets.
Start with these:
The book that introduced the world to the Toyota Production System.
        Lean Thinking by James Womack & Daniel T. Jones



A very good description of Lean from a human healthcare perspective. 
       
This is my copy of Mark's first edition of Lean Hospitals. As you can tell, I used it extensively. 
                                   
   Lean Hospitals by Mark Graban



The guiding principles behind the Lean system.
                             The Toyota Way by Jeffrey Liker



How Dr. Bahri became "The First Lean Dentist." His concept of 'flow' will change how you think about veterinary practice.
                        Follow the Learner by Dr. Sami Bahri

As you can see, Lean is no longer just for auto companies and other manufacturers. The Lean methodologies have produced incredible gains in virtually every type of business and organization. There is no doubt it can deliver similar results to veterinary medicine. 

  1. Write your “True North” statement and use it.
What would your practice look like if it were perfect or ideal? What do you need to do to start closing the gap between that vision and your current state. What are you waiting for?

Over the past few years, there has been growing evidence that veterinary medicine is becoming too expensive for more and more pet owners. Yes, we deserve to earn in accordance with our education.  And, yes we need to keep up with increased costs. However, I also feel we have neglected our practice infrastructures and systems. We have wandered from the concept of giving value to our clients from their perspective. We need bridge these gaps. We need a new paradigm. We need to, at least, explore Lean as that new model. I am convinced it can get our professional back on track now and give us a structure to adapt and improve ad infinitum. 

What do you think? Let us know. 

Thanks

Sunday, January 1, 2017

Systems, Value, Flow and Respect

Part of the mindset of thinking Lean is seeing and understanding your practice as a collection of systems. Individually, they seem appropriate and functional. However, many times our different systems unintentionally “bump” into each other. When this happens, chaos and waste can result.

Consider this collection of systems found in veterinary practice:

A multi-doctor practice operates on a “base or percent of production” format to pay associate doctors. The base salary is low to encourage production. Very typical within our industry. However, there are some problems.

First, the paperless computer system is slow and the doctors are required to input not only their original medical notes, but also generate any necessary supplementary reports and summaries. 

Tech staff are not allowed to have anything to do with inputting any part of the medical records other than a simple history, primary complaint, weight, temp, pulse and respiratory rate (TPR). They are not permitted to enter any of the physical exam findings, test results, diagnoses (differential or definitive), treatment orders or client home instructions. 

It is estimated that for every minute spent by doctors seeing patients, at least one other minute is needed to perform this non-value adding work.

Appointments are capped at two 20-minute appointments per hour per doctor. By the time the client is checked in by the receptionist, escorted to the exam room by a tech, and subjective information entered into the (sometimes mind-numbingly slow) computer system, the doctor notified of the appointment and briefed, half, or more, of the 20-minute time has passed.

There are four exam rooms for two doctors seeing appointments. The doctors (and, therefore, the exams rooms) are appointed at the same times each hour, i.e. at the :00 mark and at the :40 mark.

Tech staff are not allowed to have anything to do with entering any part of the medical records other than a simple history, primary complaint, weight, temp, pulse and respiratory rate (TPR). They are not permitted to enter any of the physical exam findings, test results, diagnoses (differential or definitive), treatment orders or client home instructions.

Systems thinking. As one can probably figure out, with only 60 minutes in an hour and every 20-minute appointment actually consuming 40, you are 20 minutes behind after the first hour and that increases linearly each hour thereafter. 

The first slot each hour has a 20-minute break afterwards until the next appointment at the last 20 minutes of the hour. However, this appointment butts up against the next first appointment of the next hour. There is no 20-minute “safety” period here.

Over an eight-hour shift, one of two scenarios can result. 

First, this allows twelve of sixteen potential appointments to be professionally serviced appointments per shift. This may be fine provided the takt (basically, the rate of demand) is less than that. But, if you are growing, it means hiring more doctors, thus increased overhead. Hardly in line with “do more, with less resources, with higher quality, and less waste” motto of Lean.

Second, and much more realistic, is that the 16 scheduled appointments will be seen, but many, if not all, of them after the first hour will be seen late. And, the doctor and staff will need to stay almost three hour longer than their shift to finish everything required per appointment. (Or, if the practice is willing to forego 16 appointments per doctor shift, then they concede to only see twelve; a 25% cut in production!).

From an associate doctor’s perspective, who is paid mostly on production, this is a problem. It severely caps their ability to earn income. We talked, in one of the first blog posts, about systems and how workers can be at the mercy of systems in which they have no control.

The associate doctor has very limited control over the systems that affect his/her ability to earn, e.g. appointment systems (number of appointments/hour, who gets which appointments and so on). There are systems that affect the extent to which staff are trained to assist and facilitate, computer systems, HR/payroll systems (contracted production percentage, hours/weeks, time of shifts, days on surgery), etc. Systems are the domain of upper management or practice ownership.

Respect. One of the two main pillars of Toyota and Lean is "respect for people" (the other is continuous improvement). This situation, as described here, is disrespectful to doctors and veterinary technicians. It disrespects doctors by forcing them to spend so much time performing work other than what they are uniquely trained for and can earn from. But, it also disrespects the trained techs that are not being utilized (or trained) to their fullest capacity.

Lean promotes the idea that resources should only be used when they are needed, where they are needed and only in the amount needed. Anything else is waste (muda). Doctors are highly trained, unique resources. Their use should be very purposeful and intentional. The only person in a veterinary office who can diagnose and treat patients, i.e. generate fees, is the doctor. Any other "job" than these should be seriously reconsidered - and maybe assigned to somebody else.

Value. Remember, part of the Lean definition of “value” from the client’s point of view is something they want and are willing to pay for. How much do you think a client is willing to pay for a take home “Examination Report” or a  “Welcome to Our Practice” card handwritten by the doctor they saw? How much do you think they value being able to get in for an appointment and being seen promptly by a doctor, having their pet diagnosed correctly and promptly, and efficaciously treated?

Flow. As I have blogged about before, flow directly and profoundly affects value from the client's perspective. All of the above scenario negatively impact flow. So, value likewise suffers. And this is a form of disrespect to the client.

I spent about five years working for a major corporate veterinary practice. As a solo doctor, I was able to routinely see 35 to 40 patients each day, including six surgeries. One way I accomplished this was by instituting a system of forms and tech training that freed me from much of the medical records input without sacrificing accuracy or neglecting my responsibility for those records. 

I never had any issues with routine audits of my records by my directors and in one of my last years with the practice, was one of the top 20 producers in the entire national practice. 

The vast majority of my time was spent in the exam rooms and surgery doing the work I was uniquely qualified to perform, improving flow and creating value for my patients and clients. But, from my very first days on the job, my practice manager and I invested extensive time and effort in tech training and doctor/tech “choreography.” Staff members are one of the only practice assets that has the potential to appreciate and get better over time.


At left is the simple, quick form I used. I would draw it on the back of the “Permission to Treat” form generated by the front desk whenever a patient was seen so I wouldn't use a new sheet of paper each time.

I divided the sheet into six sections as shown. Each section corresponds to a specific part of a “SOAP” medical record as indicated.

I would write my notes, findings, lab results, differential diagnosis or tentative diagnosis, treatment orders, client instructions and follow ups in the appropriate sections. I then gave the form to the tech on the case for input into the electronic medical record (EMR) and headed off to the next patient with a different assistant. This typically consumed about ten minutes of the 30 minute slot. The tech would then present the treatment plan, collect and/or run any lab tests, give any injections, prepare take home medications, go over home instructions and set follow up appointments. They would also enter the line item fees for invoicing and escort the the client to the receptionist for check out. It was at this point that they would input the EMR, before starting all over with a new client and patient in a different room.

We typically scheduled six or seven 15-minute exams per every two hours of available time, This allowed some flexibility in the schedule as the techs and I “leap frogged” from appointment to appointment. In addition, we tried to only book three of the four exam rooms each hour. If the value stream of an appointment could not be completed within 30 minutes, we asked that pet be dropped off and techs in Treatment took over. I would come back to that patient later, when I had a break between exam rooms.

The understanding (and training, training, training!) was that the techs were to put everything I wrote on the form into the appropriate ”SOAP” section of the EMR. If there was other information or details they felt were important, then they should include that, also. They signed their initials at the bottom and put the form in a specified area on my desk for review and editing later in the day. The final responsibility for the medical records was mine and only mine, as it should be.

We also, at a later date, did away with a separate tech history and tech physical exam. The only history and exam that was important was the doctor’s. The newly available tech time was utilized to input the history, physical exam findings, treatment orders and home care instructions into the EMR in the exam room in real-time as I informed the client.

Note: This is also a good example of Standardized Work!


Tell me what you think. How does this impact your concepts of respect? How much of the daily work in a hospital should staff be allowed to do? Understanding that doctors are ultimately responsible for the medical records, are they the only individuals that can input them into the electronic medical records (EMR)?  What situations have you been involved with where you felt at the mercy of systems; a “catch-22?”  How was it resolved? How many clients actually value “the personal touches,” such as doctor-written welcome cards or examination summary reports vs being able to get their pet seen (and out!) in a timely and cost effective manner? One client out ten; one out of 100; 1000? Where do (would) you balance a conflict between flow and “that personal touch?”

Thanks for stopping by.

Wednesday, December 7, 2016

True North

One of the primary tenets of Toyota and Lean is the pursuit of perfection. That is even the motto for the Lexus brand.

But what does that mean to you, in your practice, with your staff and your clients? What would your practice, in all of its aspects, look like if it was ideal or perfect?  

Forget that perfection is never reached,  This is why Lean is a journey, not a destination.  

What would pet care look like if it were perfect?  What would client satisfaction look like? What would your staff look like if they were able to do work in an ideal way? Challenged? Problem solvers?  Engaged? Continually learning and improving? What  would the physical property look like? In a perfect scenario, would you be helping to improve your profession, your community, or your tiny piece of this world? Write all of this down. This your “true north” statement.

Note that a “true north” statement is not the same as a “ mission”  or a “vision” statement.

“We practice to the best of our ability to help pets have full and healthy lives. We will treat our clients fairly while, at the same time, being fiscally responsible in order to sustain our practice and provide our staff with quality of life and continued employment.”

The first problem with most of these statements are they are too vague. What does “full and healthy” mean? What is “fair?” What is “fiscal responsibility?” What is “quality of life?”

The second problem is once they are written, they are immediately paraded on our websites, printed on our practice brochures, and then promptly forgotten. Can you recite your “mission” statement? Can any of your staff?  

I had a “mission” statement, because that was what the “gurus” said I should do in order to be a progressive manager. Do I remember it? No. Was it a “living” document that defined where I was trying to get on a daily basis? No. Did it define and shape every decision I made? No. Did it give direction to my staff in their improvement efforts? No. What improvement efforts?

A “True North” statement is much more of a “working” document, just as our Constitution and Bill of Rights are “working” documents of ideals that guide our laws and policies. A true north statement generally encompasses the four to six areas of your practice that will form your core, long term goals.

For example, “Patient Care”, “Client Satisfaction”, “Employee Development”, “Fiscal Improvement” and “Community Involvement.” These categories or “focus areas” are not necessarily written in stone. They may change from year to year, but this should be a rarity. Also, one or two additional categories can be added from time to time on a shorter term basis. But, do not let the number get too large as to be unmanageable and overwhelming.

Each of these focus areas usually has a small number of Key Performance Indicators. Note that “key” means two, or three, or maybe four measures that help you gauge your progress and the health of the organization.

It is from these focus areas that one year, five year and ten year strategies and improvement activity plans are developed, all attempting to get closer to your concept of perfection, your “True North.” Note: I mean “yours, “ not the practice down the street or some DVM/MBA in another state or country.  Remember, Lean is about making “your” practice the best ”your” practice it can be, not somebody else's idea of a “cookie cutter” imitation of their model.

For example, suppose senior management decided that for the next year, what we implement for “Employee Development” will be cross-training the staff so that they are capable of covering other positions in times of need or to cover multiple positions within a value stream in order to improve flow.

The areas of concentration within each category are then introduced to the leads and staff. It is the staff, through a process of nemawashi or consensus (I will explain these terms in a forthcoming blog) building with coworkers and management, that determine the specific projects they feel are a priority based on their experience at the gemba. This process is hansen kanri or strategy deployment, a topic of a future post.

Thanks for stopping by. Please let us know what you think. We haven’t reached perfection, yet.