Tuesday, July 11, 2017

My First Time with Kaizen and Value Stream Mapping

I was recently looking through the documents and photos on some old laptops when I came across photos I had taken when I was just starting to read and learn about the Toyota Production System (TPS) or Lean.

I don't remember how I first learned about TPS, but I do remember that it hit me on such a deep, intuitive, "soul" level that I was instantly and forever transformed. Lean had me at, "Greater value for the customer, better use of resources, less waste and more respect for workers!"

First Kaizen

It always intrigued me that a single groomer could bath, dry, clip, pluck ears, trim nails, and brush out a dog by themselves. In our veterinary hospital, it seemed to require two vet assistants to handle these same dogs when it came to performing a complete annual examination including vaccinations, glaucoma check, a routine blood profile and Heartworm test.

Same pets, same employee skill.

The difference, it appeared to me, was the specialized grooming table with a grooming arm and its ability to restrain the pet with both a neck leash and a flank leash. Could the same table be used in our hospital to allow a single vet tech to work with a single dog, freeing the other tech to work on a different dog at the same time, thus doubling our flow and production?

I borrowed a table from the grooming salon adjacent to our hospital and we experimented.

Long story short, it worked most of the time. It didn't work for the very fear aggressive dogs (they still required two staff for safe restraint) or dogs too big to fit on the table, and, of course, cats didn't cooperate at all. But, the majority of our canine patients were less than 25 pound and friendly, and cats made up only about thirty percent of our practice. Any time savings got all of us finished earlier.

Experimenting with a grooming table for patient treatments

Maybe treatment tables should come equipped with a grooming arm!

The neck and flank leash in action. 

Based on this experiment, we were able to come up with a system to work single handedly with larger, good natured dogs.

I eventually attached rope cleats to the outside of the cage doors to make it easier to tie and release the leashes.

One staff could perform everything needed for our comprehensive annual exams including injections and blood draws.

First Value Stream Map

After working out the grooming table kaizen, we decided to map the Comprehensive Annual Drop-off value stream. Using ‘Post It’ notes would have made the process of optimization easier, but we used what we had available (this white board).

Most important is identifying all of the value producing steps, non-value producing steps and times for both.

I don't remember, but I think this was the current state map.

To create the future state map, steps were arranged to allow some to be performed in parallel rather than in series.

Lean is about doing. Start small. Start cheap. But, start! And, get your staff involved. Lean is about deeply understanding, learning and improving as an organization.

What kaizen could you experiment with? What value stream could you map and improve? Let me know and thanks for reading.

Wednesday, June 28, 2017

Sayings of the Lean Fathers

Within the body of Jewish literature,  there is a book called "Pirke Avot", which means 'Sayings of the Fathers'. It is a collection of wisdom and quotes handed down from the ancient rabbis and the Jewish tradition. Taking that reference as a model, I decided to produce this "Sayings of the Lean Fathers." Enjoy!

Taiichi Ohno

(February 29, 1912 – May 28, 1990) was a Japanese industrial engineer and businessman. He is considered to be the father of the Toyota Production System, which became Lean Manufacturing in the U.S. He devised the seven wastes (or muda in Japanese) as part of this system. He wrote several books about the system, including Toyota Production System: Beyond Large-Scale Production. 

We are doomed to failure without a daily destruction of our various preconceptions.

Progress cannot be generated when we are satisfied with existing situations.

Start from need.

Having no problems is the biggest problem of all.

If you assume that things are all right the way they are, you can’t do Kaizen. So change something!

Ask 'why' five times about every matter.

Why not make work easier and more interesting, so people do not have to sweat? The Toyota style is not to create results by working hard. It is a system that says there is no limit to people’s creativity. People don’t go to Toyota to ‘work’, they go there to ‘think’.

Without standards, there can be no improvement.

Where there is no Standard there can be no Kaizen.

Standards should not be forced down from above but rather set by the production workers themselves.

Make your workplace into showcase that can be understood by everyone at a glance. In terms of quality, it means to make the defects immediately apparent. In terms of quantity, it means that progress or delay, measured against the plan, is made immediately apparent. When this is done, problems can be discovered immediately, and everyone can initiate improvement plans.

The slower but consistent tortoise causes less waste and is more desirable than the speedy hare that races ahead and then stops occasionally to doze. The Toyota Production System can be realized only when all the workers become tortoises.

All we are doing is looking at the time line, from the moment a customer gives us an order to the point we collect the cash. And, we are reducing the time line by reducing the non-value-added wastes.

Something is wrong if workers do not look around each day, find things that are tedious or boring, and then rewrite the procedures. Even last month's manual should be out of date.

The more inventory a company has, the less likely they will have what they need.
We are doomed to failure without a daily destruction of our various preconceptions.

The key to the Toyota Way and what makes Toyota stand out is not any of the individual elements…But what is important is having all the elements together as a system. It must be practiced every day in a very consistent manner, not in spurts.

If you are going to do TPS you must do it all the way. You also need to change the way you think. You need to change how you look at things.

The only place that work and motion are the same thing is the zoo where people pay to see the animals move around.

People who can’t understand numbers are useless. The gemba where numbers are not visible is also bad. However,  people who only look at numbers are the worst of all.

Taiichi Ohno. (n.d.). Retrieved June 16, 2017, from Web site:

W. Edwards Deming

(October 14, 1900 – December 20, 1993) was an American engineer, statistician, professor, author, lecturer, and management consultant. Educated initially as an electrical engineer and later specializing in mathematical physics, he helped develop the sampling techniques still used by the U.S. Department of the Census and the Bureau of Labor Statistics. In his book, The New Economics for Industry, Government, and Education, Deming championed the work of Walter Shewhart, including statistical process control, operational definitions, and what Deming called the "Shewhart Cycle" which had evolved into PDSA (Plan-Do-Study-Act). This was in response to the growing popularity of PDCA, which Deming viewed as tampering with the meaning of Shewhart's original work. Deming is best known for his work in Japan after WWII, particularly his work with the leaders of Japanese industry.

People are entitled to joy in work.

Management by results -- like driving a car by looking in rear view mirror.

It is not necessary to change. Survival is not mandatory.

The greatest waste in America is failure to use the abilities of people.

The moral is that it is necessary to innovate, to predict needs of the customer, give him more. He that innovates and is lucky will take the market.

The consumer is the most important point on the production-line.

Export anything to a friendly country except American management.

Whenever there is fear, you will get wrong figures.

A bad system will beat a good person every time.

To manage one must lead. To lead, one must understand the work that he and his people are responsible for.

Does experience help? No! Not if we are doing the wrong things.

The supposition is prevalent the world over that there would be no problems in production or service if only our production workers would do their jobs in the way that they were taught. Pleasant dreams. The workers are handicapped by the system, and the system belongs to the management.

Defects are not free. Somebody makes them, and gets paid for making them.

Every system is perfectly designed to get the results it gets.

A leader is a coach, not a judge.

Pay is not a motivator.

The merit rating nourishes short-term performance, annihilates long-term planning, builds fear, demolishes teamwork, [and] nourishes rivalry and politics. It leaves people bitter, crushed, bruised, battered, desolate, despondent, dejected, feeling inferior, some even depressed, unfit for work for weeks after receipt of rating, unable to comprehend why they are inferior. It is unfair, as it ascribes to the people in a group differences that may be caused totally by the system that they work in.

Quality is made in the board room. A worker can deliver lower quality, but she cannot deliver quality better than the system allows.

Shigeo Shingo

 (1909 - 1990), born in Saga CityJapan, was a Japanese industrial engineer who is considered as the world’s leading expert on manufacturing practices and the Toyota Production System.

Lean is a way of thinking- not a list of things to do.

The most dangerous kind of waste is the waste we do not recognize.

Are you too busy for improvement? Frequently, I am rebuffed by people who say they are too busy and have no time for such activities. I make it a point to respond by telling people, look, you’ll stop being busy either when you die or when the company goes bankrupt.

Unless you change direction, you will end up where you are headed.

We have to grasp not only the Know-How but also 'Know Why', if we want to master the Toyota Production System.

Those who are not dissatisfied will never make any progress.

There are four purposes of improvement: easier, better, faster, and cheaper. These four goals appear in the order of priority.

A relentless barrage of 'why’s' is the best way to prepare your mind to pierce the clouded veil of thinking caused by the status quo. Use it often.

Shigeo Shingo. (n.d.). Retrieved June 18, 2017, from Web site:

Masaaki Imai

(born, 1930) is a Japanese organizational theorist and management consultant, known for his work on quality management, specifically on Kaizen.

The message of the Kaizen strategy is that not a day should go by without some kind of improvement being made somewhere in the company.

The Kaizen Philosophy assumes that our way of life - be it our working life, our social life, or our home life - deserves to be constantly improved.

It is impossible to improve any process until it is standardized. If the process is shifting from here to there, then any improvement will just be one more variation that is occasionally used and mostly ignored. One must standardize, and thus stabilize the process, before continuous improvement can be made.

Progress is impossible without the ability to admit mistakes.

The standard is not written on the stone. The definition of the standard is that it is the best way to do the job for now. It should be regarded as a next step to make further improvement.

Where there is no standard, there can be no improvement. For these reasons, standards are the basis for both maintenance and improvement.

Kaizen means ongoing improvement involving everybody, without spending much money.

I believe that management should focus on two particular areas. One is Gemba (shop floor) and the other is customer (not the shareholder).

You can't do kaizen just once or twice and expect immediate results. You have to be in it for the long haul.

All of management's efforts for Kaizen boil down to two words: customer satisfaction.

I have a theory that among the large Western companies (mostly American) the higher an executive is promoted, the more wisdom is lost and by the time he or she reaches the top becomes a complete idiot. Certainly they do not deserve the outrageous salary.

Japanese management practices succeed simply because they are good management practices. This success has little to do with cultural factors. And the lack of cultural bias means that these practices can be - and are - just as successfully employed elsewhere.

Kaizen is like a hotbed that nurtures small and ongoing changes, while innovation is like magma that appears in abrupt eruptions from time to time.

Under the lean system, any tools which are required for solving problems are used.

Masaaki Imai. (n.d.). Retrieved June 18, 2017, from Web site:

Final Thoughts

Can you recognize some themes here? Do any of this quotes resonate with you? Maybe one or more hits a little closer to home?! Which ones are you going to take with you and/or share with others? Did any challenge your previous mindset?

Thanks for stopping by. Tell your friends about us and, please, leave any comments and questions you may have.

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!


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 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 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 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 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? 

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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.