Thursday, July 16, 2020

A Lean Referrence List

These are most of the books that I have read over the last seven or so years and that I found most helpful. When I first started reading and learning about the Toyota Production System (Lean), one could probably fit all the available books on one shelf. Today, it would require one (or more) bookcases! More proof that Lean is real.

Lean Thinking: Banish Waste and Create Wealth in Your Corporation by James Womack and Daniel Jones
Lean Hospitals: Improving Quality, Patient Safety and Employee Engagement, 3rd Ed. by Mark Graban
Healthcare Kaizen: Engaging Front-line Staff in Sustainable Continuous Improvements by Mark Graban and Joseph Swartz 
The Executive Guide to Healthcare Kaizen: Leadership for a Continuously Learning and Improving Organization by Mark Graban and Joseph Swartz
Measures of Success: React Less, Lead Better, Improve More by Mark Graban
The Toyota Way: 14 Management Principles from the World's Greatest Manufacturer by Jeffrey Liker
Follow the Learner: The Role of a Leader in Creating a Lean Culture by Dr. Sami Bahri
Lean Lexicon: A Graphical Glossary for Lean Thinkers compiled by Lean Enterprise Institute, Edited by Chet Marchwinski
Understanding Variation: The Key to Managing Chaos by Donald Wheeler
Toyota Production System: Beyond Large-Scale Production by Taiichi Ohno
Taiichi Ohno's Workplace Management by Taiichi Ohno
The Toyota Way Fieldbook by Jeffrey Liker and David Meier
Learning to See: Value Stream Mapping to Add Value and Eliminate MUDA by Mike Rother
Value Stream Mapping for Healthcare Made Easy by Cindy Jimmerson
Lean Daily Management for Healthcare: A Strategic Guide to Implementing Lean for Hospital Leaders by Brad White
Toyota Kata: Managing People for Improvement, Adaptiveness and Superior Results by Mike Rother
The Toyota Kata Practice Guide by Mike Rother
Training Within Industries: The Foundation of Lean by Donald Dinero 
Out of Crisis by W. Edwards Deming
The New Economic for Industry, Government, Education by W. Edwards Deming 
The Deming Management Method by Mary Walton
Dr. Deming: The American Who Taught the Japanese About Quality by Rafael Aguayo
The Toyota Way to Lean Leadership: Achieving and Sustaining Excellence Through Leadership Development by Jeffrey Liker and Gary Convis
Toyota Talent: Developing Your People the Toyota Way by Jeffrey Liker and David Meier
Developing Leaders at all Levels: A Practical Guide by Jeffrey Liker and George Trachilis
Toyota Culture: The Heart and Soul of the Toyota Way by Jeffrey Liker and Michael Hoseus
The Toyota Way to Continuous Improvement: Linking Strategy and Operational Excellence to Achieve Superior Performance by Jeffrey Liker and James Franz
The Toyota Way for Service Excellence: Lean Transformation in Service Organizations by Jeffrey Liker and Karen Ross
Practicing Lean: Learning How to Learn How to Get Better…Better edited by Mark Graban 
The Machine That Changed the World: The Story of Lean Production- Toyota’s Secret Weapon in the Global Car Wars That is Now Revolutionizing World Industry by James Womack, Daniel Jones and Daniel Roos
Lean Solutions: How Companies and Customers Can Create Value and Wealth Together by James Womack and Daniel Jones 
Gemba Walks by James Womack 
The Lean Turnaround: How Business Leaders Use Lean Principles to Create Value and Transform Their Company by Art Byrne
Lean for Dummies by Natalie Sayers and Bruce Williams
Creating a Lean Culture: Tools to Sustain Lean Conversions by David Mann
Managing to Learn: Using the A3 Management Process to Solve Problems, Gain Agreement, Mentor and Lead by John Shook
Beyond Heroes: A Lean Management System for Healthcare by Kim Barnes with Emily Adams
Transforming Health Care: Virginia Mason Medical Center's Pursuit of the Perfect Patient Experience by Charles Kenney
The Lean Guide to Transforming Healthcare: How to Implement Lean Principles in Hospitals, Medical Offices, Clinics and Other Healthcare Organizations by Thomas Zidel
Lean Doctors: A Bold and practical Guide to Using Lean Principles to Transform Healthcare Systems, One Doctor at a Time by Aneesh Suneja and Carolyn Suneja
On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry by John Toussaint
Value Stream Mapping: How to Visualize Work and Align Leadership for Organizations by Karen Martin and Mike Osterling
Hoshin Kanri for the Lean Enterprise: Developing Competitive Capabilities and Managing Profit by Thomas L. Jackson
The Basics of Hoshin Kanri by Randy Kesterson
Gemba Kaizen: A Commonsense Approach to a Continuous Improvement Strategy, 2nd Ed. by Masaaki Imai
The Spirit of Kaizen: Creating Lasting Excellence One Small Step at a Time by Robert Maurer
A Study of the Toyota Production System: From an Industrial Engineering Viewpoint by Shigeo Shingo
Patient-Centered Strategy: A Learning Strategy for Better Care by Jeff Hunter
The Lean Startup: How Today's Entrepreneurs Use Continuous Innovation to Create Radically Successful Businesses by Eric Ries
Implementing TWI: Creating and Managing a Skills Based Culture by Patrick Graupp and Robert J. Wrona
The 7 Kata: Toyota Kata, TWI, and Lean Training by Conrad Soltero and Patrice Boutier
The TWI Facilitator’s Guide: How to Use the TWI Programs Successfully by Donald A. Dinero
A Lean Guide to Transforming Healthcare: How to Implement Lean Principles in Hospitals, Medical Offices, Clinic and Other Healthcare Organizations by Thomas G. Zidel
The Definitive Guide to Emergency Department Operational Improvement: Employing Lean Principles with Current ED Best Practices to Create the “No Wait” Department by Jody Crane and Chuck Noon
A3 Problem Solving: Applying Lean Thinking by Jamie Flinchbaugh
A Factory of One: Applying Lean Principles to Banish Waste and Improve Your Personal Performance by Daniel Markovitz
The Outstanding Organization by Karen Martin
Clarity First by Karen Martin 
The Lean Strategy by Michael Belle, Daniel Jones, Jacques Chaize and Otest Fiume
Multipliers: How the Best Leaders Make Everyone Smarter by Liz Wiseman
Measure What Matters: How Google, Bono, and the Gates Foundation Rock the World with OKRs by John Doer
The Five Dysfunctions of a Team: A Leadership Fable by Patrick Lencioni
Scrum: The Art of Doing Twice the Work in Half the Time by Jeff Sutherland, JJ Sutherland
The New Work by Aaron Dignon 

On The Web

Lean Enterprise Institute
Dr. Ponsford's LeanVets blog
Mark Graban’s Leanblog
Shingo Institute
The Deming Institute
TWI (Training Within Industry) Institute
Catalysis (formally ThedaCare Center for Healthcare Value)
Kaizen Institute
Toyota TSSC
Toyota's TPS Page

Hope this helps.

Thursday, March 12, 2020

Systems Thinking: Bringing It Closer To Home

A mindmap illustration of a systems approach to many of the things that affect your take home (net) pay
When we think about all of things that we need to consider when negotiating compensation with a potential new owner/manager, most of us are probably only concerned about base pay, production percentages and benefits packages. If this is good, we're good. And, I used to be in this same group. But, experience can be a ruthless teacher.

So, let me share some of my experiences with those of you that have not racked up forty plus years in the profession, working on both side of the "boss" desk, in private and corporate environments, in practices of two to six doctors, in low cost/high volume and high cost/low volume practices. Maybe, you won't have to reinvent the wheel. Plus, I think this is a good illustration of understanding things from a systems point of view.

What is a system? Thank you for asking! A system is the "game" with all of its "rules" that affect us, the players, and determine if and how "we win or lose." It is all of the departments, policies, procedures, cultures, ways of thinking, agendas, biases and ignorance that come to bear on a particular area or person, namely us, the employee.  Workers are at the mercy of the systems. They have no control over systems. Leadership is responsible for systems. However, in order to know how you will fare, you need to appreciate the intricacies of the "game." You need to think from a systems stand point.

Most of us veterinarians, these days, work on a production basis, i.e. we are paid a certain percentage of what we produce in medical and surgical fees less taxes and certain deductions. Many times there is a base salary in the mix, also.  So, for example, we are paid the greater of X% of our gross production or a salary, whichever is higher for the current period. And we are happy!

But this is only the tip of the iceberg. Looking at the illustration above, one can see there is much more involved than one might expect.

U.S. Tax Code
  • Obviously, you have to pay your "favorite uncle" first. And, the government is a humongous system!

Employment Contract
  • Percent of gross, obviously.
  • Base salary. Usually, you either get your percentage of production (POP) or the base salary, whichever is higher for the period. Ideally, this is designed to give you a minimum paycheck while you are building your production. However, I have been in "systems" where the language of the contract was that POP was not based on gross production, but on gross COLLECTED production, i.e. if the client didn't pay the bill, I didn't get any POP for that invoice. So, my paycheck is dependent on the practice's accounts receivable system; an area I, as an employee, have no input or say about.
  • Negative ProSal. This is my terminology for having to pay the practice back for any base salary paid but that your POP failed to cover. For example, in the first pay period of the month, I get $500.00 base salary. At the end of the month,  I get paid another periodic base salary of $500.00. I produced $4000.00 by the end of the second pay period of which I'm entitled, by contract,  to 20%, or $800.00. They already paid me $1000.00, yet my POP only amounted to $800. So, they TAKE BACK $200.00 of "overpaid wages" and my last paycheck for the period is only $300.00. It wasn't an either/or situation, at all. It amounts to straight production. The base salary language in the contract was "smoke and mirrors." 
  • Play close attention to the Non-Compete clauses. It may not affect your earning potential with the present owner, but it very well could affect future earning potential with a different employer. (This also goes for relief Veterinary services. If you get asked to come to work for a practice that you worked at through a relief service, it might be a violation of the non-compete agreement you signed (Remember?) with the service.)
[A sideline note here. I contracted to work 4.5 days/ week for a set base salary. A pay period was every two weeks. So, I agreed to, and was available, to work  four days every week plus every other Saturday. During the first  two-week work period of my employment, my employer only scheduled me for three days each week and no Saturday. They weren't that busy. However, I only got paid for six days of base salary. This is not the definition of salary. That is per diem pay. I protested and received the other two days of salary. My point was that I was agrreable, available and willing to work the 4.5 days per week. It was their choice not to have me come in, not mine. Unless, it was my choice not to work, I was entitled to my base salary. Be careful, employers, especially of some smaller corporations (that may be under capitalized), may try to cut expenses any way they can dream up. Their "best interests" are sometimes in direct opposition to your best interests. Their systems are their systems!]

Policy Manual
  • This is where a lot of the detail about "perks" and "comps" are listed. The point here is that the Policy Manual may take on the same power as any other contract, especially if the contract refers to items in the manual. (So, get and read the Policy Manual as if it were a contract,  because it very well may be.)
  • Other items may also affect your take home pay. How much PTO do you get? How is it accumulated? How much is a "days wages"  worth if you take more PTO than allowed or take it before it has accumulated? What insurance is offered? What is the employee portion? Is there any allowance for CE? Is it enough to go to a major convention in order to cover all required hours for licensing? Who pays for uniforms? What retirement programs are available? When do they take effect? Is there employer matching? How much? When are you considered vested?

Practice Demographics
  • Where your practice is located may affect your potential pay. Which state? Urban, suburban, rural? High percent of nearby non-residential establishments (businesses)? Neighborhoods mostly house or apartments? Are the residents young with kids (and pets!), older and on Social Security, or single, career climbers? What socioeconomic level is the majority of the residents? What is the level of discretionary income? Unfortunately, considering these types of things is important.

  • It may not be immediately evident, but inventory is another system that can affect your paycheck. If you don't have it, you can't sell it. If you can't sell it, you can't earn your POP. And if this happens too much, frustrated clients will leave to go to practices that do have what they need, when they need it. (Diminished long-term growth; less net income in the future)
  • The inventory system is influenced by other sub-systems, policies and procedures. For example, the method of triggering reorders (tags, want lists, kanban bins, etc.) % of stock outs, availability of alternative drugs (variety), reorder point (is enough drug available to get through the next order/delivery cycle) to name a few.
  • The Lean concept of Just-In-Time thinking is the utilization of inventory (or any resource) only when it is needed, where it is needed and in the amount needed. Seems like a good rule of thumb, but, as with most things, it is relative. In reality, the time from selling out to ordering to receiving new product is not instantaneous. Therefore, some level of safety stock is necessary to keep on hand. How much depends on many of these aforementioned systems and sub-systems are at work and is the big question (Google 'Economic Reorder Point' and/or 'Economic Reorder Quantity').

Average Client Transaction (ACT)
  • One of the major drivers for net income is the the ACT.
  • But, the ACT is influenced by the practice's fee structure, the portfolio of services and procedures offered and whether the there are discounts and coupons available for clients to use (and how your contract counts their value toward gross production).

  • Appointments is another one of the systems that affects your net income, especially appointment density; the number of appointments available per hour or per hour per doctor. Are appointments scheduled on the hour? Half hour? Quarter hour?
  • What are the hours of operation each day? What days of the week?
  • How many surgery days per week? Who gets what days?
  • Can any Doctor see any client/patient who doesn't have a preference? Or, are all clients already assigned to other vets so that you will have to "build" your clientele from scratch with new clients to the practice? And, therefore...
  • How quickly is the practice growing and what is the practice's marketing strategy (another system)? You can't earn from clients that don't walk in the door!
  • How many other doctors are vying for clients? What is the internal competition like? (Believe me, there is ALWAYS some level of internal competition, especially as long as compensation is based on POP.)

Gender Differences 
  • Does this occur in Veterinary Medicine?

This is probably not an exhaustive or complete list of influencers on your net income. However, I'll bet it encompasses more than you previously considered.

Glance back at all of the different systems; all of the different policies, agreements, understandings, aspects of the practice you work for and/or all of the "games." How many of them do you have ANY control or, even influences, over? Taxes? Inventory? Your practice's demographics? Accounts Receivable policies? Fee structure? Appointments? Marketing? You have partial influence in the contract. The Policy Manual??  Yet they determine your ability to survive, grow, enjoy life, contribute to your world?

This is why thinking in terms of all the system involved is so important. And understanding how changes in one area can have profound effects in another.

The last time I interviewed for a job that paid on POP,  I asked to see the last several periods of ACTs, and gross income. I looked at their state of inventory and asked about how they order drugs. I asked how much a rabies and distemper vaccine, plus a fecal exam, routine deworming and flea/heartworm would cost the client. This is one of my "index" invoices that I use to evaluate fees between practices (other "index" invoices include routine canine spay + pre-anesthesia blood work + IV cath/ fluids + pain injection + pain meds to go home or a dental prophy without extractions + routine labs + IV cath/fluids. It is simular to how one might use the S&P 500 Index to evaluate other investments or how the Consumer Price Index works). I had them show me the appointments over the last few months. I drove around the practice to check out the neighborhood. I "Googled" the practice to see client reviews. I checked out if they board, do grooming or have dental xrays and ultrasound. What does the staff look like? Enough to support good client flow? Trained well enough that I only have to worry about that which I am uniquely trained and licensed for? I was interviewing the practice as much, or more, as they were interviewing me.

Just like playing Black Jack in Vegas, I know the odds are in the casino's favor (they set the rules; system) but, I want to get as much in my favor as I can. So, maybe I can choose to play at a casino where they use only three decks versus five, or one that reshuffles only after 75% of the boot is dealt, versus 50%. The more I understand the systems in use, the better my choices will be (hopefully!).

I worry about the young, naive vets coming up who haven't had the level of experiences that I have had.  They are at the mercy of their employer's systems, more and more of which are large, faceless corporations (or "wannabe" corporations) with much deeper pockets and, possibly, a different perspective and agenda. Who will speak up for these neophytes? Who will watch over them? The fox that is in charge of the hen house?

Maybe, it is time for the younger generation of veterinarians, vet techs, vet assistants  and receptionists to consider forming an employment union, the way workers had to during the Industrial Revolution, and for the same reasons. There is power in numbers they say! And, it is the "power" that determines the "game". The Registered Nurses had to do it.

Thanks for reading.

Thursday, January 2, 2020

Fractals In Your Practice, Oh My!

As I mentioned in the last post, I have been listening to the Audible version of the book "The New Work" by Aaron Dignon. I am really enjoying it and highly recommend it. At any rate, I continue to find inspiration and new perspectives with which to understand the Lean mindset. So, with that in mind…

Have you ever heard of 'fractals'? There are many applications of fractals, but I am most familiar with them as a kind of symmetrical art. The structure of much of nature is based on fractals. A very accurate measurement of the length of the craggy coastline of England was found using fractals. Animation software uses fractals to design mountains or forests, etc.

Wikipedia partially define fractals as:

Fractals exhibit similar patterns at increasingly small scales called self similarity, also known as expanding symmetry or unfolding symmetry; if this replication is exactly the same at every scale, as in the Menger sponge, it is called affine self-similar. Fractal geometry lies within the mathematical branch of topology.

Got that!?

Anyway, it might be easier to show you a sample of fractal art.

In this graphic, the branches and sub-branches are similar to the main tree trunk, but at decreasing scale. We could go on to draw successive smaller, similar branches on the sub-branches, theoretically ad infinitum.

Also, what is represented here as a complete tree very well could actually be a branch on a successively larger tree, ad infinitum. 

Any who...It reminded me of the process of strategy deployment (Hoshin Kanri) in our organizations. Recall that strategy deployment is the introduction, integration and alignment of our True North statement and focus areas down through the organization to the rest of the team.

Just like our fractal tree, each level of the practice should mirror the True North vision and focus area concepts, yet on a successively smaller, more discrete scope. In other words, the lead managers' level should reflect and further define the upper concepts as it affects them at their level and in their practice area. The lead reception's metrics would be similar in concept, but different in the data monitored than the lead surgery tech's metrics. Yet, both of them would be following and supporting Leadership's values.

The same is true for the frontline staff level as compared to the leadership level and manager level. They would monitor even more detailed metrics from their practice area's point view at their level. The frontline metrics support and give detail to the managers' metrics which, in turn, support and and give detail to the leadership level and the True North statement. 

Therefore, if we look at the entire practice, we can see that in each area, and at each level, the top most values are mirrored. Everyone is aligned and working towards the True North concepts from their perspective. Front line staff are monitoring those metrics that drive the manager metrics, and managers are monitoring those metrics that drive the Leadership (True North) metrics. The front line's "tree" is the same as the manager's "tree" which is the same as leadership's tree, but each appropriate for their particular level and function.Thus, Fractal Organization!

Thanks for reading. Let me know what you think about all of this.

Monday, December 2, 2019

Status Quo Begets Status Quo

I have been listening to the book Brave New Work by Aaron Dignon. Have you read it? I find it very interesting. 

When talk we (I) think about Process Behavior Charts (PBCs), it is usually in order to filter out the “noise” and highlight any “signals" in our metrics; to determine if we are still within the Natural Process Limits (NPLs). A PBC that stays within the NPLs indicates the system which the metric is monitoring is working as it was designed. Any data outside of the NPLs is one (of three) of the signals that indicates something has changed in the system, necessitating the need for closer scrutiny.  A PBC is referred to as the “Voice of the System” (VOS).

But the corollary to this is: 

If you are not happy with where the metric is charting, then in order to improve the chart, it means changing (improving) the system; the thinking and approach. 

As Dignon points out, if we want a 10-fold increase in production, we pretty much intuit that that will require major changes in our thinking and approach; the system. But, if we are only looking for a 10% improvement, somehow, we think that that can be achieved by "status quo " thinking. He calls this the "status quo bias." Any change in the metric requires a change in the system; the thinking and approach.

Even the modest 10% change will require different thinking and approach. Status quo thinking will only lead to status quo results. So, when the Practice Manager or area director (or even the C-suite) issues a new goal or benchmark for the new year or next operating period, then our response should be, "Great!! What are you all going to change within your thinking and approach (the system) to result in any chance of hitting that new goal?” Because, without that change first, the new goal 'just ain't going to happen!' Commanding it to happen or incentivizing it to happen or threatening if it doesn't happen will not make so.

Status quo begets status quo!

Remember, operational systems are created by and are the responsibility of Management. Workers are at the mercy of systems! 

Come join Mark Graban and I at the 2020 AVMA Veterinary Leadership Conference in Chicago as we facilitate the audience participation workshop of W. Edward’s Deming’s “Red Bead Experiment” which was designed to illuminate these concepts and more. 

Wednesday, September 18, 2019

Why Lean Is Important: From An Informed Client's Perspective

Today's post comes from Gerald Cronin of the Vivarium Operational Excellence (VOE) Network.

The VOE Network is a worldwide group of Lab Animal and Biomedical veterinarians and experts that have discovered and been successfully utilizing the Toyota Production System, or Lean,  to reduce valuable research costs while at the same time improve research quality and animal quality of life. 

From thier own website:

"Every modern industry and organization has been influenced by the operational advances of the Toyota Production System, the thinking that made Toyota the #1 auto manufacturer in the world.   Decades of research has proven that Toyota's systematic approach to improving operations has tangible long-term benefits to customer service, quality, productivity, adaptability and ultimately to reduce costs."

"The Biomedical Research community recognized these advances over a decade ago and thus began the adaptation of systematic continuous improvement techniques to the Lab Animal Industry.  Consistent with Toyota's philosophy of "sharing what they have learned from over 50 years of experimentation with the world", the Biomedical Research community understood that together, we could improve operations better, faster, cheaper if we shared our knowledge with each other." 

"With over a decade of experience, the VOE-Network was born to help the entire animal care community improve operations through members' experimentation, learning and sharing."

"The Vivarium Operational Excellence Network is a consortium of animal care institutions and companies committed to quality clinical and veterinary research driven by operational excellence.  We are a members-run organization that responds to the evolving learning needs of its members.  Learning spans the organizational spectrum from front-line technicians through Webinars, videos and Lean Belt certification to leadership skills gained from our Leadership Academy events and offerings.  We also look to industry for insights into the best ways to improve operations as well as ways to build a problem-solving culture."

Today's post:

I took my dog to a large Veterinary practice about a year ago and needed to use the restroom.  The restroom was tucked inside the clinical staff area, so I needed to navigate through some hallways to get to where I needed to be.  Along the way, I was able to see “behind the curtain” of this operation.  I was disturbed to see rooms full of medical supplies in random areas, cardboard boxes both opened and unopened piled on top of each other, medical devices stacked on top of unfolded towels and on top of unopened boxes, there was almost zero floorspace for staff to move around.  Random bottles that looked to contain some sort of medication were in random locations.  Then there was the office with piles of paperwork, computer terminals were poking through the mess, almost as if they were struggling for air.
The staff was walking from room to room and asking each other “have you seen the (X clinical item)?”  “Did you call Mrs McGillicuddy or was I supposed to”? “Sorry for the wait, Mr. Cronin, we’re really busy today” and “We will need to schedule your next appointment, we were hoping the machine would be ready today, but it’s in need of maintenance”.

I made it to the restroom and got to see more of the same on the way back. The trip made me pause, as I now questioned the quality of care my dog was about to receive.  I’m also thinking about what I was going to get billed for and why I need to come back. Piles of inventory and random clutter, medications that didn’t seem to belong there, medical devices mixed with cardboard boxes filled with supplies 3-boxes deep.  Machines that should be operational but are not. The red flags were popping up everywhere.  What am I paying for?  Can I trust this clinic?  Who can I trust here? Do they know what they are doing?

You can tell a lot from what you see in a clinic. Maybe some of the judgements are assumptions, but often they are pretty accurate. The telltale signs of disorganization, the questions staff ask each other, the delays, the missed information, the clusters of inventory that often contains expired materials; all give me the chills, no matter if I’m going for my annual physical or if I’m taking my dog to the Vet.   To me, the paying customer, they all tell a story of wasteful processes that I know are built into my bill.

I’ve been a Lean practitioner in healthcare for a few years, watching and helping clinical teams improve their care to the patient in the bed. If they can do more for the patient in a better, easier way, they are all over it.  I now work in the Veterinary world, and I have seen amazing transformations of quality of animal care and improvements to the Veterinary staff quality-of-life by focusing on improving small (sometimes tiny) process that support their daily work.  It’s so exciting to see folks enjoy the teeny challenges of improving their own work. Lousy processes are like “pebbles in your shoe”; workers agonize through the customs and clutter; given the chance, they would stop and remove the pebble to make life better.  Lean thinking does just that for workers, and the animals and their owners benefit exponentially. 

If you ever feel frustrated, rushed, frazzled, buried by complaints, or workers constantly asking questions looking for “common sense’ answers, the prescription may not be buried in a store room or office, but right here, sitting out in the open at no charge to you.  The world of Lean thinking is liberating, and Lean thinkers are eager to share their learnings and experiences with you.  We are here to help you; we’ve all been through the same frustrations and we found the prescription.  Take one small dose daily; you will be amazed at how your quality of life will improve. (My dog is OK by the way).

Gerry Cronin
Vivarium Operational Excellence Network

Tuesday, September 10, 2019

Prepare To Promote, THEN Promote

It seems to me that, on balance, there is an inordinate amount of attention and money spent on advertising, optimizing social media presence and attracting new clients without much thought being given to our practice systems and foundations. Of course, marketing is necessary and important, especially in this day and age. But beware of "putting the cart before the horse."

Make sure you are as close as you can be to your True North; that you have done everything you can to reduce wastes, improve quality and flow, utilize resources effectively and maximize value to your clients from their perspective before you embark on PR projects. Marketing poor systems and value streams is not the kind of PR you want.

My new book is now available through Kindle!

Thanks for stopping by.

Monday, April 29, 2019


Respect for people” is a fundamental principle of Lean and a major difference between Lean and the Western, more Taylor-esque, concept of management. The Western tradition, which is still a part of educating MBAs, is that management knows best and makes all decisions. Workers are to do as they are told.

There is a quotation by Henry Ford to the effect that the problem with workers is that, not only do they come with two hands, but also, unfortunately, a brain. Workers are not hired to think! Lean is much less of a top-down style of management, and much more of a bottom-up, inclusive, transparent style. This is not to say, however, that the asylum is completely handed over to the patients.
This core belief influences the relationship Toyota managers and supervisors have with their workers. For Toyota, management’s primary function is more of teacher and less of an organizational police officer. We now understand, more than before, that the focus for Toyota is not just on building quality automobiles, it is primarily focused on the building of problem solving, innovative, respected employees who, then, build quality, innovative automobiles.

Dealing with people from a basis of respect permeates every aspect of Lean.

Systems thinking:
Have you ever had the feeling that, at some point at work, you were damned if you do and damned if you don't? Or, that you are in the the middle of a Catch-22 situation? If so, you have probably been the victim of poor systems or systems colliding with each other. That feeling of not being in control or at the mercy of things bigger than you.

Thinking in terms of systems means understanding that the systems at work within an organization are management and leadership designed. Systems are the responsibility of management. Workers have no authority to control or overhaul systems. They are at the mercy of the systems. Yet, many times, staff are blamed for what is, in actuality, a system design problem.

For example, if a job is not being performed well, systems thinking would first consider such things as does the worker know that job is their responsibility, has the worker been trained adequately, does the worker have the necessary tools, and does the worker have timely and correct information?

Systems thinking is more respectful. It recognizes that systems should be investigated when problems occur before blaming people.

The Lean definition of value is that which the client wants and is willing to pay for, and that improves the health status of the pet, without defects and waste along the way. Our clients get exactly what they want, when want it and in the amount wanted. They pay for only value adding services. The concept of defining value from the client’s point of view shows respect for them.

Variance and overburdening:
Lean understands that large variances in workload can be the source of difficulties and overburden our staff. Lean suggests work loads try to be leveled as much as possible. Being watchful for the overburdening of staff comes from respect.

The Just-In-Time (JIT) concept is the procurement and delivery of resources, (whether that be drugs, supplies, access to diagnostic equipment and information, or patients, doctors and staff) just exactly where it is needed, just exactly when it is needed, and just exactly in the amount needed. Nothing more and nothing less.
With respect to staff and personnel, the Just-In-Time idea is based, in part, on recognizing and respecting the unique value of everyone's time and skills; to only use them when, where and in the amount needed.

Standardized work is the mutually agreed upon method to do or handle a certain process or situation that helps insure quality, timeliness and safety, and gets everyone on the same page working in the same direction. It shows respect by involving staff in its definition and formal writing, and by eliminating ambiguity and the anxiety it causes to workers that come from policy and process chaos.

Kaizen is a Japanese word that can be translated to mean “good change,” “change for the better,” or “continuous improvement.”

While improvements can be large, time consuming and expensive major changes, the most common are the small, daily, quick, inexpensive ideas submitted by staff that improve quality, flow, safety, value to the client and make work life just a little easier. Staff are on the frontline of our practices every minute of every day. They know, better than anyone, where and what the problems are. And, they probably know better how to remedy them than we owners and managers do.

Kaizen shows respect by recognizing what an asset our staff is, and allowing them to partner with us in improving the practice; to be engaged and be part of the solutions, rather than always being blamed for the problems.

5S projects are the physical cleaning and reorganization of a particular room or area of the practice. It helps the staff to work with less clutter, frustration and confusion on a daily basis. It creates better flow within the hospital which increase value to clients; all ways of showing respect.

Go to gemba
"Genchi Genbutsu" (go and see) means that whenever there is a problem found, all relevant stakeholders (management and staff) should go to where the problem occurs (the “gemba”) and solve it together. It shows respect by recognizing that staff have valuable input to the situation.  

On the Toyota production line, workers are provided with a mechanism to sound an alarm and ask for help anytime they find it necessary. The line stops if the problem is not quickly resolved. Toyota trains and trusts its employees to use the Andon cord when an issue of quality or safety is in question. It shows respect by creating a culture of safety and trust for anyone to speak up, even if they think there might possibly be an inkling of a concern.

It is my humble opinion that if veterinary staffs knew about and understood the Lean mindset and its worker-centric (and client-centric) philosophy, there would be such a grassroots revolution within the profession that owners, managers and corporation leadership would have no choice but to start thinking Lean within their practices. Maybe, we could start now and circumvent all of the "bloodshed."

Thanks for stopping by. Please share this blog with your contacts! And, let me know if you have any questions, comments or post ideas.

Friday, April 19, 2019

Toyota Kata

This is a continuation of the last post dealing with the training methods taught to Japan by the U.S.'s Training Within Industry after WWII. As explained in that post, the three TWI J-courses had a major influence on several of key concepts of the Toyota Production System, namely Standardized work, respect for workers and continuous improvement. But, true to Toyota’s character, they took that information, put their own “flavoring" on it, and developed what Mike Rother calls Toyota Kata.

Kata comes from  the world of oriental, martial arts. It means “form.” There are two primary kata; Improvement Kata and Coaching Kata.

Toyota Improvement Kata

When we think about the distance between where we are currently and our True North (or any other challenge), it can seem immeasurable. Or, the idea of a Lean transition and all that that entails can seem overwhelming. But, handling these emotions comes down to the metaphorical concept of how to eat an elephant; one bite at a time. Improvement kata is the standardized work for taking each bite.

The first step is to have a good understanding of where you are going; your direction, your True North or the challenge before you. In the figure above, “CC" stands for our current condition and “TC" is the target condition. The target condition is what we feel is the next logical step on our journey to True North or our goal. Part of the journey to our next TC is clearly visible and we have a very good idea how to get that far. But, after that, there is the part that is less knowable. It is more obscure, intimidating and without a clear plan. So, how do we get through this part of the quest? We PDSA our way through it.

We make a plan, experiment and see if we get closer to out target condition. The path that this takes us on is not necessarily straight. There will probably be some “zigging" this way and “zagging" that way, but through the use of A3 thinking, we will reach our TC. One bite gone! Eventually, by continuing to identify each next successive “bite" (target condition) and repeating the process, we get closer and closer to our goal. This is the essence of the Improvement Kata.

Toyota Coaching Kata

As the name implies, the Coaching kata is the standardized work for managers to mentor and monitor individuals and groups involved in improvement kata. It consists of five questions:

As you probably can tell, these questions are simply asking the group to visualize and verbalize the PDSA cycle.

  1. Where are you trying to get to? What is your direction or challenge and what is your next target?
  2. What is your current condition? Where are you now?
  3. What is one thing that is keeping you from reaching the target? What are the problems? If there are more than one, then deal with this one now, and come back to the others later.
  4. What countermeasures are you going to try and, if successful, what will that future state look like?
  5. When can we study and evaluate that experiment?

You may have several groups, each trying to reach the next target condition of their improvement project, but for you, as the coach/mentor, the questions remain basically the same. Rather than solving the problems for them, you are asking questions that will lead them, through A3 thinking, to solve their own problems, learn, and deeply understand the process. Coaching is a scheduled, periodic endeavor, much like Lean Daily Management, but less frequent. We are monitoring that the project is on task and progressing appropriately.

Thanks for reading. Your comments, suggestions, ideas and questions are always appreciated.

Monday, March 25, 2019

Training Within Industry: A Closer Look At the Job Instruction Course

With this post, I take a closer look at the Training Within Industry's Job Instruction course that I introduced in the post "The Origins of Lean Are Not All Japanese." One of the reasons, from a systems viewpoint, staff may not be performing well is inadequate training.

Job Instruction (JI) course

This course was designed to teach supervisors how to teach new workers. These people knew their jobs well and had a lot of experience, but many didn't understand how to teach someone else. This course showed them how to dissect the job into its individual steps and provided them with a standard way of instructing on a step-by-step basis. This was the nidus for Lean standardized work.


Have a Time Table--
   how much skill you expect him to have, by what date.

Break down the job—
   list important steps.
   pick out the key points. (Safety is always a key point.)

Have everything ready—
   the right equipment, materials and supplies.

Have the workplace properly arranged—
   just as the worker will be expected to keep it.


Step  1—Prepare the worker
   Put him at ease.
   State the job and find out what he already knows about it.
   Get him interested in learning job.
   Place in correct position.

Step 2—Present the operation
   Tell, show and demonstrate one IMPORTANT STEP at a time.
   Stress each KEY POINT.
   Instruct clearly, completely and patiently, but no more than he can master.

Step 3—Try out performance
   Have him do the job—correct errors.
   Have him explain each KEY POINT to you as he does the job again.
   Make sure he understands.
   Continue until YOU know HE knows.

Step 4—Follow up
   Put him on his own.
   Designate to whom he goes for help.
   Encourage questions.
   Taper off extra coaching and close follow-up.

If the Worker Hasn't Learned,
The Instructor Hasn't Taught.

Below is an example of the Job Instruction method of teaching a new student how to clean an endotracheal tube after it has been used following our standardized work for the activity.

At this point, you can have the student go through the process another time or, if you feel confident of his ability, allow him to work independently. Be sure to praise him for his attentiveness, and give him permission to reconnect with you at any time for any additional assistance he may need.

As explained in the earlier post referenced above, the three TWI J-courses had a major influence on several of key concepts of the Toyota Production System, namely Standardized Work, respect for workers and continuous Improvement. But, true to Toyota’s character, they took that information, put their own “flavoring" on it, and developed what Mike Rother calls Toyota Kata.

Kata comes from  the world of oriental, martial arts. It means “form.” There are two primary kata; Improvement Kata and Coaching Kata. I will look at Toyota Kata in the next post.

Thanks for stoping by. If you enjoy and learn from this blog, please tell a friend or colleague. And, as always, comments always appreciated.