Friday, May 4, 2018

Andon Cords and Practice Environmentalism

One of the innovations that Toyota put in place on their assembly lines is the "Andon Cord."

As the picture below illustrates, it is an actual cord (or button) that any worker can pull, which then sounds an alarm and even stops the production line if the problem cannot be resolved quickly. The alarm (blinking lights and chimes) immediately brings (to the gemba) the team leader (supervisor) to address the problem and mutually decide how to fix the issue in real time. If there are recurring problems, the team leader would then help with root cause analysis. This is important so that the same "fires" aren't being put out over and over.

Photo courtesy of Mark Graban
This demonstrates several basic precepts of the Lean philosophy. One, quality is built into the processes. Two, quality (and safety) is part of everyone’s job description. Three, problems are handled where and when they occur. And, four, creating and maintaining an environment of respect and mutual trust between the workers and the leaders.

Now, I am not suggesting that physical ropes be hung throughout the practice, or that alarm buttons be placed in every room. Although, a practice I worked for used a software management program that dedicated one the Function keys so, if pushed, it would alert all of the other computer stations that help was needed in the room where the key was activated.

What I am suggesting, however, is more metaphorical. Our practices need to be a place where anyone feels comfortable speaking up and symbolically "pulling the Andon cord!"

Lean, as much as anything else, is a culture. It is a culture that allows for mistakes and defects to be brought to management and other staff without fear of embarrassment or retaliation. And, to be handled by everyone with a stake in the process. Nothing else about Lean will ever have a chance without this concept being firmly in place and fiercely protected.


I know of a case where a young veterinarian mistakenly amputated the healthy leg of a dog, despite being informed by the surgery techs prior to surgery that this was about to happen.

This veterinarian, however, had very little respect for the staff and had created an environment around her of intimidation and fear. The staff did not feel comfortable in stopping the surgery (pulling the proverbial andon cord) when the patient was prepped incorrectly and placed on the surgery table with the improper limb draped in order to verify if it was the correct leg to remove and everyone was on the same page.

Leadership and management are the practice “environmentalists”; protecting the practice environment from all “trash and pollution", such as egos, jealousy, fear, detrimental internal competition, etc.



Thanks for participating. Please follow us. Comments and questions always welcome.

Hear ye! Hear ye!

Please mark your calendars for Monday, May 7th at 1:00pm ET when I will be giving a webinar for KaiNexus with host Mark Graban. The title of the webinar is:

From Pets to Vets: Applying Lean In Unexpected Places

Please join us! You can register here.

and you check out a preview of the webinar here.

Monday, April 30, 2018

Podcast Preview of the Upcoming Webinar on "Pets and Vets"



Hi, Mark Graban here... I'm happy that Chip is going to be doing a webinar on Monday, May 7 that's hosted by me and KaiNexus.

You can register here:

Pets and Vets: Applying Lean in Unexpected Places

If you can't attend live, at 1 pm ET that day, register anyway and you'll be sent a recording and the slides.

Monday, I interviewed Chip in a preview of the webinar... you can listen below:



Click here to learn more about the podcast series and for more info about how to subscribe.

You can also read a transcript of the conversation on my blog, LeanBlog.org.

We hope you enjoy the podcast and the webinar.

Monday, April 23, 2018

Error Proofing vs Fool Proofing

This blog post is about a Lean concept that I have wanted to share with you for awhile. It concerns the idea of error proofing or mistake proofing (poka-yoke). 

There is another similar term, baka-yoke, which translates as "fool proofing." 

Toyota prefers the former term because it is less derogatory and more respectful of the worker. It shows a systems mindset. It reflects Lean’s focus on “how” and “why” an error or defect occurred rather than “who is to blame.”

When I first graduated vet school in 1980, I purchased a personal computer (anyone remember Radio Shack’s TRS-80?) and started to learn programming. I was interested in writing small programs that would make my work easier. Eventually, I wrote a management program for my practice.

As part of the programming, it was necessary to identify proper data input by the user, so that the software would run as designed and not “crash.” If input errors were found, the user would be notified of the problem and asked to re-enter in the proper format.

For example, if the user was asked to enter a telephone number using the format (###) ###-####, I would have to write a section of code to check for proper input.

1. Are all the characters entered either a number, a “(“, a “)” or a “-“?
2. Were a total of 14 characters entered, including parentheses, spaces and dashes?
3. Was the first character entered a “(“?
4. Was the fifth character entered a “)”?
5. Was the sixth character entered a space?
6. Was the tenth character entered a “-“?

A similar set of programming code was required each and every time input was requested from the user-- very time consuming and added tremendously to the length of the program. But, GIGO (Garbage In, Garbage Out), and nobody wants that!

We can see this same idea in use all around us-- from simple warning signs to designs that make errors difficult or impossible. A three-pronged plug can only be plugged into a wall socket one way.

In general, there are five levels of error proofing, as explained by Mark Graban when he teaches Lean.


                                                                            Graphic courtesy of Mark Graban

As the graphic indicates, simply posting a sign admonishing workers to “Be careful” is the least effective. Making it impossible to make an error in the first place is the most effective means.


In the above pictures, the hospital gas panel has two ways of error proofing. First, the different hookups are color coded as a visual measure to indicate which gas hose goes to which port. Secondly, the pins of the hookup will only connect and lock with the appropriate gas port. 

Idexx has error proofed their VetTest blood test slides by designing them with strategically placed notches on the edges. With this design, the slides can only be placed in the analyzer in the proper orientation.

The file folder color coded end tabs do not prevent misfiled folders, but it illustrates the error proofing concept of making the error easier to detect.



This is an illustration of just how ineffective warning signs are. If management really wanted to control the light in the closet, maybe a motion sensing light fixture would be a better option. The light would come on when someone walked in, but would then automatically turn off shortly after the individual left. 

This next photo is something that a client of Mark Graban's shared with him years ago. Mark's not sure of the origins, but the tracks in the snow show how easy it was for somebody to just drive around the gate in the road. This wasn't error proofed (and maybe the gate was broken or not needed anyway).


Photo courtesy of Mark Graban

Of course, sometimes…where there is a will, there is a way! What are you going to do?!?

Thanks for participating in this blog. Please follow us and tell your friends about this site.

Heads up! I will be the guest presenter on a webinar series hosted by Mark Graban and KaiNexus on May 7th at 12:00 noon Central time. We will be discussing the new emergence of Lean management in veterinary medicine.  Use this link. Hope you will join us!



Sunday, April 1, 2018

Process Behavior Charts: A Better Way to Evaluate Your KPIs

Have you ever learned something new and thought, ”Gosh! If I had had only known this years ago, my life would have been so much easier!”? We all have, I suspect. What I'm writing about in this post falls into that category.


I remember owning my practice. I dutifully kept stats on everything I could think of:

  • Gross income, 
  • number of new clients, 
  • average invoice total, 
  • number of dentals or spays or neuters, etc. 

I would even plot them on charts and tape them to wall of my office like a “war room,” constantly “watching the numbers” and bouncing emotionally between feelings of “we made it through another period in good shape” and “oh sh*t, we’re down, and this must be the beginning of the end.”


The same sort of thing happened when I worked for a corporate practice. Every week, the practice manager (PM) and I were on a conference call with other PMs, lead doctors and our area managers to discuss “the numbers” -- our KPIs (key performance indicators) -- whether we were achieving our benchmarks, by comparing them to last month, last quarter or last year, and why or, more importantly, why not. Same emotional rollercoaster.


Now, for the stuff I wish I’d known back then. I recently read a book called Understanding Variation: The Key to Managing Chaos 2nd Ed., by Donald J. Wheeler, at the recommendation of my co-blogger Mark Graban. It is a fun little book about some statistics (there is that ‘S’ word) and creating Process Behavior Charts (PBC).


You know that in any process or system there is going to be some amount of variation from period to period. When this is plotted on a chart, it shows up as “ups” and “downs.” Most of this is normal, it is just “noise.” But, sometimes it can mean something significant -- a “signal.” So, how do you tell the difference? By turning your data into PBCs. This way of plotting your data will “filter” out the noise and highlight any “signals.”


I encourage you to read the book as there is more than I can briefly blog about, but, having said that, let me share some points before we get into the charts.


  1. Tables with lists of numbers are difficult to understand. There is no context, and the data is difficult to visualize in this format.
  2. Line graphs, over a longer period of time, are easier to understand and put the data in some form of continuity and context with prior periods.
  3. Comparing two data points, such as the current period data with the same data last month or last year, doesn't offer any context. Who says the data from last period was normal? Maybe, it was a really bad period due to extraneous influences, e.g. inflation or a natural disaster that occurred at that time.
  4. Averages tend to be pretty much in the middle of a range of data. Comparing to averages tends to create “binary output.” You are either above average (“good”), or you are below average (“bad”).
  5. The setting of arbitrary goals, such as a 10% increase over last period, becomes more objective and rational. It is well and good to set the goal, but if the system cannot produce to that degree, it is simply a futile “wish.” No manner of cajoling, incentivizing or threatening employees is going to help. If the goal is outside the limits, then the system is going to have to be changed from what it is right now, and employees have no control over the systems under which they operate. That is management’s domain.
  6. PBCs are the voice of the system. They show how the system is functioning, and the extents to which the system can function, as it is now designed and operating. One can also assume that, without any change, the system will continue into the future as it is currently; it is predictable. If it is not where it should be, then the system has to be changed somehow. It also shows when a data is outside the limits of the system and, therefore, is a signal that something unusual has happened, and it needs to be investigated.


The following data represents the number of new clients seen per month over the last 18 months.


18, 16, 14, 19, 15, 17, 16, 18, 15, 14, 19, 18, 15, 18, 18, 17, 19, 11

Total = 297  Average = 16.5


When just looking at a list of numbers, it is difficult to really appreciate what is going on with the data. In this form, one might easily miss the value of the last data point.

Converting the raw data into a graph is more visually helpful.




You can see that this running graph (or X-chart) is easier to understand and gives better context to the table of numbers.


This appears to be a rather stable system (or process) until, possibly we get to the 18th and last data point. Is this part of the normal “noise” or do we need to investigatte? It is lower than any prior period we have recorded. I can tell you that, for me, this would have been good for at least a week of sleepless nights and two stupid, stress related arguments with my wife!


Continuing with the chart methodology, we next determine the Moving Range (mR), between each two successive data points. This distance is always a positive number, regardless of whether the first number is larger or smaller than the first. For example, the distance between -3 and 2 is 5, or the distance between 8 and 4 (or 4 and 8) is 4.


By comparing the first data to the second, the second data to the third, the third data to fourth, etc., we get the following table:


2, 2, 5, 4, 2, 1, 2, 3,1, 5, 1, 3, 3, 0, 1, 2, 8

Total = 45  Average MR = 2.53



Graphically:





To see if the variation in the X chart is all routine or if there's something exceptional going on in that last data, we then complete the X-chart by calculating and drawing the average, an Upper Control Limit (UCL) and a Lower Control Limit(LCL).  These are calculated as follows:
          Avgx= Totalx/#x
          UCL= Avgx+(2.66×AvgmR)  = 16.5+(2.66×2.53) = 23.54
        LCL= Avgx-(2.66×AvgmR)  = 16.5-(2.66×2.53) = 9.46

Note: The 2.66 is a conversion factor that approximates three standard deviations (but we don't calculate a standard deviation in this methodology).


Updating the X-chart:



To complete the mR chart we need to calculate the Upper Range Limit, as follows:


         Upper Range Limit = AvgmR×3.27  = 2.53×3.27 = 8.66
  
Note: The Lower Range Limit is always zero, since the variances can never be a negative number.


Updating the mR chart:



Together, these two graphs make up an XmR chart or Process Behavior Chart.


Looking at the XmR charts, we can see that the last data point is still within our calculated limits. This indicates that the data is just “noise.” It is just part of the normal variation for this system or process, as it is currently designed.

That said, if we're uphappy with the average level of performance, we could try to improve the system in a systematic way. There's nothing worth investigating in terms of a reactive question like "what went wrong that month?"

The first hint of a "signal" would be any single data point above the upper limit or below the lower limit.


Wheeler’s book gives much more information about the meaning of the charts and some other types of “signals” to be aware of such as: 3 out of 3 or 3 out of 4 data points being closer to one of the limits,

or




a run of eight or more consecutive data points being on one side or the other of the central line are interpreted as being a “signal.”



Mark Graban is currently writing a book on this material. It should be completed by June, but you can buy the first three chapters now through his use of the "Lean Publishing" approach. All of Mark’s books are “Top Class.”


Heads up! I will be the guest on a webinar hosted by Mark Graban and KaiNexus on May 7th at 12:00 noon Central time. We will be discussing the new emergence of Lean management in veterinary medicine.  Use this link. Hope you will join us!

Update 4/4/18: Watch Mark Graban talk about this material here.

Thanks for reading. Tell your friends and colleagues and, as always, comments welcomed.

Thursday, February 1, 2018

Today's Lean Term: Kanban Post

As explained in a previous blog, in the Lean methodology, a "kanban" is a signal that something needs to be done. This is a Japanese word that gets translated to mean "signal" or "signpost" or the like.

For example, a patient file in a file holder on an exam room door is a kanban signal that a patient is ready to be seen in that room. Ideally, this "pulls" the doctor or appropriate staff member to the patient. A kanban might also be an empty, small plastic basket labeled “3cc Syringes-Exam 2” that's placed at a specified, marked location in the pharmacy that signals exam room 2 is running low on 3cc syringes and needs a refill.

A "kanban post" is the specific location that the kanban is placed so it can be seen (as an example of visual management) and acted upon. In the above examples, the file holder on the exam room door and the specific, marked location in pharmacy are the kanban posts for those objects.

My employer has developed a kanban and a kanban post for medical records he has made follow-up calls on. The signal is the medical file  tossed on the floor in the middle of his office.  This indicates to staff that the file is ready to be refilled in the filing cabinet (No, we have not gone paperless. What computers we do have are forever under my employer’s threat of him personally heaving said computers into the dumpster out back. But, I digress!). The post, therefore, is the floor in the middle of his office






However, the floor in the middle of his office is not specific, nor is it marked!  So, as a lean advocate (and/or just being a bit obsessive/compulsive), I decided to correct the situation...




Marked and specific



Much better!

That's one of the things I like about Lean. It is adaptable; not much is written in stone. The spirit of the methodology is the important part.
.

This kanban post will probably need to undergo some continued improvement. ;>)  Have a little fun today!

Thanks for stopping by. Tell your friends about the blog and, as always, questions and comments are welcome.

Wednesday, December 20, 2017

A Response To a Comment About My Post "Lean Self"

Last month, shortly after my blog on the “Lean Self”, my friend and mentor Mark Graban posted a comment to that blog. This was unusual.  Usually, Mark emails his questions and points of concern to me after receiving my final draft of the blog post, but before I publish the final, final draft. His questions sometimes come from sheer confusion about what it is ‘that I am really trying to say’, but many times it is his way of teaching in the Socratic (and Toyota) method. That is, rather than lecturing, asking the student a series of questions that lead the student to discovering the answer or reflecting deeper on the subject. Occasionally, I am not sure which it is.

I have decided to answer in another blog post, rather than a reply to the comment that may go unnoticed.

Mark comments:

Thanks for sharing this, Chip.

I agree that having a personal “true north” and understanding your own “current state” can be beneficial.  I don't quite see how to apply the idea of a “value stream” though. What is “value?” How does it flow? How do you see that connection in one’s personal life?

Mark

Here is my response.

Mark, thank you for your comments. Please forgive my tardiness in replying. I have been recovering from a little bit of surgery.

Your questions have caused me to re-evaluate my premise as regards extrapolating the Lean mindset to the “self.” As they should.

What is ‘value’ in this context?
Another way to arrive at an answer to this question is to ask, “What is really important to you in healthcare?” Or, “What is really important to you in a car?” For the “self” it would be, “What is really important to you in your life?” I think (hope!?) for most people it would be “contentment.” To be contented financially. To be content at work. To be content in our relationships.  To be content with ourselves. The Hebrew word “shalom” is generally translated as meaning “peace.” And it does, but it is the peace that comes from being “whole” (content spiritually, physically, emotionally, psychologically); not having excess or being destitute, but from having enough or being grateful with what you do have.

Part of the Lean definition of “value” is that the customer be willing to pay for it. If you are not willing to put a price on what you want, it doesn’t really hold any value. This holds true for the “self”, also. But, it doesn’t necessarily mean money. It means doing the hard work of honest self reflection, letting go of false assumptions, admitting mistakes, mending relationships, simplifying, budgeting, pushing back the ego, stepping out of the forest and,then, prioritizing and starting, somewhere, on a lifelong journey of improvement.

What is the “value stream’?
The Lean concept of the “value stream” requires, amongst other things, a provider, a customer and a “gemba” (the place where the work actually occurs). Unlike other applications of Lean where the provider and customer are separate entities, for the “self” they are the same, us. And the “gemba” is our hearts and minds.

The steps we go through in our hearts, minds and lives to get whatever value we get is the “value stream”. Whether that process results in contentment or “dis-ease” in a particular area of our life depends on how much muda (waste, i.e. faulty thinking, biases, rewritten history, skewed priorities, energy vampires, B**l S**t, etc.) is embedded. Graphically representing this thought process produces a “value stream map”

For example: I must be perfect →  I burned the turkey → I’m a bad cook → I’m a lousy wife → I’m a bad person.  Not good “flow.” Lots of bad processes and “trash.” What’s the value here?

Note that using 5 Why might take you back through this process. For example:
     Why are you a bad person?  Because, I am a lousy wife.
     Why are you a lousy wife? Because, I am a bad cook.
     Why are you a bad cook? Because, I burned the turkey AND I must be perfect!
BINGO!! A possible root cause. The false belief that “I must be perfect!”!

Now, to be able to map this current state value stream may not be easy and it may require the help of “stakeholders” (others who have our best interest at heart). And, just as in any other Lean application, finding the “waste” in order to produce a better future value stream will work best if our “stakeholders” are given access to our gemba and are present; if we are open, honest and communicative about what is going on inside of us and in our lives.

Thus, I think the Lean concepts of value, true North, gemba, current value stream, future value stream, A3 thinking, 5S, 5 Why and kaizen are just as valid working on improving ourselves as it is in improving manufacturing, service industries, healthcare, etc. for the customer- us!

Monday, November 20, 2017

Lean Self

One of the aspects of the Lean methodology that I appreciate most of all is the breadth of its  application. Lean is applicable to manufacturing, retail, service businesses, professional associations (Nudge, nudge AVMA!), human healthcare, dental practice and veterinary practice. It can even be extrapolated to one’s own life.

One of my extended family members is going through a rough time, as we all do on occasion. She came to us for some help. Since I naturally think and problem solve with a Lean mindset, I took this approach. Via guided questioning, we went through considering her problems, as I would with a practice problem.

As with any Lean application, the first step is to define the ideal state: our ‘True North. If you were perfect, what would that look like? What areas of your life would you choose to define that perfection? What would be the focus areas? These might include such areas as spiritual ideals, physical ideals, financial ideals, relationship ideals, career ideals, etc. Pick four to six to work on at this time (or even just one!); choosing too many will be overwhelming and spread your work too thin. Create a True North statement in writing. Refer to this document often.

Now that you have some conception of where you want to go, you need to honestly define your current state. Where are you right now in each of your focus areas? In an organization, this would be facilitated by going to the gemba with all of the stakeholders (line workers, supervisors, managers, etc) present, in order to observe what is really occurring in the Value Stream and, perhaps, drawing a Value Stream Map. Your gemba is deep inside you. It is your true self, warts and all. No preconceived ideas, no masks, no ego. What is the reality on your “shop floor?” Who are your stakeholders? Consider spouses, good friends, clergy, close colleagues, doctors, advisors. Write down your current situations.

Identify the Gaps.
At this point, you know where you want to be, and where you are in your focus areas. What are the differences or gaps? For example, you know you would like to be at some ideal state financially, and you know where you’re at currently. What is the difference between these two states? These are the problems you need to solve now. Write these down for each of the focus areas.

Root Cause Analysis (5 Whys)
Take some time to think about this step. Why are these gaps present? How did they come about? Why did this reason occur, and why did it happen? How did it happen? Ask enough times that you feel you have identified a root cause. This is important because, until the root cause is found and dealt with successfully, it will continue to be a problem. Notice I didn’t ask who was to blame. Try to concentrate on the systems, biases, prejudices, emotional needs, habits and the like. The idea is to deeply understand how this issue came about. It’s not because you are a bad person. We all are damaged in some way and have shortcomings,but how did these root causes contribute to your current state? Talking with your stakeholders may help.

Design Countermeasures
Now it is time to actively try to remedy the gaps: the problems. In each of your focus areas, what can you do to get even a little bit closer to your ideal state? Remember, though, your ideal state is perfection, and that is not realistic. There are always going to be gaps (problems), but with patience and persistence, you can get very close, greatly reduce your stress and frustration, and greatly increase your happiness, confidence and self-actualization.

Pick the low hanging fruit. Start with the easy stuff. Rack up some small successes that will then lead to greater momentum to tackle the bigger stuff. Focus on baby steps.

These countermeasures are experiments. After the trial period, evaluate the results. If they didn’t work out as planned, reflect on why and how, then tweak the experiment and try again. Try not to get disheartened. Lean is a journey. There will always be experiments to try.

If they do produce gains, then reflect on this, also. Why did this experiment work? What did you learn about the situation, about yourself. Can this same idea or principle be utilized in another aspect of yourself? Sustain this new you and rewrite your new current state. Congratulations!

5S is one of the “tools” in the Lean system. It stands for Sort, Straighten, Shine, Systematize, and Sustain. It typically is used to reorganize a physical space, such as a surgery room, exam room drawer, office. It is used to decrease confusion, wasted time hunting down instruments or tools, and increase visual management.

Are there aspects of your life that could benefit from eliminating “garbage,” reorganizing, and/or prioritizing? What about faulty thought processes, biases, relationships, habits, wasted resources, beliefs?

Kaizen means continuous improvement. There is no set amount that is required, only that we try to be better tomorrow than we were today. There is no punishment if we are not successful on every attempt. We just try again. Again, baby steps. As stated above, Lean is a journey, it is a philosophy, it is a mindset. It is lifelong. The process of defining our current state, identifying gaps and experimenting will never end. But, success will come, if only one millimeter at a time.  “Patience, Grasshopper”!

Final Note
I am not speaking from any ivory tower. I struggle with all of this from time to time and have for most of my life. I, too, am on a journey; a work in progress. Veterinary medicine is not easy.  Veterinary practice management is even harder. I have started a practice and been a solo practitioner for over 30 years (for two of those years I owned and operated two practices), merged practices, worked for a corporation and three other employers. I have stayed awake many a night worrying about my business, my family, my health and my faith. I have experienced complete ‘burn out’ and come out the other end. My goal is to attempt to be better tomorrow than today. None of us are responsible for saving the world, but we are required to participate. Success, in my humble opinion, is to leave this world a little better for having lived here. A Lean mindset supports this effort.

Thanks for stopping by. Comments always welcome.

Thursday, September 21, 2017

A Lean Staff Meeting Micro-experiment

The Lean philosophy is built largely around the concept of problem solving and continuous improvement (kaizen) by involving the workers who do the work on the floor (gemba) day in and day out. The idea is to foster and coach (working together) problem solving with them (bottom up), rather than telling them what to do and how (top down). Kaizen is the essence of what we strive for when we build teams or imagine when we use the term “teamwork”. 

The results of all of this are:

  1. Many vs. a few minds working to solve the problem.
  2. Identifying more problems.
  3. Better determination of the root cause(s) of the problem(s).
  4. Fosters the Lean concept of a leader/manager being a teacher as well as a supervisor in problem solving.
  5. Shifts some of the frustration of management off our "plate" (without losing responsibility).
  6. By involving staff in this process, it shows that we value and respect their input.
  7. Engages staff in the practice.
  8. Increases their value to the practice. Their value appreciates over time.

So, with all of this in mind, try this micro-experiment with your employees (team) at your next staff meeting by taking a more Socratic approach to problem solving (teaching through questioning rather than lecturing).

The Micro-Experiment

  • Chose or a elicit a small, non-crisis problem to work on.
  • Communicate that this is a safe environment and a "Judgement free zone.” Everyone is intelligent and has ideas to contribute.
  • Place three coins in front of you. You are allowed three declarative statements during the staff meeting. If you make such a statement, then remove a coin. All other statements need to be in the form of open-ended questions.
  • Think in terms of system failures, not people failures.
  • Ask lots of “Why?”s, “How?”s and “What makes you say/think that?”s, not “Who (is to blame)?”s
  • No leading questions like “Don't you think it would be better to do _______?” You are not trying to 'manipulate' them into arriving at a solution you've already decided on or simply making it seem like they are participating. This is truly listening to their ideas and honestly involving them in finding possible solutions through concensus (nemawashi).
  • Praise participation.

Remember back to when you were learning how to diagnose and what questions to ask and how? Formulating a list of deferential diagnoses and, then, trying to arrive at a definitive diagnosis. It is basically the same process that you are trying to teach your staff about, except instead of a pet with a problem, we are dealing with a practice system, process, flow, and/or communication problem.

It won't work perfectly the first time. This is completely different than how most staff meetings are conducted. Look for small successes and then build upon them. With enough coaching and practicing, one day your staff may identify a problem, find its root cause and decide, together, on a viable solution to try, collect the results and plan the next step with little more than oversight involvement from you. Can I get a “Hallelujah!”?

Let me know how it went. Did your staff surprise you with their deep understanding of the issues? Were they more creative than you expected? Did they have a more realistic perception of the actual problem and root causes than you? How difficult was it for you to teach by asking questions? What did you learn? What would you change the next time? Could you cut back to two coins? One?

Thanks for stopping by. Please tell your friends, staff and colleagues about the blog. Comments and questions always appreciated.

Tuesday, September 5, 2017

What! No Research and Development Department!?!

Many of the major corporations in the world have a department they call "Research and Development" (R&D). These are the people responsible for innovating new products, improving previous products, fixing design defects, and adapting to new environments, including technological and economic; keeping the organization on the “cutting edge.”

Veterinary practices have an R&D group, also. We just don't recognize them as such.

I'm talking about our staff.  Our staff members know better than anyone what the problems are, where there is opportunity for new services or products, unmet client needs, wastes in our systems, etc.

They hear the comments made by clients that we are never aware of. They understand and recognize the gaps between our current state and our ideal state (True North) or the “cutting edge” of what's possible. And, they are willing and capable of partnering with us to correct those gaps, if we allow and empower them to do so.

When I first graduated from vet school and opened my practice, the business side of practice was coming into its own. One of the major subjects of management seminars at that time was to better delegate and leverage our staff members in our practices. It was like pulling teeth to get veterinarians to stop thinking they were the only ones that could pull blood samples, read a fecal exam or bandage a paw. The role of staff was to greet clients, restrain pets, clean cages and collect money.

These days, thankfully, we have evolved to delegating to staff almost everything in a veterinary practice except diagnosis, prescribing, surgery and... participating in identifying waste, innovating new products and service, meeting unmet client needs; to continuously improve, to become and stay ‘cutting edge.’

The concept of "kaizen" means partnering with staff (leveraging them) to continually improve value for the client, with value being defined from the client's point of view. It is part of the “bottom up” management philosophy of Lean (as opposed to the “top down” or “command and control” philosophy of contemporary Western management).

Vets and the "gurus" think they understand the terms 'teams', 'teamwork' and 'team building', but kaizen takes it to a whole new level. In kaizen, team means TEAM.

Isn't it time to take staff leveraging and delegation to the next level? Isn't it time to recognize and developed our potential "R&D" departments? Isn't it time to start developing a kaizen mindset and culture within our practices?  A culture that respects and recognizes the asset that our staff membrers represent, and, thereby engages them?

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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.