Monday, December 28, 2015


In Japanese, gemba means “the real place.” This is the place where work happens; where the facts can be found. In veterinary medicine, it would be the reception area, the exam room, the surgery room, etc. It is the place to go see where a problem exists, as it exists, when it exists. Contrary to Western management, Toyota understands that if a problem is to be fully understood, then all stakeholders, such as executives, supervisors, managers and workers, must be present at the problem site in order to consider all points of view and ideas, and build a consensus on how to fix it permanently. Lean leaders will “go to the gemba” when there is a problem to investigate and solve. It’s also a common practice to do planned “gemba walks” to get out of the office, to engage with staff, and to see problems and opportunities for improvement first hand.

Monday, December 21, 2015

Value Stream

 The value stream is the overall high-level sequence of steps necessary to take a product or service from start to finish (and the delays that occur between steps). A value stream is the “end to end” process, as opposed to just looking at one department or one function.  For example, it might be all the steps necessary to take an animal presented with an illness to a condition where it is healthy enough to go home. Ideally, each step should move the product along towards that which the customer values, and be devoid of any waste. Value stream thinking helps us break down silos that interfere with delivering value to the customer.
The current state map is created by going to gemba with all stakeholders present in order see and record all the steps (and delays). Then, all unnecessary waste is identified and removed. Finally, any steps that can be performed concurrently, combined or need to be rearranged are changed in order to  create the future state map.

Organizations create value stream maps to help people understand the big picture and how to improve things systemically. 
A current state map documents how things are today, while a future state map is used to create a vision and a plan for an improved system.

Monday, December 7, 2015


According to Lean, value is defined by three concepts. First, it is something that the client wants or needs and is willing to pay for. If the client brings in a pet, but is not willing to pay for vaccinations, they are obviously not valuable to the client, at least at this time, and we certainly would not perform that service. Secondly, it must move the care process forward in some, in terms of comfort, diagnosis, treatment, or education -- working toward restoring or maintaining health and wellness. The pet presented for vaccinations must be moved towards a more healthy condition by actually vaccinating the animal. And, thirdly, it must be performed correctly the first time (quality). Giving the wrong vaccines or inappropriate vaccines is of no value. Especially, if we have to go back a second time and vaccinate with the appropriate vaccines.

If a step is not value, it is waste. Lean organizations are focused, ultimately, on adding value from the client's point of view.  Improved efficiency, improved safety, reduced costs, better resource utilization, increased staff engagement, a culture of continuous improvement, and quality are all important aspects of Lean, but they are by-products of the methodologies Lean uses in order to provide value to the customer from the customer's point of view.

It’s important to note that adding value and being busy are not the same thing. Just because you are running around doing something, does not mean you are adding value. There is a lot of motion and activity involved in chaos, but the vast majority of it is not adding value to the patient or client.

Monday, November 16, 2015

Some Basic Concepts

As consumers, we all have had those epic experiences with call centers, auto repair shops, plumbers, etc. Why can they not see the consumer’s point of view? Yet, back in our practices, our “provider hats” go on, and we, too, fail to consider what our clients have to deal with. In Lean, the perspective of the consumer is the priority.

One of the goals of Lean is perfection. The book Lean Thinking talks about the “continuous pursuit of perfection” (and that also might remind you of a Lexus ad slogan). We know we will most likely never get to that point of absolute perfection, but we continually try, working toward an ideal state of safety, quality, waiting times, customer satisfaction, and other meaningful measures. Just as repeatedly dividing one in half will never get us to zero, it does get us darn close. If we can eliminate 50% of waste with each attempt, then after only 5 iterations, we have removed 96.875%. That’s not perfect, but really, really close (and more importantly, far better than our starting point). With just two more iterations, we get to 99.21875%. That's really, really, really close! The Lean mindset of continuous improvement drives us to solve problems that matter and to keep working at it. Think of how to do it, not why it cannot be done.

Try to keep an open mind. Lean is not particularly difficult to understand in concept, but it is different… and it can be difficult to change an organization of any size. Discard conventional thinking. It has proven itself over and over in every company and industry that has embraced it as a complete package and given it an honest trial, practicing Lean over time. We believe the same will occur in the veterinary medicine setting.

Nothing is written in stone. Lean is about experimenting in order to deeply understand and improve. But, if that doesn't happen, we can learn from it, adjust and try again. "Best medicine does not equal absolutely correct. In school, they told us that 80% of what we were learning would be proven wrong. We just didn't know which 80%. It's the same way with best management practices. Keep iterating.

Lean takes a systems approach to management. It tends to blame faulty systems rather than people. Systems are the responsibility of management, not the workers. Workers are at the mercy of systems, and systems can be very complicated with strange ramifications.

Lean is, foremost, concerned about quality. Toyota has been able to turn operational excellence into a successful business strategy. Facebook, Twitter and practice web sites have accelerated and amplified the effects of “word of mouth” advertising.  Before you promote, you better have “all of your ducks in a row” or all of your time and money may actually be counter-productive. Remember, prepare to promote and then promote!

Lean originated out of manufacturing; automobile manufacturing more specifically. And, although it has been successfully implemented in almost every industry, including human health care, it will require some adapting for use in veterinary medicine. This technology has only been experimented with very recently and only on a very small scale in veterinary medicine. This will be a new paradigm for us. We are the ones who will define Lean in our industry.

Monday, November 9, 2015

A New Paradigm For Veterinary Practice Management

There is a new paradigm, a new methodology, with proven results over many different industries including human health care. The new model is the Toyota Production System (TPS), better known in the West as Lean, for its consistent ability to deliver both quality and value without the waste and frustration that we see in so many organizations.

Over the course of 70 years, Toyota has grown from being a small, domestic, truck manufacturer in a devastated post-war Japan to being the largest auto maker in the world, for a time in 2012, even surpassing America’s industrial revolution icon, Ford Motor Company. Additionally, they have been profitable in every one of those years except three. How has Toyota been able to accomplish such milestones? By relentlessly pursuing a strategy of operational excellence, which includes a leadership style and organizational culture that is very different than most companies.

Lean is not just a set of tools. Toyota’s own website describes their production system as being a combination of:

  1. Technical tools and methods
  2.  Management methods
  3. Philosophy and mindsets 

Practiced together, this results in an organizational culture that develops people in the organization and sets up the organization for long-term success. Toyota also emphasizes that the main goals are improving flow (in the case of healthcare, providing the right care at the right place at the right time) and ensuring quality at the source. There is a foundation of safety being a top priority (for patients and employees) instead of being a separate program or initiative. 

            Toyota also described their “Toyota Way” management system as having two key pillars:

Being respectful in the workplace is not just a matter of being nice. It means challenging people in a constructive way so they can grow and perform to the best of their ability. “Respect for people” is a phrase that is also sometimes expressed as “respect for humanity.” This means not just showing respect for all stakeholders (such as customers, employees, suppliers and the partners, the community), but also respecting our human nature. For example, Lean leaders understand that we have human limitations, such as making more errors when we get distracted or are physically or mentally exhausted. This drives us to error proof systems to help prevent common human errors, rather than just asking people to be careful.

In the Lean framework, operational excellence is based concepts, such as the following:

  1. Value ( is defined from the customer’s point of view.
  2. Work relentlessly to reduce or eliminate waste (
  3. Build a culture of continuous improvement.
  4. Standardize work to improve flow.
  5. Make problems visible and react quickly.
  6. Understand problems and solve them at their root cause(s).
  7. Demonstrate deep respect for workers and all stakeholders. 

Successful practices realize that long-term success comes from satisfied clients. Clients should truly feel we have their best interests at heart. Hopefully, they would choose our practice not necessarily because we are less expensive than another practice, but that they received value for the hard-earned money they spend with us. We are responsive to their desires, and we value their time as much as we value ours. Satisfied clients help resurrect the idea of positive, direct ”word of mouth" advertising.

Saturday, March 21, 2015

W. Edwards Deming's Red Bead Experiment

In Lean, we talk a lot about systems; that Lean is a systems approach to management.  The axiom is that there are no evil workers, only evil systems.  One of the tools of Lean to discover the root cause of problems is 5 Whys. Notice, it is not called 5 Whos. As veterinarians and scientists, we understand systems, but, I think, we have a difficult time extrapolating this understanding to areas of practice other than medicine. We want to blame problems on other people; our employees. The truth of the matter is that rarely is it a people problem, it is a system problem.  

I was once taught that there are only four reasons a job is not being performed adequately:

  1. The person does know that the job is his/her responsibility
  2. He/she has not been thoroughly trained on how to perform the job
  3. He/she does not have access to the tools required to perform the job correctly
  4. 4) He/she is not receiving correct input or adequate, timely communications (garbage in, garbage out). 
Therefore, if these four thing are not the problem, then it must be because the employee does not not want to do the job correctly and should find employment elsewhere.  

But in Lean thinking, we would look at the system. We would assume that employees are generally well intentioned, conscientious, hard working, and truly wish to do a good job. In Lean, the system is the problem, until proven otherwise (and maybe the system failure is the hiring system). The system, then, is scrutinized to identify problems at their root cause, changes made to the system and put it place.  The new system is  re-evaluated later to determine if the results were positive or negative, and then adjusted, or adopted as new standard policy.

Consider mitral valve insufficiency (MVI) leading to congestive heart failure (CHF). The patient has fluid in the lungs, the heart is beating more rapidly, there is weight loss, etc.  If you look at this system of failure from a "who" perspective, then maybe it is the kidney's fault. If the kidneys would just work harder, excess fluid would be eliminated and that would solve the problem. Or maybe it is the vascular system that is the culprit.  If it would just do its job, then the arteries would not respond detrimentally.  No, it is the lung's fault. We need newer lungs. Or maybe it's the endocrine system. We'll offer it a bonus for improved function. Or the A-V node. Maybe it needs more CE training. And, in fact, we treat the illness with symptomatic therapy designed to  "improve" (micro manage) the different organs.  The patient improves, but is still in congestive heart failure, because it is none of these individual organs that are at fault. The system is broken and the system is not going to be fixed until the mitral valve is replaced. Only then do we eliminate CHF. This is obviously a somewhat contrived analogy, but hopefully, makes the point.

As I stated above, we understand systems, but I think we have not been educated to see veterinary practice as a system, also.  Below is a link to a series of YouTube videos demonstrating Dr. W. Edwards Deming's famous Red Bead Experiment. It demonstrates, among other things, how management typically deals with employees when key performance indicators are not meeting goals.  Workers have no control over the system they work in. Systems are designed and dictated by management.  It is management's responsibility to fix systems.

The video link below is actually a series of short videos. The Red Bead Experiment is in 6 parts via the playlist, below.  

Please participate in this blog by leaving a comment. This blog is for all of us to learn, discuss, experiment and improve together.

Sunday, March 15, 2015


Welcome to LeanVets.  The purpose of this site is to promote Toyota Production System, or Lean, methodologies in veterinary medicine and veterinary practice management, and to provide a place for all us to learn, explore and discuss this intriguing topic.  This is a new concept in veterinary medicine, though it has been used very successfully in human health care (and one known case of dentistry) for several years. 

This is the first time I have ever set up a blog and forum, so please be gentle. As is the case with Lean, it will be an object of the PDCA cycle and kaizen (continuous improvement).  It will never be perfect, but through creativity, experimentation and a intense desire to provide value to you, it will be the best I can make it!

So, if you want to learn more about what Lean can do for veterinary practice, please participate. If you are in the process of implimenting a Lean initiative in your practice, please participate. If you have knowledge or expertise in Lean, especially Lean Veterinary Healthcare, please participate.  Let's get Lean, together!