Wednesday, December 7, 2016

True North

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

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

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

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

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

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

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

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

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

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

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

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

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

For example, suppose senior management decided that for the next year, what we implement for “Employee Development” will be cross-training the staff so that they are capable of covering other positions in times of need or to cover multiple positions within a value stream in order to improve flow. Staff takes it from here. They know best what that should look like at the gemba and they can best work out the schedule. They can decide on the metrics best suited to monitor this process and create the visual management charts so everyone can tell where in the journey the effort is in real time.

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


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

Wednesday, November 23, 2016

"Pushy" Veterinary Processes

This is a continuation of the previous blog “‘Pushy’ Rescue Groups.” We are revisiting the difference between “pull” and “push” systems.

Veterinary practice is, in general, a “pull” system. Our services are initiated (“pulled”) by the client. We don’t go out and fix random pets and, then, hope one of them belongs to one of our clients! However, we have been talking about “external” customers (clients). Within the value stream, there are “internal” customers as well (the person who does work after you in a process or value stream). It is here that we can suffer from “push” systems.

The Lean concept of “pulling” value within the value stream means that each step in the sequence of treating the patient “flows like a river”, as often gets said in the Lean literature. There should be a person (an “internal customer”) ready to perform Step 2 as soon as Step 1 is finished; Step 3 as soon as Step 2 is finished, etc. through the rest of the value stream. Step X pulls from Step X-1 which pulls from Step X-2 which pulls from Step X-3, and so on back “up” the the value stream. Thus, it is said that ”value is pulled ‘up’ the value stream. If Step 3 is not ready and Step 2 sends the patient on, Step 2 is “pushing” the patient “down” the value stream. Since Step 3 is not ready, the flow of the patient stalls until Step 3 is ready. The patient is essentially “warehoused” and has to wait, which is one the types of muda (waste) that Lean organizations are trying to remove from the value stream in order to improve value to the customer (flow).

On a related issue, Dr. Eliyahu Goldratt put forth the “Theory of Constraints” which, in part, says that if you want to find the “bottlenecks” within a production sequence, look for piles of work in process (WIP) inventory. You should find a “bottleneck” at the next step. Waiting patients and clients are signs of “bottlenecks” in our sequence of production.

Check for yourself. Do a gemba walk; i.e. go to where the work is done and observe the value stream. If you see patients and/or clients waiting, check the status of the next step in the sequence. Chances are something is delaying the progress of that patient/client at that point. Utilizing 5 Why and problem solving methodologies are indicated to fix the issue.

Thanks for stopping by.  If there is a topic you would like discussed, please let us know.

Monday, October 31, 2016

"Pushy" Rescue Groups

I thought I would look, again, at “push” vs. “pull” systems. Though I have written on this topic before, it can be a little difficult to comprehend. What we are really looking at is when the customer enters the value stream.

If the customer comes onto the scene at the end of the value stream, then we are probably looking at a “push” type system. The product is manufactured and sent to market where, hopefully, there is a customer (or millions!) eagerly waiting for the store doors to open in order that they can purchase said product. We don’t identify a particular customer until the end of the process cycle.This system is typically chock full of wasted inventories along with the warehousing costs to store all of it, not to mention the capital tied up until the first sale is made.

On the other hand, if the customer enters the value stream at the beginning, then we are most likely observing a “pull” system. It is a particular customer order that triggers (begins) the manufacturing of that product, at that time, for that customer. This means relatively little inventory, with little to no warehousing and associated costs.

Let’s take, for example, your basic, “walkin’ down the street” rescue group. They go to the local animal control facility where they pick those animals they think (or hope) can be adopted out later. At some point in the future, they take the animal to a veterinarian to be examined, vaccinated, checked for intestinal parasites, tested for heartworms or FeLV/FIV. If the animal is ill or needs other medical attention, then additional visits may be required. At a later time, the intact animals are returned to the vet for spaying or neutering. The veterinarian is, of course, paid for his/her time, drugs, supplies and knowledge; all of this is an investment on the part of the rescue group. In between all of these steps and at the end, the rescue has to “warehouse” all of these pets in foster homes until a suitable adoptive family can be located, if at all, and recoup their costs by charging an adoption fee. This is a “push”system. The customer (adopting family) only becomes known at the end of this value stream.

If the rescue group utilized a “pull” system, the value stream would begin with the adopting family requesting a certain pet; i.e. a certain species, breed, gender, color, age, etc. and then, only then, the rescue group would scour the local “pounds” until a match was found. The pet would go to the vet for any routine procedures or medical care. It would then be given to its new family for an appropriate adoption fee. No warehousing. Any money spent is basically paid for by the adopting family immediately or, at least, much quicker than in the “push” scenario.

In general veterinary practice is a “pull” system, but there are places where we “push”, also. In my next blog, we will revisit the concept of “internal customers” and “pushy” veterinary processes.

Thanks for stopping by. As always, your comments and questions are welcomed.



Tuesday, September 6, 2016

Einstein's Equation of Lean Relativity



No, not Albert Einstein! Moraito “Morey” Einstein, Albert’s third cousin, twice removed on his mother’s side.

Just kidding! However, this, in a simple equation, explains Lean.

“F” stands for Flow and “V” stands for Value from the client’s point of view.

Taiichi Ohno’s equation states:

                                      Capacity = Work + Waste

What this equation states is that there is always waste in our current state. When we remove some waste, we create a new current state, but there is still waste. We pursue perfection, but never achieve perfection.

If we substitute our total “Value Streams” for “Present Capacity” and “Flow” for “Work”, we get:

                                     Value Streams = Flow + Waste

Rewriting the equation gives us:

                                     Flow = Value Streams - Waste



This, then, is essentially what flow means. Flow is all the different processes (value streams) that occur in the management of a veterinary practice with as much waste removed as possible (and then continually improved).

Also, remember that Value is defined as that which a client desires (Dc) and is willing to pay for, that moves (Mp) the patient's condition toward the desired outcome and is performed correctly (without waste; W) the first time.

                                           V = Dc + Mp - W


Everything about Lean is about improving flow, because flow ultimately results in greater value. A3 problem solving, 5S projects, kanban, Just-In-Time (JIT) concepts, error proofing (jidoka), visual management, continuous improvement (kaizen), everything is aimed at pursuing the perfection of flow. We continually improve systems and processes in order to improve flow, and therefore, value. 5S organizes the hospital by removing clutter from work areas, organizing the areas so that they have only the needed equipment close to hand with a consistent place for everything and everything in its place. 5S also makes problems visible, and solving those problems allows us to improve flow.

For example, at our hospital we were constantly having to leave the exams rooms to find this or that item. Not good for flow! So, we went to each of the exam rooms and got rid of duplicate suture scissors, hemostats, tourniquets, etc. Then, the staff and I created a list of the supplies and instruments that we routinely use within the rooms. We chose a roll of tape, Vetrap, cotton swabs, gauze squares, clippers, a small supply of various syringes, a digital thermometer, a Nye tourniquet, a stethoscope, fecal loops, etc. We even put some blood tubes, Idexx spinners, and a bottle of heparin in each room to facilitate quick blood draws for lab tests. Finally, we organized the drawers so that they were the same in each exam room. Now, each room is the same, with the most used resources close at hand. In addition, we all now know, regardless of which room we’re in, that tape is in the right hand drawer and the tourniquet is in the left. There is less confusion. We don't have to think, “This is exam room 1, so the suture scissors are here...no, there...no, in that drawer.” There’s no more time spent searching for items. Also, doctors and/or staff can now quickly (visually) tell if the drawers are complete (standardized). If not, the problem is fixed right then so it doesn't continue to be a disruption. This improves flow, thus value.

Kanban and JIT improve resource utilization by creating a system that provides drugs, supplies, staff schedules and doctor’s time, to name a few, only when needed, where needed and in the amount needed. This frees up cash, space, staff and doctors to do more patient care which improves flow which equates with higher value. Visual management techniques, A3 (PDSA) thinking, and “5 Whys” root cause analysis allow problems to be easily seen and fixed at the root cause(s), again, in order to improve flow and value. Even kaizen, the concept of utilizing our ultimate resource, our staff, to identify and fix problems and remove waste (muda) from our value streams is for the purpose of perfecting flow.

Time is money. And, time spent on wasteful activities and processes is money lost. Everything in our hospital, even wasted items, has to be paid for through income from clients. Otherwise, it comes out of our pockets, our bottom line. Value from the client's perspective means not being charged higher fees in order to cover waste.


All of this, then, is contained in the equation F=V. Simple, right?

The different individual concepts and “tools” of Lean are relatively simple. The difficulty is conceptualizing how the different elements interrelate to create Lean, putting it into operation within your practice and, then sustaining it long enough to get positive results and change the organizational mindset to automatically think Lean. But, that is a different equation and a different blog!

For now, just remember, “it's all about da flow, ‘bout da flow, ‘bout da flow…!“

What are your thoughts? Let us know.

Tuesday, July 5, 2016

Have You Checked Your SMED, Lately!

SMED stands for Single Minute Exchange of Dies. One of Shigeo Shingo’s and Toyota’s greatest gains in increasing flow was figuring out how to change the extremely large, heavy dies used to produce (stamp) the large body parts of different car models quickly. Toyota was able to improve this changeover time for one part to another from an industry standard of many hours (often eight or more) to less than five minutes!

So, what did this allow Toyota to do? It allowed them the ability to make smaller, more efficient, lots of the different models of cars. When you lose a whole day of production to change the dies, you can’t afford to do it very often. Which means, for economy's sake, you need to make large batches (there’s that “b-word”) at one time, which, also, means large inventories of parts, which then need to be paid for and stored at high costs. All very “un-Lean.” Toyota was a small company back then. They couldn’t afford any of that and stay competitive. Plus they had a small market in Japan and had to challenge themselves to produce a high mix of different products.

What did Toyota do? They had a need, a problem, that required a solution. Shingo and the workers got to work using what we’d recognize today as A3 Thinking. They went to the gemba, observed every aspect of the change over, “brainstormed”  possible countermeasures (together), and experimented until they reached their goal, or very close to it, being much better than before.

The equivalent of SMED in veterinary medicine is the time it takes to get an exam room ready for the next patient, or the surgery room ready for the next procedure, after you’re done with the previous. How fast can you go from spay to neuter to dental to cat abscess?

In essence, what we are are doing is looking at the flow between “flows”; identifying the time (delays and activity) between value added operations. A competitive swimmer must perfect his/her strokes and pace, but races can be lost by sloppy "flips" between the laps. So, swimmers must perfect this process, also. How fast can you “reload, aim and get ready to fire, again?” Consider ways to eliminate waste, 5S projects in the exam room or surgery room to facilitate quick change over, standardizes work to get everyone on the same page, and improved resource (doctors, staff, supplies, inventory, etc.) utilization through kanbans (signals).

What does this mean for a vet clinic? For example, could the previous surgery be recovered someplace other than the surgery table? Could a staff member clean and repack instruments while the doctor is busy performing the next procedure so they are ready to be autoclaved later? Could a trained, licensed tech induce anesthesia, intubate and prep the next patient while the doctor is placing skin sutures in the current patient? If so, what safety procedures and standardized work would need to be put in place? In the past, I have allowed trained staff to draw up injectable anesthesia, inject it, intubate the patient and start prepping. BUT, a second trained tech had to verify the proper type and amount of injectable anesthesia, and had to double-check the correct endotracheal tube placement. Any uncertainty or questions resulted in a halt of the process by those involved until verification and resolution by a doctor could occur.

In all of my years of practice ownership and management, I had never thought about, or even heard about, this concept before. That is one of the things that intrigues me so much about Lean. The different perspective and mindset that it brings to the day-to-day practice of veterinary medicine.

So, after some work on improving your value streams, take a look at your own SMEDs. Don’t be embarrassed!  And then, let us know how it went!

Tuesday, June 28, 2016

An Interview with Samantha Parrett: NC State Vet Hospital's Dive Into Lean

I am especially pleased to present this edition of leanvets.com for a couple of reasons.

1)  It is the first podcast for me. Hopefully, others will follow in the future as subject material arises. I debated whether to present this blog as a written interview or as a phone interview. Mark Graban, my “partner in crime” for this thing, convinced me to try a podcast and said he would set it up, which he did. Thank you (again), Mark. (This is also being "simul-blogged" on Mark’s wonderful site, LeanBlog.org). I am so glad we did it this way. I want everyone to appreciate the enthusiasm and confidence about this Lean veterinary success that Samantha brought to the interview, which wouldn’t have been so apparent had we done this in a written, email format.

2) This references, to my knowledge, the first published report of the Lean philosophy and methodologies being applied in the veterinary practice arena. AND… it was very successful.  It has been very difficult trying to educate my profession on the merits of Lean. We’re a stubborn lot, at times. “It may work for building cars and even for human hospitals, but this is veterinary medicine. We’re different! Show me the proof it will work in our profession.”, everyone would say. Well, here’s at least one report that indicates veterinary medicine can benefit from Lean, the same as everyone else who has made the commitment to give it an honest trial.

Our guest today is Samantha Parrett. She is the Director of  Business & Administrative Services for North Carolina State Veterinary Hospital. I first came across NC State’s story, “NC State Vet College Dives Into Lean,” last summer while Mark and I were preparing our lecture for the 2016 TVMA Convention and Expo. I have been waiting eagerly for the opportunity to learn more ever since.

There are several points I would like to draw your attention to. 

First, is the enthusiasm and conviction that comes from trying Lean and experiencing the success that can be realized from Lean. 

Second, Sam mentions many of the Lean concepts and “tools” that we have tried to explain here at LeanVets.com. This demonstrates the “real world” applications of these methods. 

Thirdly, the problem of getting more of the surgeries performed during the normal business hours which had been unsuccessfully remedied for a number of years, finally found some success through Lean. 

And lastly, the positive effect the Lean mindset has had on the staff, doctors and, even, students at NC State Veterinary Hospitals. Lean works...even in veterinary medicine!

Thank you for listening. Here is Ms. Samantha Parrett’s interview.



To read a transcript of the interview,  click here.

Monday, June 20, 2016

The 3rd edition of Mark Graban's Lean Hospitals is now available

You all can breathe again! Mark Graban's Lean Hospitals, 3rd Edition is now available. The fact that there is a 3rd edition speaks volumes about the quality information found in this book and the respect it has garnered within the field of Lean Health care. 


My copy of the 1st Ed. of Lean Hospitals by Mark Graban


The picture to the left shows my copy of the first edition of Lean Hospitals.

As you can tell, it has been well read and shared with many interested staff and colleagues. I also have the 2nd edition, but it is a Kindle ebook and, therefore, impossible for me to show how much I have referenced it, also. 






My copy of the 3rd edition has been ordered. I'm going back to the actual book format (although it is also available from Kindle). I like being able to "dog ear" page corners, write notes in the margins and stick different colored Post-em notes to the pages to remind me of the great ideas and insights I get every time I read Lean Hospitals.

If you only get one book to read about Lean in general, and Lean Healthcare specifically, Mark Graban's Lean Hospital, 3rd Ed. is, by far, the book to get. Order your copy here!

Thursday, June 2, 2016

Seeking General Questions: A Forum MVP

No, not "Most Valuable Player." MVP in this case stands for "Minimal Viable Product. It comes from the book The Lean Startup by Eric Ries. It is his entrepreneurial form of Lean.

The idea is to get the bare essence of your idea or product out to the public and then started iterating as rapidly as possible based on feedback from your customers. Get feedback, make changes, redeploy,  get feedback, etc. The faster you are able to do this, then the faster you learn what is valuable to your customer or not, and the farther ahead of any potential competitors you will be. Whoever gets to market with a viable product has the best chance at capturing market share. Of course, maintaining that lead is a different story, and this is where all of the rest of the Lean concepts come into play. This blog is my MVP into Lean and veterinary medicine on the Internet.

So, I am going to run a small experiment. I originally had a page of this blog devoted to a forum, but decided learning about and maintaining  both a blog and a forum was redundant and too much at once. So, I dropped the forum page.

It occurred to me, however, that, maybe, some of you might have other questions about Lean that don't necessarily fall neatly under one of the already posted articles. Therefore, this  post is my MVP for a forum, possibly, sometime in the future. If you have any  questions or comments about Lean, Lean in veterinary medicine or this blog, please send a comment to this post below. I and/or Mark Graban will respond ASAP.  If I get an indication that a forum would be of value, I will reconsider adding it to  the site.

Please use the  comment section below to ask any questions or leave any comments. Thanks for checking in!

Tuesday, May 3, 2016

What Is This Takt Time You Speak About?


When I first started learning about Lean, one of the terms I seemed to have difficulty wrapping my brain around was "takt time."

Or, maybe it was getting straight the difference between takt time, cycle time, lead time, process time, value creating time, non-value creating time and all of the other “times.”

At any rate, if you read much about Lean, you will come across the term. So, I thought I would explain.

According to Lean Lexicon-5th Ed by the Lean Enterprise Institute:
Takt Time is the available production time divided by customer demand. For example, if a widget factory operates 480 minutes per day and customers demand 240 widgets per day, takt time is two minutes. Similarly, if customers want two new products per month, takt time is two weeks. The purpose of takt time is to precisely match production with demand. It provides the heartbeat of a lean production system. Takt time first was used as a production management tool in the German aircraft industry in the 1930s. (Takt is German for a precise interval of time such as a musical meter.) It was the interval at which aircraft were moved ahead to the next production station. The concept was widely utilized within Toyota in the 1950s and was in widespread use throughout the Toyota supply base by the late 1960s. Toyota typically reviews the takt time for a process every month, with a tweaking review every 10 days.
And:
Cycle Time is the time required to produce a part or complete a process, as timed by actual measurement.
For example, if you have 90 clients wanting routine annual exams and vaccinations performed on their pets each week and you have 30 planned hours available Monday through Saturday (40 hours/week/doctor, less surgery time, less in-patient treatment time, less new sick pet time), then your takt time is 30 hours/90 visits or or 1800 minutes/90 visits or 20 minutes per appointment.

Takt time is a time that represents the pace at which you need to work in order to meet current demand. To meet demand within the allotted time, a routine annual exam would need to be completed, on average, every 20 minutes.

In order to find the cycle time, an actual measured time, you would measure several appointments and calculate the the average time required to actually complete them. If you have a lot of variation, you might measure ten appointments, which is a good Industrial Engineering guideline (thanks to Mark Graban for that tip).

If the actual cycle time is less than or equal to takt time (meaning you can work faster than the demand rate), then you can meet demand within the available time restraints and everything should be good.

But, if cycle time is greater than takt time, then you definitely have a problem, because you cann not meet demand as performed within the time requirements. This scenario will necessitate a kaizen project and/or A3 thinking to work out some countermeasures. These might include finding more time for these exams sometime during the week (expanding your working hours), or eliminating waste and improving flow so the cycle time falls within takt time. We'd want to reduce the time it takes to complete the appointment, but without rushing or impacting quality or client satisfaction.

In manufacturing, it is sometimes a little less complicated because product is often moving through the production line at a much more precise interval and the time for each step has very little or no variation. So, cycle times in manufacturing are much more consistent. Manufacturers also have the opportunity to level their production rate by using inventory as a buffer against variation in demand. In a vet clinic, we might be able to somewhat level our workload through appointment schedule, but if we're taking walk ins, we have to be able to react and adjust to that variation in demand.

But, again in veterinary medicine, we have more variation. There is variability in how long an annual exam actually requires. Are there issues that need to be addressed? Will a fecal exam be required? How about a heartworm test? How many vaccinations are due? Do medicines needed to be filled and dispensed? In addition, there is variability in the arrival times of clients, even with appointments. This results in variance squared (variance X variance), and that = chaos.

There are two points that should be made here. The first is that variability is a form of waste and should be reduced as much as possible using the Lean mindset and methodologies. Meeting takt time is a first goal. The second point is that this is the reason you probably should not schedule more than 85% of your available appointment times. This allows you some "wiggle"room. I have heard some advocate high density scheduling, i.e. close to or at 100% booked.  But, even with a highly trained staff in a Lean environment, you just can't escape variation. The first time an appointment goes long or a client shows up late, you are behind schedule which means each subsequent appointment will have to wait. Waiting is muda. High density appointments are not value for the client, from the client's point of view.

In a later blog, I hope to write about queueing theory, exponential statistical distribution, and Poisson distributions. These concepts produce more realistic models that take into account the variabilities of arrivals and cycle times.

Tuesday, April 5, 2016

Resourses for Lean Veterinary Medicine

Here are some recommendations for further reading and web resources. At some point in the future, this post will be moved to a separate page of this blog to facilitate future additions and updates.
Enjoy! And, be sure to let us know what you think or if you have a recommendation for an addition to the list. 

Suggested Reading:
Follow the Learner: The Role of a Leader in Creating a Lean Culture by Sami Bahri, DDS
Management on the Mend, by Dr. John Toussaint
The High Velocity Edge, by Steven J. Spear
Transforming Health Care: Virginia Mason Medical Center's Pursuit of the Perfect Patient Experience by Charles Kenney
The Toyota Way: 14 Management Principles From the World’s Greatest Manufacturer by Jeffrey K. Liker
Lean Thinking: Banish Waste and Create Wealth in Your Corporation by Daniel P. Womack and Daniel T. Jones
Lean Lexicon: A Graphical Glossary For Lean Thinkers; 5th Ed. by the Lean Enterprise Institute
Value Stream Mapping for Healthcare Made Easy by Cindy Jimmerson
Toyota Production System: Beyond Large-Scale Production by Taiichi Ohno
Workplace Management by Taiichi Ohno
Managing to Learn: Using the A3 Management Process to Solve Problems, Gain Agreement, Mentor, and Lead by John Shook
A3 Problem Solving for Healthcare: A Practical Method for Eliminating Waste by Cindy Jimmerson
Out of Crisis by W. Edwards Deming
Harvard Business Review article, "Time-and-Motion Regained



Web Resources:
Lean Enterprise Institute              
Mark Graban’s Lean Blog              
Kaizen Institute                 
Shingo Institute                  
Toyota TSSC                    
Toyota’s TPS page        

Tuesday, March 22, 2016

Ohno's Circle and Gemba Walks

While Mark Graban and I were at the recent TVMA Convention and Expo presenting our Lean lecture a couple of weeks ago, a veterinarian came up to us and said that he routinely schedules each of his staff to spend 30 minutes several times each week to just observe procedures and flows around the hospital. In Lean terms, these are called a “gemba walks.” We, of course, think this is a great idea, and it reminded me of the story of Taiichi Ohno and his chalk circle (Ohno’s circle).

Taiichi Ohno was an engineer at Toyota in the 50s. He is considered to be one of “The Fathers of TPS” (Toyota Production System). The story says that when a new engineer was assigned to him for mentoring, he would take the individual to the shop floor (gemba), draw a four foot circle on the floor, near one of the processes of the production line, and “ask” him to stand inside the circle and observe for any improvements he could find. With no other instructions, Mr. Ohno would leave. 

After several hours, he would return and ask the young engineer what he had observed. If Ohno was not satisfied with the response, he would again “ask” that the trainee remain in the circle and continue to observe, and, again, leave for several hours. Evidently, some of these “students” spent as much as an entire eight hour shift standing in Ohno’s circle and considered it an honor to do so; to learn from the master. The improvement they suggested could be as small as moving the pneumatic wrench two inches to the right, so it would be easier, and faster, for the worker to do his job. Now, you know there have already been several hundred (or thousand!) iterations of kaizen when moving a tool two inch is the only improvement you can find!

What Ohno was trying to demonstrate to these young managers is quintessential Lean. It is not enough to just “look.” One must truly “see”; to deeply understand the process and how it affects the value stream, the greater systems, the customer and the worker at the gemba. Even more importantly, he was trying to instill into their “being” the process of how to think, to analyze, to pursue perfection through continuous improvement (kaizen).

Now, I think most of us here in the west would consider Ohno’s circle to border on the “cruel and unusual,” but I celebrate the veterinarian I talked to for his vision, understanding and the investment in the long term effects of assigning “gemba walks.” I hope he is also carving out time for himself and the other doctors to observe the work that occurs around them. I think we, as doctors, owners and practice managers, act like we know everything that is going on in our hospitals (our gembas), yet we know that isn't true. We just put off dealing with it, and the problems keep recurring. When was the last time we went into our “waiting room” and just observed what was really happening? Might we be surprised at what we saw?

The other thing that I hope is happening at this vet’s practice during these “walks” is that everyone is stretching their comfort zones. In other words, the surgery tech should spend some observation time at the exam room gemba, the receptionist should go to the surgery gemba, the kennel tech should go to the reception gemba, etc. 

After a few “walks”, I think it is important to schedule an additional period of group reflection (hansei). Did you discover something you weren't expecting? How did your idea(s) of how processes were occurring compare with reality? Did you find some opportunities for improvement (kaizen)? Were you able to see your value stream from your client’s point of view? How would your staff change things? Why? Use the Socratic method of teaching by asking questions, so everyone deeply understands, learns to think and create ideas for solutions.

“Gemba walks” are an easy, inexpensive, enlightening experiment into the Lean culture.  Schedule them at your gemba, and then be sure to share your experiences with the rest of us by adding a comment to this post.

Wednesday, March 16, 2016

Benchmarks

Toyota has long been very generous in allowing other organizations serious about beginning a Lean initiative (even competitors!) access to their Toyota Production System, even to the point of mentoring these companies as they attempt to implement a Lean initiative. See how their TSSC group does this with suppliers and non-profit organizations.

However, Toyota has been very forthright in stressing that the TPS that works for them may not be the form of TPS that is right for others. They are very careful to help these companies find the particular form of TPS that will work best in that industry, organization and culture. The tools can be extrapolated, but the goals, processes and outcomes will be unique.

This brought to mind the use of industry benchmarks, especially for a practice that is embarking on the unique journey of Lean. Are they useful?  Should the performance of others set  the goals for a Lean veterinary initiative?  Should they represent the future state aims and goals? Could those benchmarks actually set limits to our own progress?

Every practice is different, with unique visions, talents, clientele, resources, floorplans, etc.  The tools and specific methods that work for one might not be right for another (but the philosophy is very transferrable). The goal to a Lean thinker is to be better tomorrow than you are today; to get closer and closer to perfection or your ideal state, not just an industry benchmark. Besides, with a culture and mindset of kaizen, a Lean practice will probably leave these benchmarks “in the dust.”

So, in my mind, it is more important to focus on your particular practice processes. Concentrate on closing the gap between your current state and future state using the PDCA / PDSA cycle (blog on PDCA/PDSA), kaizen and continuous improvement (blog on Kaizen).

Also, a Lean practice will come up with Key Performance Indicators (KPIs) and benchmarks that are unique to this mindset, such as Door-to-Doc time, Doc-to-Discharge time, # of kaizens submitted per staff member per month, # of kaizens completed, etc.

The competition (or the goal!) is not the hospital down the street, it is yourself. Strive not to emulate, but to innovate and experiment...and learn!  This takes effort, creativity, and persistence. If you can find that... the rest will take care of itself. 

Tuesday, March 8, 2016

Introducing Lean to the Texas Veterinary Medical Association Conference 2016

Mark Graban and I had the pleasure of presenting a two and a half hour lecture introduction to the Toyota Production System, Lean, entitled "What Veterinary Medicine Can (and Should) Learn From Toyota," at the 2016 TVMA Convention and Expo, held March 3-6 in San Marcos, Texas.

Although the convention was small, compared to regional and national conventions, and primarily a working meeting for the different TVMA committees, we had about 40-45 attendees. Everyone appeared truly interested and engaged. In fact, everyone returned to the lecture after the break, which was very good sign.

As mentioned, the lecture only lasted two and a half hours, which was a real task,  as the material to cover, even for a basic introduction to Lean, could have easily filled four hours or more. But, we got through all of the material with time left at the end for a short Q and A session.

Responses and feedback after the lecture were very positive, such as, "I wish my practice manager could have been here" and  "I wish I had this information years ago."  One practice owner caught me in the exhibits hall and said the information was "an epiphany. " Really, an epiphany?  Well, who am I to argue!  I felt the same way when I first discovered Lean, so I definitely understand.

The material presented included topics such as value, value streams, "pull" systems, kanban, Just in Time philosophy,  flow, visual management, and problem solving. The written notes published in the Proceedings totaled 16 pages and, in fact, form most of this blog's posts to date.

All and all, Mark and I were extremely pleased with this "experiment" of working together and introducing the Toyota Production System to veterinary medicine. Both of us have strong feelings concerning the positive effect Lean could have on our profession, and are ready, willing and able to teach more veterinarians and staff in the future.

Here is Mark's post about this at www.LeanBlog.org.

Monday, February 29, 2016

Kaizen

Kaizen is a Japanese word that can be translated to mean “good change,” “change for the better,” or “continuous improvement.” The methodology strives for, as Masaaki Imai says, “everybody improving, everywhere, and every day.” Toyota says the two pillars of its “Toyota Way” management system are continuous improvement and respect for people. These go hand in hand, as we are driven to improve because we respect our clients, staff, suppliers, and other stakeholders. A practice can achieve a culture of continuous improvement only by respecting and engaging everybody in improving and redesigning the way work is done.

It’s tempting for people to dream up large, expensive improvements. “We need to expand our parking lot” or “Give us better health benefits” might be two things suggested by employees. In a kaizen model, we are focused on small problems that we can solve within our span of control. Doctors and practice managers can ask staff to speak up about small problems that they encounter during the day - frustrations, annoyances, causes of delay and rework - and then ask for their ideas or “countermeasures” that could reduce waste or making things better in the practice. No idea is too small to be considered in the practice of kaizen. In fact, starting with small ideas can be a very effective way to get the process of culture change under way.

Kaizen improvements often involve low-cost and low-risk changes, putting “creativity before capital.” It’s not to say money should never be spent, but throwing money at problems or just asking for more resources doesn’t always solve problems in a sustainable way.

A kaizen process, it should be noted, is not managed like a traditional suggestion box system. Suggestion box systems have been dysfunctional for a number of reasons, including suggestions sitting in a box for weeks or months, a vast majority of ideas being rejected by management, and a disconnect between identifying suggestions and implementing them.

In a kaizen process, we start with a problem or opportunity statement followed by an idea, rather than starting with a solution. The role of management shifts from accepting and rejecting ideas to collaborating with staff to find a countermeasure that can work - solving the problem or, at least, making things a bit better. If an initial suggestion is impractical or too expensive, a practice manager should work with the employee and team to find something else to try. In a suggestion system, managers might get overburdened by having to implement everything themselves. In a kaizen process, staff and veterinarians play a major role in testing and evaluating ideas - but the practice needs to find ways to make time for improvement work.

In a simple and effective kaizen process, as explained more fully in the book Healthcare Kaizen, we follow five high-level steps:


  1. Find opportunities for improvement
  2. Discuss them with others
  3. Implement or test the idea (following the PDSA model)
  4. Document the before and after in a simple way
  5. Share what was implemented with colleagues and other offices


People everywhere can be creative, and that’s true in every role. With kaizen, we understand that the people doing the work are the experts in that work. Sure, managers and improvement specialists can play a role, but that role is more of a coach and facilitator instead of telling people what do. Creating a culture of continuous improvement requires the right leadership mindsets and behaviors.

In one practice the authors visited, an employee was cut badly by a sharp edge on a cabinet. Staff said that, on about 12 previous occasions, an employee had a minor scrape caused by that cabinet. In a kaizen culture, somebody would have spoken up to point out that problem, long before a serious injury occurred. Instead of downplaying the risk or saying “Well, don’t touch that edge,” a practice manager in a kaizen culture would work with staff to implement some countermeasure, such as putting a foam piece over the edge, that would reduce the risk of injury.

In a kaizen model, this problem and idea would be written down on a simple, standardized card. The card would be displayed visually and transparently on a bulletin board. The idea would be discussed informally or in a team huddle. Ownership would be assigned to an employee or small team, and they would then update the status of the improvement on the card. As improvements are implemented, if successful, protocols would be updated as needed and a simple “before and after” summary would be created and shared across the practice. In larger organizations with multiple practice locations, the “cloud” or software systems could be used to share and spread ideas more widely. If a practice in Dallas finds a problem and solves it, the other practice location in Fort Worth might benefit from seeing what was done. Sharing and spreading ideas can help prevent each office from having to reinvent the wheel. Or, seeing the ideas implemented by others might inspire our own.

Our view is that a practice with a solid culture of continuous improvement, along with simple methods for facilitating and tracking ideas, would outperform clinics where staff and doctors are told to just show up and do their jobs. As Toyota and Lean healthcare organizations say, “Everybody has two jobs... to do the work and to improve the work.” Kaizen will lead to better client service and outcomes for patients, a better workplace, and better financial results for the practice owner.

Read more in the book Healthcare Kaizen by Mark Graban and Joe Swartz.

Thursday, February 25, 2016

A3 Reports

A3 reports are the written documents that succinctly record the PDCA cycle problem solving effort, often providing a bit more structure than the four steps. The thought process and steps are very similar to the Practical Problem Solving method. This is sometimes called “A3 thinking.” The PDCA thought process is more important than the specific A3 report format.

The name A3 comes from the international size of paper that’s approximately 11 by 17-inches (in landscape orientation) traditionally used by Toyota and Lean organizations for these reports.

The left side of the A3 is for the Plan step of PDCA. It should include a title, a statement of the problem and a description of the current state. This side is filled out with such information as facts, graphs, charts, key performance indicators, value stream maps and 5 Whys root cause analysis, to name a few. The fact that the Plan step takes close to fifty percent of the entire report is an indication of the importance Toyota places on planning.

The right side of the document contains the Do, Check and Act steps of the cycle. This side might contain the implementation plan (along with the “who”, “what”, “where”, “when” and “how”), the future state value stream map, a short cost/benefit analysis, the result of the implementation plan, the root causes that were eliminated (or not), the changes in policy and procedures (the new standardized work) and a date to revisit the issue in order to continually improve.

Tuesday, February 23, 2016

Lean Veterinary Articles on DVM360

We've written a few introductory articles on the DVM360 site:

Cut the fat—get Lean

VETERINARY ECONOMICS - Mar 01, 2015
What Toyota has to teach veterinary hospitals.


Growing the Lean veterinary practice

VETERINARY ECONOMICS - Mar 06, 2015
Dr. Chip Ponsford explores how to "tend" your veterinary practice in order to harvest an efficient, successful business.

Put the Lean concept into action at your veterinary practice

VETERINARY ECONOMICS - May 21, 2015
Begin and maintain this system's philosophy to make your practice more productive and efficient.

Check them out!

Monday, February 22, 2016

PDCA (PDSA) Cycle

We're all familiar with the diagnostic and treatment process. First, we collect as much subjective and objective data as possible. Then, we formulate the tentative diagnosis. Next, we test our diagnosis by prescribing a series of drugs, surgeries or other treatment modalities. If the patient responds, then we continue the course, usually at home with drugs we dispense and instructions for the client. If the patient does not respond, we seek new data and/or formulate a new treatment plan and try again. This process is based on the scientific method of problem solving.


When we have a problem or a question, we design an experiment, we evaluate the results and then we formulate a conclusion. The PDCA cycle is also based on the scientific method. It stands for Plan, Do, Check and Act. It is the Lean method of diagnosing and treating problems at the gemba. 

Created by Walter Shewhart at Bell Labs in the 1930s, it was introduced to post World War II Japan by W. Edwards Deming. It is also known as the Deming Cycle or the Shewhart Cycle. (Some refer to it as the PDSA cycle; Plan, Do, Study, Adjust).

Everyone at Toyota, from executives to managers to floor workers, is taught, understands and utilizes the PDCA cycle. It is a methodology to deeply understand the reasons of the problem(s); to discover what is known and what is unknown. It helps to propose and test countermeasures based on workplace observation, data collection, and consensus from all stakeholders and to evaluate the results of the test. In many workplaces, people “know” the solution and are afraid to (or are unwilling to) admit that their solution didn’t really work out in practice. The PDSA process emphasizes learning both on an individual and an organizational level, and continually improving systems and processes. It requires humility and a scientific spirit - again, one that should be familiar to those in veterinary medicine.

Plan
The plan step involves the critically important step of defining the problem. Instead of talking about problems in an office or conference room, this step should take place at the gemba as much possible, with all stakeholders present, so the problem may be observed where it occurs, when it occurs, and as it occurs. It is also during this step that any other data such as costs, charts, statistics, 5 Whys analysis results, current value stream maps, etc. are presented.

Based on all of this information, a team might propose some potential countermeasures to discuss, test, and evaluate. 

Do 
In the do step, we do an initial test of the proposed countermeasures as small experiments of change. If we have an idea, we might test it first in one exam room or one office, instead of rushing to implement something throughout the organization. Doing a small test of change helps mitigate and minimize risk. That way, if the change we test turns out to not actually be an improvement (or if it creates unintended side effects), less harm is done. If the initial test of change is promising, we can move forward in the area and spread the improvement to other areas.

Check (Study) 
At this point in the cycle, we evaluate the initial results of our countermeasures and compare them with our hypotheses and expectations. Did we accomplish our objectives or fall short? Were there any unexpected results? What did we learn along the way?

Act (Adjust)
If the results are positive, then we can more formally implement the new changes, write new standardized work, train others, and sustain. If the results have fallen short, adjustments are made, and the PDCA / PDSA cycle is repeated with new countermeasures.

Saturday, February 20, 2016

Root Cause Problem Solving and The 5 Whys

Do you ever feel like you’re playing a game of “Whack-A-Mole?” The same problems, previously thought to be solved, keep popping up in different areas of your practice at different times. One of the reasons may be that the root cause of the problem has not been identified and dealt with effectively. Lean offers a number of solutions to this situation.

Toyota uses a method called “Practical Problem Solving” or 8-Step Problem Solving, that provides a structured way to investigate and solve problems.

These steps are, as mapped to the PDSA cycle (http://www.leanvets.com/2016/02/pdca-pdsa-cycle.html):

Step #                      Step                         PDSA Phase
1                  Clarify the problem              Plan
2             Break down the problem
3                   Target setting      
4               Root cause analysis
5          Develop countermeasures
6       See countermeasures through        Do
7  Monitor the results and processes      Study
8   Standardize successful processes      Adjust

In step 4, one method for root cause analysis is called “The 5 Whys,” which suggests that you ask “why” five times, sequentially, in order to find the root cause.
Why does that problem occur? Why is that? We keep drilling down deeper, rather than just answering the original why five different ways.

The number five is somewhat arbitrary - it’s not always five whys that are required. The idea is to ask enough times to get to a root cause or causes, to get beneath the surface of a problem. Once suspected root cause(s) are identified, countermeasures can be tested and, if they are effective, standardized work can be updated or written to prevent recurrence. It is important that this take place at the gemba, where the problem occurs, with all stakeholders present in order to build consensus about an appropriate countermeasure to test.  If, at this point, you continue to have recurrences of the same problem, then it’s possible that the correct root cause was not identified, or there’s a different root cause this time, or standards that have been put in place are not being followed.

For example, at a large animal veterinary clinic, there was a hydraulic rotating machine that was used to turn cows on their side for treatment. One day, there was some hydraulic fluid on the ground near the machine. The tech noticed this and, instead of just cleaning up the grease, she stopped to investigate. We can start asking why:

Why was there fluid on the ground? Because the hydraulic cylinder had stopped working.
Why had the hydraulic cylinder stopped working? Because the filter was clogged.
Why was the filter clogged? It had not been changed in a long time.
Why hadn’t it been changed in a long time? There was not a standardized work method for doing so. 

There were not clear roles and responsibilities, nor was there a standard changing frequency.
So, instead of just putting out the fire and replacing the filter, a Lean organization would look for a more systemic cause and countermeasure. Not having standardized work could have caused the machine to fail in a catastrophic way, possibly harming an animal or a tech. Just replacing the filter would not have fixed the process in a root cause to prevent the same problem from occurring in the future. Asking “why?” and digging deeper allowed the tech and engineering to come up with a better solution.


Wednesday, February 17, 2016

Visual Management

5S is just one example of a Lean concept called “visual management.” We can also think of visual management as a form of “standardized work” for everyone in the practice.

As explained in the book Lean Hospitals (3rd edition), the goal of visual management is to make waste, problems and abnormal conditions readily apparent to employees and managers. As Fujio Cho, honorary chairman of Toyota says, “One of the worst situations… is not being able to tell whether things are standard or out of standard (normal or abnormal).” Our aim should be to expose problems so they can be fixed, as opposed to the old approach of hiding problems to make things look good. Jamie Bonini of the Toyota Production System Support Center organization says, "The ideal is to be notified of any abnormality immediately and to solve problems as they occur, while the situation is still fresh."

Visual management has two main tenets: first, make problems or status visible; and, second, manage those situations, reacting as needed in the short term and solving root causes of those problems over the longer term. Even before Lean, healthcare organizations might put multi-colored plastic “flags” up in the hallway outside each exam room. These flags, if used consistently by staff, can provide a clear visual indicator that answer questions such as, “Is there a client in that room yet?” or “Where does Dr. Y need to go next?”

While visual management is ideally used for real-time decision making and problem solving, Lean organizations tend to also post performance measures (or metrics) on the wall for everybody to see. Understanding the performance of a practice (in areas such as safety, quality, patient satisfaction, or financials) can help everybody focus their kaizen improvement efforts (as described later). Posting metrics cannot become an exercise in blaming or just pressuring people to perform better. Everybody must work together to improve the systems and processes that lead to those results.

Flow (One Piece Flow)

In a Lean manufacturing setting, products are ideally “pulled” through the value stream, one piece at a time, continually. There might be times when batches greater than one are necessary. But, the goal with Lean is to find ways to reduce batch sizes in a way that improves flow without harming quality. Each step is ideally adding value, without waste, when the customer requests it (although there might be some “necessary waste.”) It is a similar process when performing a service for a client. 

Think of a value stream as a relay race. When the gun goes off (initiation of the value stream), each of the four runners advances one baton in a predetermined order (using standardized work). Each runner runs his leg of the race quickly and skillfully (adding value), and the hand-offs (pull) occur smoothly and without delay (waste), just at the right time (JIT) when the next runner signals his readiness (kanban). The result is, hopefully, a flawless (perfect) execution, in record time resulting in a first place medal (satisfied clients). The runners are ecstatic and proud (confident and engaged). The fans go wild (positive word of mouth advertising)!

This is opposed to “batch and queue” production where batches of product are produced at one time and then stored before going on to the next step. This results in much “hurry up and wait,” a lot of work in process (WIP) inventory, large amounts of warehousing space, and longer lead times.

For example, a product requires three steps to produce. Each step requires 10 minutes. In “batch and queue” mode, 10 units are produced at one time. The first step requires 10 units × 10 minutes = 100 minutes. The second step requires 10 units ×10 minutes = 100 minutes. The third step requires 10 units × 10 minutes = 100 minutes for the entire batch. However, the first unit is off the line in step 3 after 10 minutes. Therefore, it requires a total of 210 minutes (the lead time) for the first unit to be available to the consumer, and 300 minutes for the entire batch to be ready. This is not considering any waiting time between the batch processing steps (which tends to occur any time we have batching). 

Compare this with one-piece flow, where the first unit is through step 1 in 10 minutes. It then progresses straight through step 2 in 10 minutes and, finally, straight through step 3 in 10 minutes. The total elapsed time until the consumer receives his product is 30 minutes, plus any delays between steps. One-piece flow results in a savings of 180 minutes and is 85.7% faster.

In a multi-doctor hospital, four 10:00 am appointments arrive at the same time. Each client requires ten minutes to get the primary complaint, update the client information, pull the file, write the date and reason for the visit in the medical records, weigh the pet, and enter that data into the medical records.

The receptionist checks in all four clients before signaling to the techs that clients are ready to be seen.  This means that the first client is not seen until 40 minutes after his/her arrival.

In one-piece flow, the first client could be seen within ten minutes of arrival (and probably be checked out and on the way home before the fourth client gets into an exam room).

Or, techs draw all of the morning blood samples of hospitalized patients before centrifuging and running any of the tests. This keeps the doctor from being able to formulate any treatment orders as quickly as he could if blood samples were run as they were drawn.

Flow is the result of good value streams, JIT, kanban systems and standardized work. Flow equals value to the client. What’s also unintuitive is that reducing batch sizes can improve productivity. People often think working in batches in faster. Sometimes this is true, but not always. It depends on the work and the setting. We do know that working in batches creates a lot of waste -- sorting, moving, inspecting batches, logging them in computer systems, etc. -- work that wouldn’t be required if we had better flow. 

Improving flow in healthcare settings often requires changes to the process, such as the physical layout of a department or clinic. In the Lean mindset, we’d challenge ourselves to ask why we have batching or a particular office layout. “It’s always been that way” doesn’t mean it has to be that way in the future. If it is not adding value for the client or pet, it's probably muda and needs to be removed from the system.