Monday, January 25, 2016


The Japanese word for “sign” or “signboard” is kanban. It is a visual means of requesting a resource, e.g. supplies, inventory, maintenance, doctors, etc. In many practices, inventory management is a perpetual problem.  It seems like it is always “feast or famine”; balancing “stock-outs” and expired “over stocks.”  The problem is not the person in charge of inventory. The problem is the system.  And, it isn't just about inventory levels, it is about managing all resources.

One example of a kanban would be an inventory card with the name, location, amount, supplier name, etc. being written on it that would be placed at the reorder point of the particular unit on the shelf to signal reordering. Lean organizations often use “two-bin” kanban systems such as an empty microscope slide box set aside at a specific location (a kanban post) that triggers replenishment of the slides at the microscope in the lab from a central supply area. It could also be a file holder on the exam room door that holds patient records which indicates there is a client and patient in the room ready to be seen, “pulling” the doctor or tech to the room. Or, it could be the plastic, colored flags mounted next to an exam room door that request an action take place in the room such as a doctor is needed, the exam room needs cleaning, or the exam room is ready for a new patient. Kanban is part of visual management, and just-in-time philosophy that we discuss later.

Monday, January 18, 2016

Pull Systems

This is the Lean concept that value should be “pulled” from downstream in the value stream by a consumer, backward up the value stream. “Pull” is initiated by a consumer, when the work or item he/she wants or needs it and then proceeds backwards up the value stream. It is the opposite of a “push” system where providers produce a product or service (or information) and then “push” it onto the consumer, down the value stream regardless of whether the consumer wants it or needs it (at that time or at all). This results in much waste, work-in-progress inventory, possibly unnecessary production, increased warehousing and lost capital. All are forms of waste (muda). An example of a “pull” system is filling the gas tank in your car. You don’t typically just put gas in your car at arbitrary times or times scheduled far in advance, regardless of fuel usage. You wait until the gas gauge reads relatively near empty. The gas gauge is the initiating trigger (visual sign). It “pulls” the need to put gas into the car at just the right time, and in just the right amount. The doctor “pulls” the taking of radiographs as needed. Radiographs are not simply taken because a patient has presented to the practice. Supplies are generally ordered on a pull system in a Lean organization, both the restocking from a supplier or distributor to the location, and from a stock room to each point of use, like exam rooms.

Monday, January 11, 2016

Waste (Muda)

In Japanese, the word for waste is muda. Any time, activity or resources that do not add value can be considered waste. Traditionally, there are seven forms of muda. However, many Lean practitioners have added an eighth, in recent years.  The “waste of talent” or the “waste of underutilized human potential” is the waste of not utilizing staff effectively, not acknowledging their unique talents and perceptions, or potential intellectual contributions. Lean considers people to be the most valuable asset in an organization. Lean encourages us to seek the wisdom of ten people, rather than the knowledge of one.

As stated in the book Lean Hospitals, the types of waste and their definitions are:

Time spent doing something incorrectly, inspecting for errors, or fixing errors.
Ex.: Surgery pack missing the scalpel handle; replacing a bandage that was applied too tightly.

Doing more than what is needed by the customer or doing it sooner than needed.
Ex.: Labeling heartworm preventative before the test results are available.

Unnecessary movement of the “product” (patients, specimens, materials) in a system.
Ex.: Repeatedly taking a patient back and forth to a cage because resources are not available when needed.

Waiting for the next event to occur or next work activity.
Ex.: Waiting for the processor to be turned on and warmed up before being able to take a needed radiograph.

Excess inventory cost through financial costs, storage and movement costs, spoilage, wastage.
Ex.: Ordering 3 years worth of ointment because you got a free pair of “earbuds” for your smart phone.

Unnecessary movement by employees in the system.
Ex.: Chasing down the pair of bandage scissors that belong in Exam 1.

Doing work that is not valued by the customer or caused by definitions of quality that are not aligned with patient needs.
Ex.: Centrifuging a blood tube longer than necessary; collecting client email addresses that are never used.

Human potential
Waste and loss due to not engaging employees, listening to their ideas, or supporting their careers.
Ex.: Idea by staff to attach a small basket to front of cage to keep patient personal items and meds from being misplaced is ignored.

There are two types of muda. Type 1 muda is “necessary waste,” or at least necessary for the time being. For example, taking time to write medical records is not something that the client would voluntarily pay for and it does not physically make the patient any healthier (transform the product), but it is necessary in a veterinary practice for legal or other reasons.

Type 2 muda is unnecessary waste. It is waste that can be removed immediately without causing any other ill effect. For example, waiting an excessively long time for the doctor to get into the exam room. This is not something that the client would pay for and it does not make the patient healthier. It has no place in the value stream. This category is sometimes called “pure waste.”

Monday, January 4, 2016


For us in veterinary medicine, the external customer is, of course, the client. They are the reason that we are in business, the initiator of a value stream’s work and they are the ultimate determiner of value. But, there are also internal customers. Within a value stream, the customer is the receiver of the product, service, or information from the previous step. For instance, the doctor would be the internal customer of the results in the step that performs a general health profile on a patient.