Monday, February 29, 2016


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

What Toyota has to teach veterinary hospitals.

Growing the Lean veterinary practice

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

Begin and maintain this system's philosophy to make your practice more productive and efficient.

Check them out!

Monday, February 22, 2016


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.

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. 

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:

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.

Monday, February 15, 2016


5S is part of the Lean approach to of “visual management,” as a way to show problems and irregularities, so they can be fixed quickly. As such, it is also an aspect of flow, standardized work and the elimination of waste. 5S deals with workplace organization, i.e. exam rooms, pharmacy, lab, surgery, or even the organization of email and information, etc. The workplace is organized to make work easier, clutter is removed, areas are cleaned, and the locations for supplies and movable equipment are labeled. A place for everything and everything in its place (once we figure out the right place!), and in the right amount. It requires the answering of two questions: (1) Do we have all that we need at the gemba, and (2) Do we need all that we have at the Gemba?

The five Ss stand for:

Sort (Seiri)
Go through the work area looking for any old, expired, irrelevant or broken items, and remove them. Throw them away or, at least, get them out of the way (if they are items that are used infrequently or non urgently). Do you really need to keep rabies certificates from 1987? Does anyone even know what a hemocytometer is, let alone still use it? Besides, the latex tubes disintegrated a decade ago!

Straighten (Seiton)
For everything else that remains, organize it. In the exam rooms, for instance, you try to make each exam room similar to the others so that there is continuity from one exam room to the other. Items used more frequently should be placed closer at hand to save time for staff and veterinarians, which can reduce delays for patients and increase office capacity and throughput.

Shine (Seiso)
Clean up the area and have a process for ongoing cleaning and sanitizing (as a form of standardized work). This minimizes contamination and infectious disease. The regular shine process is also the time to check equipment and perform timely maintenance. This keeps the hospital in a state that is a source of pride, with improved quality and safety

Systemize (Seiketsu)
Once the first 3Ss are done, we need to help make this an ongoing system, rather than a onetime activity. Ask if each of the drawers in cabinets, in each of the exam rooms, contain the same supplies and are they arranged in the same way? Systematizing helps prevent confusion and wasted time looking for items. This step provides the method to the madness. Label the drawers, cabinets and even the tops, so everyone knows what is supposed to be there and can easily see if it is not. It is similar to the woodworker who paints silhouettes of his hand tools on the wall to show where they belong, and to quickly, visually highlight when they might be missing.

Sustain (Shitsuke)
Again, 5S is not meant to be a one-time project. It should be an ongoing activity in the practice, to keep things organized, and to be continually improved. Management oversight, 5S audits, and continued improvement are the key to ongoing 5S success.

Monday, February 8, 2016

Standardized Work

Mary is licensed veterinary technician. When a shocky, weak puppy was presented, Dr. A tells her that a PCV and blood glucose is always indicated in cases such as this and should be performed even before the doctor sees the pet. Two weeks later, a similar case presents and Mary performs both tests immediately upon intake. Dr. B, the doctor on duty, pulls her aside and angrily instructs her to never perform any blood tests without orders from the case doctor.

Unfortunately, we have all been witness to such scenarios. The doctors may not realize these type of situations are occurring.  But, the effects on staff can be far reaching.  It engenders feelings on the part of staff of anger, resentment, confusion and loss of confidence in management.

In the Lean method, “standardized work” is our definition of the best way to do work in a way that ensures safety and quality, while driving the best productivity and minimizing delays for the customer. It is the foundation for continuous improvement and employee empowerment. It is necessary for “flow” and “pull”. Standardized work gets everybody on the same page and reduces employee anxiety. When processes are in chaos, they must first be brought into some semblance of stability. What is the best way to do our work? This stability (and ongoing improvement) is achieved through standardized work. Once there has been some degree of order established, then the processes can be improved by applying other Lean methodologies, such as kaizen.

Standardized work is not the same as “standard” work. Standard work might imply written in stone, inflexible, inappropriately detailed or micromanaged. Standardized work is broader in concept. Think in terms of simple algorithms or checklists. For example, requiring the drawing of a blood sample for a routine health profile into a 3 cc syringe as opposed to a 5cc syringe would, in most cases, be too detailed for standardized work. However, in the diagnosing of the cause of a “red eye,” it is important to specify that the Schirmer tear test be run prior to staining the cornea or using any topical anesthetic drops in order to check for glaucoma. “Canned” computer estimates might be thought of as another form of standardized work in that they do not dictate a specific recipe, but suggest considering the need for such drugs or services such as antibiotics, hospitalization, analgesics, diagnostic tests, etc. They act as a reminder.

When we create standardized work documents, it’s important to ask what should be standardized and to what level of detail. What problems are solved or prevented by having standardized work? What goals are being accomplished? The goal is not to have standardized work. The goal is better performance in all dimensions and a better workplace for all. Standardized work is a “means to an end”, not a raison d’etre. As mentioned above, the reason for standardized work is to start the process of improvement, which ultimately is for the purpose of increasing quality and value for the client, the “holy grail” of Lean.

Chaos must be brought under some control with Standardized Work before Lean "tools" can improve processes. Note that the blue dot becomes increasingly evident as abnormal as the process is first standardized and then improved. Lean helps identify problems.

But there are also some important ramifications. Like most of the methodologies that make up TPS, standardized work is designed by consensus with staff.  Consensus means obtaining ideas for problem solving from all stakeholders, including staff. It comes from the mindset that all workers have valuable input, knowledge and skills that are assets to the organization in problem solving. It is a sign of respect for workers. It does not mean that all opinions are valid and must be taken or that each individual gets to do the work however they want. Toyota has long emphasized that standardized work must be created by those who do the work. It is not dictated by managers or experts.

By involving workers in this way, a vital resource is utilized and leads to increased “buy in” and engagement. It improves communication and reduces anxiety on the part of everyone of not knowing what is the correct (preferred, agreed upon) way or doing something incorrectly. It helps insure that vital information is available even if a key staff member is absent or has moved on. Plus, standardized work becomes the basis for a formal, in-house training program and is the foundation for continuous improvement.

Monday, February 1, 2016

Just In Time (JIT)

JIT, one of the two pillars of the Toyota Production System, is the procurement and delivery of resources, whether that be drugs, supplies, access to diagnostic equipment, doctors or staff, just exactly where it is needed, when it is needed, and in the amount needed. Nothing more and nothing less. JIT is an ideal direction and goal, but in a real world, we may have “buffer inventories” that protect us from running out of supplies due to variation that we did not anticipate. It is based on the way United States supermarkets restock inventory on the shelves during the night, to replace what was purchased the previous day. For instance, the ultimate JIT would be for a drug company to send you the 14 antibiotic tablets as soon as you dispense them to a patient. Again, in reality, we may choose to order no more than weekly or order in certain box quantities, so we end up with some inventory (this could be viewed as Type 2 or “necessary” waste).

But, as mentioned above, this idea doesn’t have to refer to just inventory. For example, a doctor’s time is limited and his or her skills are unique and valuable. These resources should be committed only in the necessary places, at the correct time and in the right amount. A doctor’s time is best utilized doing work such as diagnosing illness, creating treatment plans, or performing surgery, rather than running fecal exams, drawing blood samples for lab profiles, or invoicing clients. Making sure that doctors are spending most of their time being doctors is another example of the “respect for people” principle or making sure we don’t waste their talents or capabilities. The scenario of the radiographs mentioned above is an example of JIT. They are taken only when necessary and in the amount necessary.