Wednesday, December 20, 2017

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

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

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

Mark comments:

Thanks for sharing this, Chip.

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


Here is my response.

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

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

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

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

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

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

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

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

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

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

Monday, November 20, 2017

Lean Self

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thanks for stopping by. Comments always welcome.

Thursday, September 21, 2017

A Lean Staff Meeting Micro-experiment

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

The results of all of this are:

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

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

The Micro-Experiment

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

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

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

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

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

Tuesday, September 5, 2017

What! No Research and Development Department!?!

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

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

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

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

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

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

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

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

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

Thanks for reading. Please leave a comment and, please, tell your friends about our blog.

Tuesday, July 11, 2017

My First Time with Kaizen and Value Stream Mapping

I was recently looking through the documents and photos on some old laptops when I came across photos I had taken when I was just starting to read and learn about the Toyota Production System (TPS) or Lean.

I don't remember how I first learned about TPS, but I do remember that it hit me on such a deep, intuitive, "soul" level that I was instantly and forever transformed. Lean had me at, "Greater value for the customer, better use of resources, less waste and more respect for workers!"

First Kaizen

It always intrigued me that a single groomer could bath, dry, clip, pluck ears, trim nails, and brush out a dog by themselves. In our veterinary hospital, it seemed to require two vet assistants to handle these same dogs when it came to performing a complete annual examination including vaccinations, glaucoma check, a routine blood profile and Heartworm test.

Same pets, same employee skill.

The difference, it appeared to me, was the specialized grooming table with a grooming arm and its ability to restrain the pet with both a neck leash and a flank leash. Could the same table be used in our hospital to allow a single vet tech to work with a single dog, freeing the other tech to work on a different dog at the same time, thus doubling our flow and production?

I borrowed a table from the grooming salon adjacent to our hospital and we experimented.

Long story short, it worked most of the time. It didn't work for the very fear aggressive dogs (they still required two staff for safe restraint) or dogs too big to fit on the table, and, of course, cats didn't cooperate at all. But, the majority of our canine patients were less than 25 pound and friendly, and cats made up only about thirty percent of our practice. Any time savings got all of us finished earlier.

Experimenting with a grooming table for patient treatments

Maybe treatment tables should come equipped with a grooming arm!

The neck and flank leash in action. 

Based on this experiment, we were able to come up with a system to work single handedly with larger, good natured dogs.

I eventually attached rope cleats to the outside of the cage doors to make it easier to tie and release the leashes.

One staff could perform everything needed for our comprehensive annual exams including injections and blood draws.

First Value Stream Map

After working out the grooming table kaizen, we decided to map the Comprehensive Annual Drop-off value stream. Using ‘Post It’ notes would have made the process of optimization easier, but we used what we had available (this white board).

Most important is identifying all of the value producing steps, non-value producing steps and times for both.

I don't remember, but I think this was the current state map.

To create the future state map, steps were arranged to allow some to be performed in parallel rather than in series.

Lean is about doing. Start small. Start cheap. But, start! And, get your staff involved. Lean is about deeply understanding, learning and improving as an organization.

What kaizen could you experiment with? What value stream could you map and improve? Let me know and thanks for reading.

Wednesday, June 28, 2017

Sayings of the Lean Fathers

Within the body of Jewish literature,  there is a book called "Pirke Avot", which means 'Sayings of the Fathers'. It is a collection of wisdom and quotes handed down from the ancient rabbis and the Jewish tradition. Taking that reference as a model, I decided to produce this "Sayings of the Lean Fathers." Enjoy!

Taiichi Ohno

(February 29, 1912 – May 28, 1990) was a Japanese industrial engineer and businessman. He is considered to be the father of the Toyota Production System, which became Lean Manufacturing in the U.S. He devised the seven wastes (or muda in Japanese) as part of this system. He wrote several books about the system, including Toyota Production System: Beyond Large-Scale Production. 

We are doomed to failure without a daily destruction of our various preconceptions.

Progress cannot be generated when we are satisfied with existing situations.

Start from need.

Having no problems is the biggest problem of all.

If you assume that things are all right the way they are, you can’t do Kaizen. So change something!

Ask 'why' five times about every matter.

Why not make work easier and more interesting, so people do not have to sweat? The Toyota style is not to create results by working hard. It is a system that says there is no limit to people’s creativity. People don’t go to Toyota to ‘work’, they go there to ‘think’.

Without standards, there can be no improvement.

Where there is no Standard there can be no Kaizen.

Standards should not be forced down from above but rather set by the production workers themselves.

Make your workplace into showcase that can be understood by everyone at a glance. In terms of quality, it means to make the defects immediately apparent. In terms of quantity, it means that progress or delay, measured against the plan, is made immediately apparent. When this is done, problems can be discovered immediately, and everyone can initiate improvement plans.

The slower but consistent tortoise causes less waste and is more desirable than the speedy hare that races ahead and then stops occasionally to doze. The Toyota Production System can be realized only when all the workers become tortoises.

All we are doing is looking at the time line, from the moment a customer gives us an order to the point we collect the cash. And, we are reducing the time line by reducing the non-value-added wastes.

Something is wrong if workers do not look around each day, find things that are tedious or boring, and then rewrite the procedures. Even last month's manual should be out of date.

The more inventory a company has, the less likely they will have what they need.
We are doomed to failure without a daily destruction of our various preconceptions.

The key to the Toyota Way and what makes Toyota stand out is not any of the individual elements…But what is important is having all the elements together as a system. It must be practiced every day in a very consistent manner, not in spurts.

If you are going to do TPS you must do it all the way. You also need to change the way you think. You need to change how you look at things.

The only place that work and motion are the same thing is the zoo where people pay to see the animals move around.

People who can’t understand numbers are useless. The gemba where numbers are not visible is also bad. However,  people who only look at numbers are the worst of all.

Taiichi Ohno. (n.d.). Retrieved June 16, 2017, from Web site:

W. Edwards Deming

(October 14, 1900 – December 20, 1993) was an American engineer, statistician, professor, author, lecturer, and management consultant. Educated initially as an electrical engineer and later specializing in mathematical physics, he helped develop the sampling techniques still used by the U.S. Department of the Census and the Bureau of Labor Statistics. In his book, The New Economics for Industry, Government, and Education, Deming championed the work of Walter Shewhart, including statistical process control, operational definitions, and what Deming called the "Shewhart Cycle" which had evolved into PDSA (Plan-Do-Study-Act). This was in response to the growing popularity of PDCA, which Deming viewed as tampering with the meaning of Shewhart's original work. Deming is best known for his work in Japan after WWII, particularly his work with the leaders of Japanese industry.

People are entitled to joy in work.

Management by results -- like driving a car by looking in rear view mirror.

It is not necessary to change. Survival is not mandatory.

The greatest waste in America is failure to use the abilities of people.

The moral is that it is necessary to innovate, to predict needs of the customer, give him more. He that innovates and is lucky will take the market.

The consumer is the most important point on the production-line.

Export anything to a friendly country except American management.

Whenever there is fear, you will get wrong figures.

A bad system will beat a good person every time.

To manage one must lead. To lead, one must understand the work that he and his people are responsible for.

Does experience help? No! Not if we are doing the wrong things.

The supposition is prevalent the world over that there would be no problems in production or service if only our production workers would do their jobs in the way that they were taught. Pleasant dreams. The workers are handicapped by the system, and the system belongs to the management.

Defects are not free. Somebody makes them, and gets paid for making them.

Every system is perfectly designed to get the results it gets.

A leader is a coach, not a judge.

Pay is not a motivator.

The merit rating nourishes short-term performance, annihilates long-term planning, builds fear, demolishes teamwork, [and] nourishes rivalry and politics. It leaves people bitter, crushed, bruised, battered, desolate, despondent, dejected, feeling inferior, some even depressed, unfit for work for weeks after receipt of rating, unable to comprehend why they are inferior. It is unfair, as it ascribes to the people in a group differences that may be caused totally by the system that they work in.

Quality is made in the board room. A worker can deliver lower quality, but she cannot deliver quality better than the system allows.

Shigeo Shingo

 (1909 - 1990), born in Saga CityJapan, was a Japanese industrial engineer who is considered as the world’s leading expert on manufacturing practices and the Toyota Production System.

Lean is a way of thinking- not a list of things to do.

The most dangerous kind of waste is the waste we do not recognize.

Are you too busy for improvement? Frequently, I am rebuffed by people who say they are too busy and have no time for such activities. I make it a point to respond by telling people, look, you’ll stop being busy either when you die or when the company goes bankrupt.

Unless you change direction, you will end up where you are headed.

We have to grasp not only the Know-How but also 'Know Why', if we want to master the Toyota Production System.

Those who are not dissatisfied will never make any progress.

There are four purposes of improvement: easier, better, faster, and cheaper. These four goals appear in the order of priority.

A relentless barrage of 'why’s' is the best way to prepare your mind to pierce the clouded veil of thinking caused by the status quo. Use it often.

Shigeo Shingo. (n.d.). Retrieved June 18, 2017, from Web site:

Masaaki Imai

(born, 1930) is a Japanese organizational theorist and management consultant, known for his work on quality management, specifically on Kaizen.

The message of the Kaizen strategy is that not a day should go by without some kind of improvement being made somewhere in the company.

The Kaizen Philosophy assumes that our way of life - be it our working life, our social life, or our home life - deserves to be constantly improved.

It is impossible to improve any process until it is standardized. If the process is shifting from here to there, then any improvement will just be one more variation that is occasionally used and mostly ignored. One must standardize, and thus stabilize the process, before continuous improvement can be made.

Progress is impossible without the ability to admit mistakes.

The standard is not written on the stone. The definition of the standard is that it is the best way to do the job for now. It should be regarded as a next step to make further improvement.

Where there is no standard, there can be no improvement. For these reasons, standards are the basis for both maintenance and improvement.

Kaizen means ongoing improvement involving everybody, without spending much money.

I believe that management should focus on two particular areas. One is Gemba (shop floor) and the other is customer (not the shareholder).

You can't do kaizen just once or twice and expect immediate results. You have to be in it for the long haul.

All of management's efforts for Kaizen boil down to two words: customer satisfaction.

I have a theory that among the large Western companies (mostly American) the higher an executive is promoted, the more wisdom is lost and by the time he or she reaches the top becomes a complete idiot. Certainly they do not deserve the outrageous salary.

Japanese management practices succeed simply because they are good management practices. This success has little to do with cultural factors. And the lack of cultural bias means that these practices can be - and are - just as successfully employed elsewhere.

Kaizen is like a hotbed that nurtures small and ongoing changes, while innovation is like magma that appears in abrupt eruptions from time to time.

Under the lean system, any tools which are required for solving problems are used.

Masaaki Imai. (n.d.). Retrieved June 18, 2017, from Web site:

Final Thoughts

Can you recognize some themes here? Do any of this quotes resonate with you? Maybe one or more hits a little closer to home?! Which ones are you going to take with you and/or share with others? Did any challenge your previous mindset?

Thanks for stopping by. Tell your friends about us and, please, leave any comments and questions you may have.

Thursday, June 8, 2017

Lean and Veterinary Medicine: Like a Glove

After reading, studying and thinking about Lean over the past seven years, I am convinced that Veterinary practice and Lean are destined for each other. As veterinarians and systematic problem solvers, we already know and are familiar with over eighty percent of Lean; we just don’t know it. Lean promotes greater value for the customer (from the customer’s perspective), with higher quality, better utilization of all resources  (especially our human resources), less expense and increased engagement of staff. I think most veterinarians want the same things.

Lean is the Western name for the Toyota Production System (TPS). Coined for its ability to remove the “fat” (wastes or muda) from processes.  Toyota developed TPS in an effort to rise out of war torn Japan, with its limited resources, to be able to go beyond truck manufacturing for the small, Japanese economy to complete with the American auto giants in a global economy. Since then, most other industries have found successes with Lean, including human healthcare. Can it do for veterinary medicine what it has done for many hospitals and healthcare system around the world? I think it can and that we need to try.

We’re Not That Different, Really

First of all, Lean takes a systems approach to problems. Problems are examined from a systems breakdown perspective before people are blamed. Lean asks “Why did this happen?”, or “How did this happen?” as opposed to “Who is responsible?” As doctors, we work with systems in our patients every day. We understand inputs, outputs, delays and feedback loops, both positive and negative. We know what can happen when one system is changed and how it can affect other systems for the better or the worse.

In order to identify the abnormal, we must first understand what is normal; what is ideal for this species, breed or animal. In veterinary school, we learned normal anatomy and physiology before we studied pathology. The same concept is true for Lean. We must have a very clear idea of what our ideal practice would look and function like. Notice, that I did not say an ideal practice. Lean is not trying to make your practice some management guru’s idea of the perfect “cookie cutter” practice. Lean understands that your practice is unique. The doctors are different. Their biases, philosophies and perspective are unique. The neighborhood where your practice is located is different than other neighborhoods. The mix of your employees is one of a kind. The Lean objective is to make your practice the best “your” practice it can be, now and into the future.

In the Lean mindset, this ideal is called our “True North.”  What would your practice look like if it was perfect? How would your practice perfectly relate to your clients? What would your ideal staff look and function like? How would your practice benefit your neighborhood and community if it is was perfect? It’s totally up to you. What ever you decide your True North is, Lean is designed to get you there. Forget, what a “Top 100 Best Practice” says you should be. What is important from the Lean perspective is that you are closer to your True North today than yesterday; closer this month than last month.  The perpetual destination of the Lean journey is perfection, knowing full well, of course, that this is impossible. The Lean journey never ends. As Vincent Lombardi said, we pursue perfection, knowing we will never get there, in order to reach excellence.

We Know This

As veterinarians, we are already quite familiar with eighty percent, or more, of the Lean methodology. We just don’t know it. Both mindsets are based on the scientific method of problem solving.

When a sick pet comes into our practice, health is our goal, our ideal state. The first step in diagnosing that pet is to understand fully the current state of that patient. We start with the primary client complaint. Regardless of whatever else we discover, we want to make sure we address this problem. Next, we collect a complete history; vaccinations, diet, current medications, symptoms and their progression, etc.

The second step is to perform a complete “tip of the nose to tip the tail” physical exam, paying particular attention to the client’s primary complaint. Can you imagine trying to make a diagnosis without performing a physical exam on the patient?

Next, we might perform diagnostic tests, such as a complete blood count, a general organ profile, urinalysis, radiography, and specific serology tests. We are attempting to explain why the patient is having the symptoms it is having. Medicine is based on facts, objective data, not fantasy.

At this point, we should have a reasonable understanding of the pet’s current state of health. Now, because we know what the ideal state of health is for this species, breed, gender and age, we can identify the problems; the gaps between our patient’s current state and the ideal state.

Based on our problems list, we formulate a treatment plan. This is an experiment. We don’t know if our treatments will work, but we decide, maybe with consultation with colleagues and specialists, what we are going to do. Later, we will follow up with the client and pet in order to analyze if we were successful  at reaching our ideal state of health. If we were successful, we will set a time for the next review, maybe in six months or a year. Remember the 3Rs; Recall, Re-examine or Reminder? If we were not successful, we reflect on what went wrong and start the process over again with additional history, another, possibly more in depth, physical exam, additional tests, a second, adjusted round of treatments (another experiment) and another analysis of the outcome.

As I said, the Lean methodology of management problem solving is also based on the scientific method. The process is almost identical to the one described above for diagnosing and treating sick pets. So how do we know we have problems? Because we have not reached our ideal state in one form or another.

The first step in Lean problem solving is to thoroughly define and understand our current state, just as it was with our patient. This step might include past and current metrics; key performance indicators. What is our story? “The facts, ma’am, only the facts!”

Defining the current state also includes an essential “physical exam.” In Lean, this is called “going to gemba.” Gemba is the Japanese word for the work floor, the place where the work (and problem) actually occurs. For instance, if the problem has to do with surgery, then the surgery room is the gemba. Lean emphasizes the importance of physically observing the flows and processes (the “value stream”) in real time in order to deeply understand the current state as it really is. A big difference in the Lean mindset, however, is that this observation (physical exam) should take place with the staff that are there on the floor, because they know better than anyone what the real issues are. They deal with it every minute of every day. They are an organization’s most valuable asset and resource, especially for helping to identify and provide solutions to problems. Lean promotes partnering with employees in this effort. Our staff wants to be part of the process of finding solutions, rather than always being seen as the cause of problems. This is a big part of what engages them.

Now, as in the diagnostic process, we can identify the gaps between our current state (disease) and our True North (health). However, many problems can appear to be caused by a particular cause when, in fact, it is caused by something much deeper; something more basic. Just as not diagnosing and treating the real problem versus treating symptoms will probably not yield a cure for or patients, not solving problems at their root cause will not provide a permanent solution to the problem at hand.

So, in Lean there is a “diagnostic” called “5 Whys.” This is the idea that one should ask “why” five times to insure the root cause has been identified. A fix for anything less will not solve the problem once and for all. The number five is somewhat arbitrary. It could be four or it could be seven. The idea is to ask enough times that the root (absolute) cause has been identified.

Does it ever seem like you are having to deal with the same problems over and over again? As if you are constantly playing the game “Whack-A-Mole?” As soon as you think a problem has been squashed in one place, it “pops up” again somewhere else? One of the main reasons for this could be the fact that the root cause (the definitive diagnosis) has not been found (another reason could be that your unique, valuable and knowledgeable staff played no part in the process). That it has always only been handled with “Band-Aids.” And, all of this effort is found to be just a waste of time and effort.

Once we know the gaps between our current state and our ideal state, we, in dialogue with our staff,  can devise the counter measures (treatments) we feel are indicated. This is an experiment, also, since we don’t know if it will work. It will give us an idea of what the future state should look like. Since our True North, or ideal state, is perfection, and we know that is impossible,  then the best we can do is aim for the next, improved, future state. Lean is a journey that never reaches its final destination of perfection. It is the process of continuous improvement toward ever better future states. We can never reach our True North, but with constant effort, we can get really, really close!

The final step, as with our patients, is to study the results of our tiny experiments. If the results are positive, then we institute it as the new, best method or standardized work and the staff is trained to this new current state. We will continually, from time to time revisit this process in order to improve it  even more down the road. If our “treatments” does not turn out well, then we (along with staff) will make adjustments and start the whole process over again with different countermeasures and experiments.
I hope it is evident, now, how much diagnosis and treating patients in our veterinary practices is similar to the Lean methodology of management and problem solving. I told you that you knew more about Lean than you realized!


We are all familiar with the SOAP format for writing medical record. “S” stands for “Subjective, “O” stands for “Objective”, “A” stands for “Assessment” and “P” stands for “Plan.” The Subjective and Objective parts define the current state of the patient. Assessment delineates our tentative diagnosis. Plan communicates our, hopefully, successful treatment. It is not the medical record that is so important. It is the diagnostic thought process that is important. We could write medical records with a different format, but the thought process is the same, regardless.

In Lean, the written document is called an A3 report because it was written on an A3 sized (approximately 11 inches by 17 inches) piece of paper which was the largest paper that would fit in a fax machine at the time. It is based on the Deming (named for the American, W. Edwards Deming, one of the first to use statistics for quality control and improvement) or PDSA cycle that is the thought process.

“P” stand for “Plan.” In this part of the report (which typically occupies about 50% of the entire report), we provide a statement of the problem, any 5 Why analyses, the necessary information (e.g. data, charts, graphs, Value Stream maps, etc.) to describe our current state, possibly a Future State map, and any cost estimates relevant to the experiment . 

Following is the “D” or “Do” section. This section delineates the proposed countermeasures we will experiment with. 

Next is the "C" or "Check" (some use “S” or “Study”) portion of the report. Here, we explain and study the results of the experiment. 

The final section is the “A” section which stands for “Act” or “Adjust.” Here, we reflect (hansei) on the results of our experiment. If it was successful,  then we act on the results by instituting them within the practice. If not, we adjust, come up with new countermeasures and experiments in a new PDSA cycle and A3 report. Again, it is not the format of the report that is important (although the idea that everything should be concise enough to fit on one A3 sized paper is an important aspect), it is the process (called A3 thinking) that is.

Because the diagnostic process and Lean problem solving are both based on the scientific mindset, both reports are similar. More that we didn’t know that we know!

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Saturday, May 13, 2017

This Kanban System Works

Several months ago, I helped a practice set up a small, experimental kanban system for drug inventory. This particular system uses a kanban card as the signal to re-order.

The other common system utilizes two bins to hold a predetermined amount of product. When the first bin is empty, it is  removed and placed in a specified place known as a kanban post. From here, someone routinely (determined by standardized work) collects the empty bins and refills them from a central supply area. These bins are then returned and placed under (behind) the bin currently in use. The cycle repeats. This type of system is most often utilized in work areas, such as exam rooms, treatment areas or the lab to manage syringes, blood tubes, gauze squares, microscope slides, etc.

This was the “system” that was used previously. Excess drugs were stored throughout the hospital wherever there was room, such as this exam room cabinet. Notice the somewhat haphazard way the bottles are arranged.  Nothing is labeled. There are two empty slots on the second shelf. What is missing and needs to be ordered? And, how many? How long has this shortage been going on?

This “system” requires a staff member to go to all the the different “nooks and crannies” in order to create a complete drug order. In addition, this person would need to be experienced enough to “know” what belongs in empty spaces and how many to order. Inventory must be taken daily in order to identify depleted drugs, and get them ordered and delivered, hopefully, before a doctor needs to prescribed them. There is no reserved supply to cover the time necessary to get a new order in. Fortunately, for this hospital, orders placed by 10:00a.m. would be delivered by 3:00p.m. Not horrible, but still a gap before anyone can use the drug. For many hospitals, the lead time is days, not hours. Daily ordering also means daily receiving, daily invoice reconciliation, and daily restocking of shelves. That’s a lot of muda (waste)!!

In the new system, a place was found to install a couple of shelf units to experiment with. The drugs and supplies chosen were arranged in alphabetical order, with a few spaces left open for future additions.

The front of the shelves were labeled for each item. A place for everything, and everything in its place!
Even at this point, a missing item would be noticeable and identifiable.

The final step was making and placing the kanban cards (the signals). In order to keep this experiment as inexpensive as possible and to allow for quick, easy changes, I used pink index cards. The cards were bent in an “L” shape so they would stand up and be more visible.

On the front of the cards, I wrote the name of the drug, its size (e.g. milligrams), the unit size (e.g. tablets per bottle), the number of units to order and the number of units to keep behind the card. Our goal with this system was to only need to order once weekly. We wanted no more than two months supply up front, if possible, and, at least, one week's worth behind the card. When a new order comes in, the inventory is rotated by placing the items behind the card in front and replacing the reserve stock behind; a FIFO ( First In, First Out) system.

Now, once a week, a staff member (any staff member, because the system makes this possible) looks at the shelves and records the item, size and quantity to order. Ba-da-bing, ba-da-boom!

An improvement experiment might be to place a bar code on the card and read it with a smartphone or tablet into a form to be faxed or transmitted directly into a vendor's ordering software.

There are several Lean concepts here.

  1. It is visual. With a single glance and one can see what is needed and what is not.
  2. Just-In-Time. Item are only ordered when they are needed and in the amount needed, but before they run out completely.
  3. Elimination of waste (muda). Wasted time in ordering, receiving, reconciling  and shelving, i.e. once weekly vs once daily. Wasted space in warehousing large amounts of inventory. Wasted use of capital that might be needed for other situations. And, wasted transportation and motion by the vendor. Increased workload on the rest of the staff to “cover” for an employee to handle inventory on a daily basis.
  4. Use of  small, inexpensive, manual systems to experiment with and work out the “bugs” before investing in and expanding the system to include all other drugs or supplies, such as office supplies, or implementing more advanced technology, such as expensive and cumbersome software.

I had the opportunity to speak with the doctors and staff last month. They are still using the system and admitted that it has resulted in near zero shortages of these drugs. They were planning to expand it to other areas in the very near future.

Thanks for visiting? Comments and questions always welcome.