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?

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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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