Monday, December 3, 2018

Acknowledgements For My In-Progress Book "Lean Veterinary Practice Management"

I know it is not typical to publish acknowledgments separately, outside of the book and in a public forum. But, it is important for me to do so.


I have been so fortunate, in my life and career, to have been part of a profession that has been both rewarding (and frustrating!) and self satisfying (and humbling!). A veterinarian is all I ever wanted to be. I never had a backup plan, so it is good that it all worked out!

In the book Honey From the Rock, Lawrence Kushner, writes about Malachim Elyon, ordinary people who, knowingly or unknowingly, act as a messenger from God to intervene in the lives of other ordinary people in their times of need. We all are called for these “errands”, whether we know it or not. I have come to recognize, at least, some of these angel messengers.

I grew up in El Paso, Texas. It was there that I became interested in Veterinary Medicine. My second home, during my high school years, was Northeast Veterinary Clinic, and one of my second “Dads” was Dr. Robert Morrison, of blessed memory. He, more than anyone, helped to solidify my determination to pursue my “calling” of Veterinary Medicine and exemplified, for me, what it truly meant to be a healer for “creatures great and small.” Thank you, Doc.

The veterinarians of El Paso, Texas, are a unique group of individuals. Maybe, because they  were all trying do the same, often difficult and thankless, job in a place that is somewhat isolated in many ways; but mostly because they were just good people!  While we were friendly competitors, we all knew we were colleagues first and foremost, working toward the same honorable goals; we always had each other's “backs.” Of special importance to me were Dr. Bernie Page, Dr. Guy Johnsen, Dr. Robert Rohrbaugh, Dr. Robert Garrick and Dr. Ed Silverman. You all have been very special and very needed in my life.

My dad was a mechanical engineer with an incredible life story. He built a power plant in El Paso, TX, a dam on the Roanoke River in North Carolina, the first radio telescope at Green Bank, West Virginia, and a radiation fishery in Gloucester, Massachusetts, that preserved fish fresh off the boats for more than a year without refrigeration. We owned a toy store later in my youth (not as cool as one might think) and I learned the fundamentals of entrepreneurship and the discipline it takes to be self employed.  

He was my first teacher of the scientific method, of understanding flow, of the Plan-Do-Study-Act cycle (though it wasn't formally taught as such), continual improvement, deep understanding, self reliance, the importance of education, honoring yourself and your family, and of respecting everyone. He was “Lean” before anyone knew that term. Dad, I am so happy that my soul chose our family to be born into. I miss you everyday!

Several years ago, after discovering the Toyota Production System, or Lean, I reached out to Mark Graban. Mark had already firmly established himself as a world-renowned expert in Lean Healthcare. He has authored or co-authored three books: Lean Hospitals, Healthcare Kaizen and The Executive Guide to Healthcare Kaizen, two of which have been awarded the prestigious Shingo Research Award. He acted as Editor for a fourth anthology book, Practicing Lean, which contains practical Lean experiences with contributions from many of his colleagues. He has also published a fifth book dedicated to Process Behavior Charts, a book titled Measures of Success. Mark writes a post almost every day for his blog He lectures across the globe, holds popular Lean workshops, hosts webinars, is part of the leadership of KaiNexus, a software company, is an advocate for patient safety and has a Lean consulting business. 

As if that weren't enough, he took on a “geeky” veterinarian who knew just enough about Lean to be dangerous, and has been such a friend and mentor to me since that fateful day. He has been my co-author for several articles about Lean in veterinary journals, co-presenter for a lecture on Lean in Veterinary Medicine at a Texas state veterinary conference and continues to edit (i.e. make intelligible) my blog posts at 

In the ancient and honorable Japanese tradition, Mark is truly a sensei; a master and a teacher. Arigato, Mark.

People often say that they married their soul mates. But, with somewhere around fifty percent of marriages ending in divorce, finding your “true soul mate” evidently takes, at least, two tries. 

That wasn't the case with me. Chris recognized me as soon as she met me! Fortunately, I was aware enough to see the same in her. She was a client of my veterinary practice (imagine that!). Since then she has been my best friend, my wife, my teacher, my guiding light, my sun and my moon. She knows me better than I know myself. Just ask her!

But, it is true. She has an old and gentle soul. I often think of her as the Merlin to my Arthur; my guide in the physical and metaphysical worlds. If there was ever a “messenger of God” sent to someone in need, Chris has been that for me. God has indeed blessed me! I love you more!

In addition, Chris has given me three of the most wonderful children, Paul, Caitlin and Corinne. They have arrived at adulthood with intelligence, common sense, good hearts and the same gentle soul as their mother. Being a father to this group has, almost, been too easy…almost!

For the past seven years my family has indulged my constant obsession with the Toyota Production System and Lean. They have been my de facto sounding boards, proofreaders, editors, “critiquers”, champions and cheer squad. They have learned more about Lean than they ever really wanted to. For this, for their unwavering love and for their perpetual respect, I am truly humbled and so deeply appreciative. Thank you. I love you all.

Chip Ponsford
Dallas, Texas
May 2018

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Wednesday, November 7, 2018

Lean Veterinary Strategy Deployment (Hoshin kanri)

Hoshin kanri is a Japanese word for strategy deployment. It literally translates to mean “compass management.” It is the process of introducing and aligning the organization’s True North vision down through managers to the frontline staff. It consists of a series of PDSA cycles complete with consensus building (nemawashi) and playing “catchball” along the way.

The first PDSA cycle is undertaken among leadership. It is here that the concept of True North is defined along with the four to six (typically) high-level focus areas and their metrics

When looked at as a whole, these few focus areas should completely define your practice. In other words, monitoring the metrics of the focus areas should give you a high-level indication of how the practice is functioning. If these metrics are improving, then the practice should be improving, also. The lower level metrics will compliment these metrics by highlighting the more detailed processes.

This a true PDSA cycle in that all of the stages (Plan, Do, Study, Adjust) are completed and what is eventually chosen is not written in stone. It is an attempt at alignment; high-level standardized work. It is an experiment. If the True North statement turns out to be inadequate in some respect, then leadership simply adjusts and starts a new cycle. A3 reports can follow the process in order to keep stakeholders up to speed.

The second cycle is between leadership (Owners, C-suite, etc.) and supervisors (lead receptionist, lead surgery techs, lead hospital tech, lead groomer, lead boarding tech, etc.). Again, consensus building is of prime interest. This is not the typical management philosophy of “command and control.” It is a typical Lean “bottom-up” endeavor with "catchball" input from leaders. Leadership introduces True North focus areas to the supervisors and, then, mentors and coaches them in order to help them to decide what True North would look like at their level.

and what processes they'll need to monitor in order to help ensure the top focus are metrics are positive. Again, this may be subject to adjustment after a period of experimentation. A3 reports are kept current.

The third cycle is between the lead staff and the frontline workers. It proceeds similarly to the cycle just described.

So, what we now have is is an overall alignment of the practice from leadership through lead techs down to frontline staff. How that looks and what metrics are monitored will vary based on the the different areas of the practice. 

For example, we might have a True North focus area of "Processes Improvement." This applies to everyone. However, at the lead and frontline level, the metrics are different between, for instance, receptionists or exam techs or surgery techs, etc. Their metrics will be determined by what that focus area means to them from their perspectives. 

If all of this is successful, then everyone, from leadership to frontline staff, should have a hold on the same rope, on the same end, pulling in the same direction and at the same time...and winning!

Mark Graban's 4 Hypotheses of Strategy Deployment

Mark has described strategy deployment as a series of four hypotheses in a series of two blog posts - here and here:
 1.  If we focus our improvement efforts and close performance gaps in our four or five True North areas, we will therefore perform well as an organization, this year and into the future.
For example, if we choose Client education, Staff development, Community involvement, Fiscal responsibility and Hospital improvement as our five True North focus areas, then we posit that if we are successful in these areas, the practice as a whole will be successful. In other words, these five areas are the best five areas to monitor in order for the overall practice to be successful. 
Remember, this is your True North statement with your focus areas for your practice with your staff and clients. 
Is this the right True North? We don't know.  But, we will start with these and experiment. If it is determined these are not the best five, we can adjust them and try again. Just like treating our patients. If one diagnosis or treatment is not working, then we “back up" and try again
What are the four or five focus areas that make up your True North and that, if successful, will results in a high probability that the hospital/clinic will be successful overall.
   2.   If we can improve and close our performance gaps in these key performance indicators, we will satisfy our need for improvement in our key focus areas, and therefore will be successful as an organization, overall.
What are the metrics (two or three per focus area) that will show that our focus areas are heading in the right direction (which, in turn, indicates that the whole practice is headed in the right direction).
Are these the right metrics? We don't know, but we'll try them for a while and then evaluate our decision. If they are the right metrics, why? If they aren’t, why not? It is important to deeply understand both of these scenarios in order to learn.
Are these metrics still relevant to your organization and staff?
3. If we actually execute and complete these top X initiatives,  projects, events and A3s, then we will make the greatest strides toward closing the key focus areas (Hypothesis  2) and therefore we'll be more successful in our strategy.
Not everything can be a high priority. It is easy to get sidetracked and pulled off task. You have already prioritized in the last hypothesis. Stay focused. Close the performance gaps in these focus areas in order to get the greatest gains, then you can start over with other focus areas. Err on the side of too few initiatives (so you can actually get something accomplished), rather than too many (and none of them get done or done right). With experience and reflection, you will get more accurate in choosing the number of areas you can tackle without the whole team becoming overburdened. 
4. We actually have the organizational capacity to complete these top X priorities in a year or a given timeframe (and with the right quality).
Do we have the capacity in terms of personnel, resources and capital to actually accomplish these priorities in a timely fashion? If not, then either we obtain them or deselect this priority in favor of another one that can be accomplished at this time.

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Monday, October 15, 2018

You're invited! ... to help me write the first Lean book devoted to veterinary practice

I am ready to start the process of publishing my book on the Toyota Production System,  or Lean, for veterinarians and veterinary staff. This process will use Lean methodology, so I invite everyone who is interested to participate by leaving comments and questions as I go forward. This will be the first book about Lean devoted to the veterinary profession.

I have decided to utilize for this book. The book will initially be published in multiple e-book formats with, hopefully, a paper version later. uses the Lean mindset of starting small, then iterating quickly and updating frequently based on reader feedback. 

So, I will start uploading a new chapter every couple of days to a week. At the same time I will update previous chapters and republish them. I will keep everyone updated through LinkedIn and my blog,

With,  a minimum price and a suggested price are listed. You can get the current version of the book, and all future updates, for either of these prices (or more if you would like for me to get paid more). You decide. At the beginning, the minimum price will be free and suggested price will be $4.99. As more chapters and updates are published, both prices to purchase the book will go up slightly. I anticipate the final suggested price to be around $16.00.

My plan is to use the majority of any proceeds to go towards the continued teaching of Lean principles through lecturing at professional veterinary conventions and the development of staff workshops. Maybe, one day in the future, we can all come together for an annual Lean Veterinary Summit. 

The book covers the majority of the Lean methodology that I have learned over the years of study and presents it from a diagnosis and treatment perspective that veterinarians and their staff are familiar with. Just as our patients are composed of different systems, have a defined state of health and can develope problems which require an objective methodology of diagnosis and treatment, so, in actuality, do our practices. The chapters are designed to follow the same path we traveled as students in veterinary school and our daily diagnostic methods. With your help, as knowledgable and respected stakeholders in our profession, we will be successful with this new beginning; a new paradigm of veterinary practice management. 

Here is the working Table Of Contents:

Physiology: Some basics
  1. Systems
  2. Value
  3. Customer
  4. Flow
  5. Value Stream
  6. Just In Time
  7. Push vs Pull
Health: True North
Pathology: The 3 “M’s”
  1. Waste
  2. Overburden
  3. Variance
Physical Exam: Establishing the Current State
  1. Gemba
  2. Value Stream Maps
The Working Diagnosis: Gaps and Root Cause Analysis
  1. Gaps = Problems
  2. 5 Why Root Cause Analysis
Treatment: The Lean “Medical Bag”
  1. Eliminate Wastes
  2. Standardized Work
  3. Kanban
  4. 5S
  5. Visual Management
  6. Poka yoke
  7. Andon Cord
Records: A3 Reports
  1. Scientific Method
  2. SOAP
  3. Deming’s PDCA Cycle
  4. A3 Reports
  5. Nemawashi: The Importance of Consensus Building
Kaizen: The Environment of Continuous Improvement
Process Behavior Charts: The Voice of the System
Where To Start
Continuing Education
  1. Further Reading
  2. On the Web
About the Authors
  1. E. E. “Chip” Ponsford, III, DVM
  2. Mark Graban MS, MBA

So, the first step is choosing a title and sub-title so I can get a couple of book covers designed to choose from.

The current leanpub title is

Lean Veterinary Practice Management (Click here)

Here are my ideas. Notice I have placed a number in front of each title and a letter in front of each sub-title. I have paired a title with a sub-title, but you are welcome to suggest a different combination in the format #/A to make it easy, or an entirely new idea. 

(1) A Strategy of Excellence 
(A) A Lean Guide For Veterinarians 

(2) The Lean Veterinary Practice 
(B)Higher Quality,  Lower Costs, Less Waste, Better Resource Utilization  and Greater Staff Engagement  

(3) Towards Your Ideal Practice 
(C) Making Your Veterinary Practice the Best Your Practice It Can Be

(4) Lean Veterinarians 
(D) The New Science of Veterinary Practice Management 

You can vote by leaving a comment on this post or email me at

Please participate. I value your input, suggestions and questions!

Saturday, October 13, 2018

Lean Veterinary Scoreboards

In my last post, I discussed the difference between Management By Means (MBM) versus Management by Results (MBR). MBR means only focusing on the end result of the metric or KPI (and hoping the means of getting there are efficient and value-adding processes) or focusing on the processes that lead to that result, understanding that if all of the processes are behaving as designed and under control, the end result is a reasonable assumption. Too often with MBR, dollars is the only metric.

So, I wondered, could it be possible (theoretically speaking only!) to successfully manage a practice without actually measuring any money related metrics? And, what would that look like?

In other words, without tracking gross income, average client invoice, payroll expense as a percent of gross; any money metric?

What non-financial Key Performance Indicators (KPIs) could be used to assure the monetary goals are met? The trick is to be able to identify all (or many) of the processes that are components of the money goals and to assign a metric to adequately monitor those processes.

For example, Average Client Transaction is composed of gross income divided by the number of client visits. However, these two components are the result of other systems, such as fees, reminder efficacy, ease of appointments, number of incoming calls that result in a busy signal, hours of operation, client satisfaction, medical record audits (% of services performed that get invoiced) , etc.

Here is a list of some of the non-monetary metrics I came up with in order to manage a veterinary practice:

  • Door to Doc time 
    • The time from the moment the client enters the practice to the time they see the doctor; a measure of flow and, therefore, value to the client.
  • Number of unscheduled follow-ups
    • The number patients needed to be seen a second ( or more) time in order to get resolution of the pet's condition. Notice this is not scheduled follow-ups for additional treatment, tests or monitoring.
  • % visits scheduled for recall
  • % recalls made
  • Response to 1st reminder
  • Response to 2nd reminder
  • Response to 3rd reminder
  • % pets current on RV (rabies vacs)
  • # client surveys returned
  • # of client referrals
  • % staff completely cross trained
  • % dogs current on HW (heartworm) prevention
  • % pets current on flea prevention
  • % blood sample hemolysed
  • # of blood samples requiring redrawing
  • % of medical rounds performed on time
  • # idea (kaizen) cards submitted
  • # idea (kaizen) cards/ staff
  • # idea (kaizen) cards completed
  • % idea (kaizen) cards completed
  • # staff injuries / time period
  • # pet injuries / time period
  • # of adverse anesthesia events
  • # of drugs or supplies found to be out of stock
  • % blood sample hemolysed
  • # of blood samples requiring redrawing
Some of these probably have sub-systems or sub-processes that might require monitoring and, thus, metrics of their own.

I am not proposing that no financial KPIs be watched. Veterinary practice is a business, after all. Some financial metrics are important and necessary. (However, they shouldn't all be financially focused, either.) Maybe we have not thought about the role that systems, processes, quality, waste, and flow plays in the money numbers; the Lean mindset. Maybe we should not worry as much about the end results and concentrate more on how we get there.

What metrics you decide to monitor is up to you and your staff. Remember, Lean is about making your practice the best "your" practice it can be, not a carbon copy of the practice down the road or on the other side of the country or, even, what a management guru says it should be in order to conform to some cookie cutter model. Your True North and your team (and some experimentation) will decide what metrics are important.

There would be high level, focus area metrics for leadership to monitor, sub-system metrics that managers would monitor and, still another layer (sub-sub-system) that frontline staff would create. These metrics are all aligned and make up your management scoreboards. Incidentally, this is an example of visual management.


Note that these layers generally flow down from our True North statement (they're top down, but there's input from lower levels along the way). Leadership metrics arise from our practice's focus areas. They check the destiny or course of the ship. Are we heading in the right direction?

The middle and lower level metrics, created by the people responsible for that work (with some input from their leaders), check the systems and processes that make up the focus area (leadership) metrics. Are we getting to our destination with quality, safety, effectiveness and without waste?

This flow is, in essence, what Lean strategy deployment (hoshin kanri) is all about; getting the ideals of the practice down to the floor (gemba) and aligned throughout the practice. It is everyone pulling the same rope, from the same end, in the same direction and at the same time.

The routine of management and frontline staff huddling together in a safe, honest and trusting environment every morning to discuss the scoreboards is Lean Daily Management; a topic of later posting.

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Wednesday, August 29, 2018

Management By Means

There are several reasons why some organizations have had difficulty obtaining the kind of results with Lean that Toyota has. One of the main reasons could be that they confuse the use of Lean "tools" with the incorporation of  the complete Lean philosophy and mindset deep into their DNA.
Take, for example, the difference between Management By Means (MBM) and Management By Results (MBR), also known as Management By Objective (MBO).

With MBR/MBO, management sets the goals (usually financial) for the metrics. The objective of the organization is to reach the goal, without much attention to the processes or methods involved. Leaders might say things like, "I don't care how you get the results, just get it done, no matter what." Pay incentives or threats of dismissal often can, at different times, be part of the conversations and scenarios. 

Look at the Process Behavior Chart below, which shows only the last data point (for a metric where higher is better). 

This is typical top-down management, which is common in the West. Workers do whatever they feel necessary in order to arrive at the goal by the deadline set by the forces that be. The method or means of getting there is a distant second concern. The focus is the end result.

One of the problems with this approach, as seen below, is that the systems and processes, if they were exposed, may be riddled with errors, defects and/or fraud (ala Wells Fargo). There is a lot of variation which implies the systems and processes are not as tight as they could be. In addition, notice there is a recurring pattern to the data-- three weeks of down data followed a an up data. This very well could indicate that, for three week every month, the employees not hitting there number until the week before monthly reports come out. If the reports only show the ending point for the current month, leadership is happy (and leaves the staff alone!) 

MBR is similar to trying drive by looking in the rearview mirror. 

Workers have no control over systems. They are at the mercy of systems, good or bad. It is management or leadership that is responsible for the system in place. As such, if results are not predicted to be good, then the only pragmatic way they can affect the result, and not be disciplined, is to "fudge" the system somehow. 

In a bad system, no amount of motivational rhetoric, monetary prizes or threats is going to change the system. The system gets changed by the "uppity ups" changing the system. An object in motion tends to stay in motion in the same direction unless some external force is applied to the system. That isn't part of the job description (or domain) of workers.

MBR is managing the results

By contrast, MBM is focused on the processes and systems ("the means") that lead to the results ("the ends"). The metrics of MBM monitor the systems involved. The idea is that if all of the processes are stable and positive, then the results are a foregone conclusion. It is much more of a bottom-up style of management since the staff is much more involved in choosing the metrics and monitoring the day to day functioning of the organization. The journey is as important as the destination.

In the graphic above, we really don't need to see the final result (below) to have a reliable expectation that it will be where it needs to be. In addition, we know that our systems and processes are probably functioning properly and free of waste. While there is some variation, they appear to be under control. 

(Notice that three out of the last four data points are closer to the upper limit,  which indicates that the system has changed for the better; improved. If we do know why this has occurred, we need to investigate in order to understand how to continue this trend.)

MBM is managing the processes; the operations

This is the management style of Toyota and promoted by Lean. People often say, "The right process brings the right results." We care about results... but you manage a process, not the results.

Lean is all about objective systems thinking!

I will continue with the next idea in this theme in my next blog "The Practice Scoreboard."

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Saturday, June 23, 2018

A "Supersize" Father's Day

I’m taking a little break from my usual Lean topics this time around for a little pet fun.

Let me introduce you to “Supersize”. “Supersize” is a nine or ten year old, steel blue, neutered male, short haired cat. We obtained him from my mother-in-law when he was just a kitten. Ever since he has been my “best cat buddy” and has trained me well. Every night, around 8:30, “Supersize” starts meowing at me to let me know he is ready for bed and that I need to lay down so he can crawl next to me and go to sleep. Typical cat; always thinking they are in charge (which they are!) and bossing everyone around.

Several years back, I was trying sleep in late one Sunday morning, when I heard a lot of commotion out in the kitchen and could smell the pleasing aroma of fresh coffee brewing. I looked to the other side of the bed to see if my wife had woken up early. She had not. There she laid, sound asleep. So, who could be up at this time of morning making coffee? I went to investigate and this is what I found…

It was “Supersize” relaxing in the recliner with some fresh ‘joe’ in his favorite cup.

But, I was even more surprised this past Father’s Day, when I found the gift below packaged in an appropriate gift bag.

And, he even signed It.

What is really impressive, however, is that he ordered it himself on the internet.

I didn’t even know he had a credit card!!

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