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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Thanks for reading. Comments always welcome. Please, let your friends and colleagues know about the blog.