Monday, December 2, 2019

Status Quo Begets Status Quo

I have been listening to the book Brave New Work by Aaron Dignon. Have you read it? I find it very interesting. 

When talk we (I) think about Process Behavior Charts (PBCs), it is usually in order to filter out the “noise” and highlight any “signals" in our metrics; to determine if we are still within the Natural Process Limits (NPLs). A PBC that stays within the NPLs indicates the system which the metric is monitoring is working as it was designed. Any data outside of the NPLs is one (of three) of the signals that indicates something has changed in the system, necessitating the need for closer scrutiny.  A PBC is referred to as the “Voice of the System” (VOS).

But the corollary to this is: 

If you are not happy with where the metric is charting, then in order to improve the chart, it means changing (improving) the system; the thinking and approach. 

As Dignon points out, if we want a 10-fold increase in production, we pretty much intuit that that will require major changes in our thinking and approach; the system. But, if we are only looking for a 10% improvement, somehow, we think that that can be achieved by "status quo " thinking. He calls this the "status quo bias." Any change in the metric requires a change in the system; the thinking and approach.

Even the modest 10% change will require different thinking and approach. Status quo thinking will only lead to status quo results. So, when the Practice Manager or area director (or even the C-suite) issues a new goal or benchmark for the new year or next operating period, then our response should be, "Great!! What are you all going to change within your thinking and approach (the system) to result in any chance of hitting that new goal?” Because, without that change first, the new goal 'just ain't going to happen!' Commanding it to happen or incentivizing it to happen or threatening if it doesn't happen will not make so.

Status quo begets status quo!

Remember, operational systems are created by and are the responsibility of Management. Workers are at the mercy of systems! 

Come join Mark Graban and I at the 2020 AVMA Veterinary Leadership Conference in Chicago as we facilitate the audience participation workshop of W. Edward’s Deming’s “Red Bead Experiment” which was designed to illuminate these concepts and more. 

Wednesday, September 18, 2019

Why Lean Is Important: From An Informed Client's Perspective

Today's post comes from Gerald Cronin of the Vivarium Operational Excellence (VOE) Network.

The VOE Network is a worldwide group of Lab Animal and Biomedical veterinarians and experts that have discovered and been successfully utilizing the Toyota Production System, or Lean,  to reduce valuable research costs while at the same time improve research quality and animal quality of life. 

From thier own website:

"Every modern industry and organization has been influenced by the operational advances of the Toyota Production System, the thinking that made Toyota the #1 auto manufacturer in the world.   Decades of research has proven that Toyota's systematic approach to improving operations has tangible long-term benefits to customer service, quality, productivity, adaptability and ultimately to reduce costs."

"The Biomedical Research community recognized these advances over a decade ago and thus began the adaptation of systematic continuous improvement techniques to the Lab Animal Industry.  Consistent with Toyota's philosophy of "sharing what they have learned from over 50 years of experimentation with the world", the Biomedical Research community understood that together, we could improve operations better, faster, cheaper if we shared our knowledge with each other." 

"With over a decade of experience, the VOE-Network was born to help the entire animal care community improve operations through members' experimentation, learning and sharing."

"The Vivarium Operational Excellence Network is a consortium of animal care institutions and companies committed to quality clinical and veterinary research driven by operational excellence.  We are a members-run organization that responds to the evolving learning needs of its members.  Learning spans the organizational spectrum from front-line technicians through Webinars, videos and Lean Belt certification to leadership skills gained from our Leadership Academy events and offerings.  We also look to industry for insights into the best ways to improve operations as well as ways to build a problem-solving culture."

Today's post:

I took my dog to a large Veterinary practice about a year ago and needed to use the restroom.  The restroom was tucked inside the clinical staff area, so I needed to navigate through some hallways to get to where I needed to be.  Along the way, I was able to see “behind the curtain” of this operation.  I was disturbed to see rooms full of medical supplies in random areas, cardboard boxes both opened and unopened piled on top of each other, medical devices stacked on top of unfolded towels and on top of unopened boxes, there was almost zero floorspace for staff to move around.  Random bottles that looked to contain some sort of medication were in random locations.  Then there was the office with piles of paperwork, computer terminals were poking through the mess, almost as if they were struggling for air.
The staff was walking from room to room and asking each other “have you seen the (X clinical item)?”  “Did you call Mrs McGillicuddy or was I supposed to”? “Sorry for the wait, Mr. Cronin, we’re really busy today” and “We will need to schedule your next appointment, we were hoping the machine would be ready today, but it’s in need of maintenance”.

I made it to the restroom and got to see more of the same on the way back. The trip made me pause, as I now questioned the quality of care my dog was about to receive.  I’m also thinking about what I was going to get billed for and why I need to come back. Piles of inventory and random clutter, medications that didn’t seem to belong there, medical devices mixed with cardboard boxes filled with supplies 3-boxes deep.  Machines that should be operational but are not. The red flags were popping up everywhere.  What am I paying for?  Can I trust this clinic?  Who can I trust here? Do they know what they are doing?

You can tell a lot from what you see in a clinic. Maybe some of the judgements are assumptions, but often they are pretty accurate. The telltale signs of disorganization, the questions staff ask each other, the delays, the missed information, the clusters of inventory that often contains expired materials; all give me the chills, no matter if I’m going for my annual physical or if I’m taking my dog to the Vet.   To me, the paying customer, they all tell a story of wasteful processes that I know are built into my bill.

I’ve been a Lean practitioner in healthcare for a few years, watching and helping clinical teams improve their care to the patient in the bed. If they can do more for the patient in a better, easier way, they are all over it.  I now work in the Veterinary world, and I have seen amazing transformations of quality of animal care and improvements to the Veterinary staff quality-of-life by focusing on improving small (sometimes tiny) process that support their daily work.  It’s so exciting to see folks enjoy the teeny challenges of improving their own work. Lousy processes are like “pebbles in your shoe”; workers agonize through the customs and clutter; given the chance, they would stop and remove the pebble to make life better.  Lean thinking does just that for workers, and the animals and their owners benefit exponentially. 

If you ever feel frustrated, rushed, frazzled, buried by complaints, or workers constantly asking questions looking for “common sense’ answers, the prescription may not be buried in a store room or office, but right here, sitting out in the open at no charge to you.  The world of Lean thinking is liberating, and Lean thinkers are eager to share their learnings and experiences with you.  We are here to help you; we’ve all been through the same frustrations and we found the prescription.  Take one small dose daily; you will be amazed at how your quality of life will improve. (My dog is OK by the way).

Gerry Cronin
Vivarium Operational Excellence Network

Tuesday, September 10, 2019

Prepare To Promote, THEN Promote

It seems to me that, on balance, there is an inordinate amount of attention and money spent on advertising, optimizing social media presence and attracting new clients without much thought being given to our practice systems and foundations. Of course, marketing is necessary and important, especially in this day and age. But beware of "putting the cart before the horse."

Make sure you are as close as you can be to your True North; that you have done everything you can to reduce wastes, improve quality and flow, utilize resources effectively and maximize value to your clients from their perspective before you embark on PR projects. Marketing poor systems and value streams is not the kind of PR you want.

My new book is now available through Kindle!

Thanks for stopping by.

Monday, April 29, 2019


Respect for people” is a fundamental principle of Lean and a major difference between Lean and the Western, more Taylor-esque, concept of management. The Western tradition, which is still a part of educating MBAs, is that management knows best and makes all decisions. Workers are to do as they are told.

There is a quotation by Henry Ford to the effect that the problem with workers is that, not only do they come with two hands, but also, unfortunately, a brain. Workers are not hired to think! Lean is much less of a top-down style of management, and much more of a bottom-up, inclusive, transparent style. This is not to say, however, that the asylum is completely handed over to the patients.
This core belief influences the relationship Toyota managers and supervisors have with their workers. For Toyota, management’s primary function is more of teacher and less of an organizational police officer. We now understand, more than before, that the focus for Toyota is not just on building quality automobiles, it is primarily focused on the building of problem solving, innovative, respected employees who, then, build quality, innovative automobiles.

Dealing with people from a basis of respect permeates every aspect of Lean.

Systems thinking:
Have you ever had the feeling that, at some point at work, you were damned if you do and damned if you don't? Or, that you are in the the middle of a Catch-22 situation? If so, you have probably been the victim of poor systems or systems colliding with each other. That feeling of not being in control or at the mercy of things bigger than you.

Thinking in terms of systems means understanding that the systems at work within an organization are management and leadership designed. Systems are the responsibility of management. Workers have no authority to control or overhaul systems. They are at the mercy of the systems. Yet, many times, staff are blamed for what is, in actuality, a system design problem.

For example, if a job is not being performed well, systems thinking would first consider such things as does the worker know that job is their responsibility, has the worker been trained adequately, does the worker have the necessary tools, and does the worker have timely and correct information?

Systems thinking is more respectful. It recognizes that systems should be investigated when problems occur before blaming people.

The Lean definition of value is that which the client wants and is willing to pay for, and that improves the health status of the pet, without defects and waste along the way. Our clients get exactly what they want, when want it and in the amount wanted. They pay for only value adding services. The concept of defining value from the client’s point of view shows respect for them.

Variance and overburdening:
Lean understands that large variances in workload can be the source of difficulties and overburden our staff. Lean suggests work loads try to be leveled as much as possible. Being watchful for the overburdening of staff comes from respect.

The Just-In-Time (JIT) concept is the procurement and delivery of resources, (whether that be drugs, supplies, access to diagnostic equipment and information, or patients, doctors and staff) just exactly where it is needed, just exactly when it is needed, and just exactly in the amount needed. Nothing more and nothing less.
With respect to staff and personnel, the Just-In-Time idea is based, in part, on recognizing and respecting the unique value of everyone's time and skills; to only use them when, where and in the amount needed.

Standardized work is the mutually agreed upon method to do or handle a certain process or situation that helps insure quality, timeliness and safety, and gets everyone on the same page working in the same direction. It shows respect by involving staff in its definition and formal writing, and by eliminating ambiguity and the anxiety it causes to workers that come from policy and process chaos.

Kaizen is a Japanese word that can be translated to mean “good change,” “change for the better,” or “continuous improvement.”

While improvements can be large, time consuming and expensive major changes, the most common are the small, daily, quick, inexpensive ideas submitted by staff that improve quality, flow, safety, value to the client and make work life just a little easier. Staff are on the frontline of our practices every minute of every day. They know, better than anyone, where and what the problems are. And, they probably know better how to remedy them than we owners and managers do.

Kaizen shows respect by recognizing what an asset our staff is, and allowing them to partner with us in improving the practice; to be engaged and be part of the solutions, rather than always being blamed for the problems.

5S projects are the physical cleaning and reorganization of a particular room or area of the practice. It helps the staff to work with less clutter, frustration and confusion on a daily basis. It creates better flow within the hospital which increase value to clients; all ways of showing respect.

Go to gemba
"Genchi Genbutsu" (go and see) means that whenever there is a problem found, all relevant stakeholders (management and staff) should go to where the problem occurs (the “gemba”) and solve it together. It shows respect by recognizing that staff have valuable input to the situation.  

On the Toyota production line, workers are provided with a mechanism to sound an alarm and ask for help anytime they find it necessary. The line stops if the problem is not quickly resolved. Toyota trains and trusts its employees to use the Andon cord when an issue of quality or safety is in question. It shows respect by creating a culture of safety and trust for anyone to speak up, even if they think there might possibly be an inkling of a concern.

It is my humble opinion that if veterinary staffs knew about and understood the Lean mindset and its worker-centric (and client-centric) philosophy, there would be such a grassroots revolution within the profession that owners, managers and corporation leadership would have no choice but to start thinking Lean within their practices. Maybe, we could start now and circumvent all of the "bloodshed."

Thanks for stopping by. Please share this blog with your contacts! And, let me know if you have any questions, comments or post ideas.

Friday, April 19, 2019

Toyota Kata

This is a continuation of the last post dealing with the training methods taught to Japan by the U.S.'s Training Within Industry after WWII. As explained in that post, the three TWI J-courses had a major influence on several of key concepts of the Toyota Production System, namely Standardized work, respect for workers and continuous improvement. But, true to Toyota’s character, they took that information, put their own “flavoring" on it, and developed what Mike Rother calls Toyota Kata.

Kata comes from  the world of oriental, martial arts. It means “form.” There are two primary kata; Improvement Kata and Coaching Kata.

Toyota Improvement Kata

When we think about the distance between where we are currently and our True North (or any other challenge), it can seem immeasurable. Or, the idea of a Lean transition and all that that entails can seem overwhelming. But, handling these emotions comes down to the metaphorical concept of how to eat an elephant; one bite at a time. Improvement kata is the standardized work for taking each bite.

The first step is to have a good understanding of where you are going; your direction, your True North or the challenge before you. In the figure above, “CC" stands for our current condition and “TC" is the target condition. The target condition is what we feel is the next logical step on our journey to True North or our goal. Part of the journey to our next TC is clearly visible and we have a very good idea how to get that far. But, after that, there is the part that is less knowable. It is more obscure, intimidating and without a clear plan. So, how do we get through this part of the quest? We PDSA our way through it.

We make a plan, experiment and see if we get closer to out target condition. The path that this takes us on is not necessarily straight. There will probably be some “zigging" this way and “zagging" that way, but through the use of A3 thinking, we will reach our TC. One bite gone! Eventually, by continuing to identify each next successive “bite" (target condition) and repeating the process, we get closer and closer to our goal. This is the essence of the Improvement Kata.

Toyota Coaching Kata

As the name implies, the Coaching kata is the standardized work for managers to mentor and monitor individuals and groups involved in improvement kata. It consists of five questions:

As you probably can tell, these questions are simply asking the group to visualize and verbalize the PDSA cycle.

  1. Where are you trying to get to? What is your direction or challenge and what is your next target?
  2. What is your current condition? Where are you now?
  3. What is one thing that is keeping you from reaching the target? What are the problems? If there are more than one, then deal with this one now, and come back to the others later.
  4. What countermeasures are you going to try and, if successful, what will that future state look like?
  5. When can we study and evaluate that experiment?

You may have several groups, each trying to reach the next target condition of their improvement project, but for you, as the coach/mentor, the questions remain basically the same. Rather than solving the problems for them, you are asking questions that will lead them, through A3 thinking, to solve their own problems, learn, and deeply understand the process. Coaching is a scheduled, periodic endeavor, much like Lean Daily Management, but less frequent. We are monitoring that the project is on task and progressing appropriately.

Thanks for reading. Your comments, suggestions, ideas and questions are always appreciated.

Monday, March 25, 2019

Training Within Industry: A Closer Look At the Job Instruction Course

With this post, I take a closer look at the Training Within Industry's Job Instruction course that I introduced in the post "The Origins of Lean Are Not All Japanese." One of the reasons, from a systems viewpoint, staff may not be performing well is inadequate training.

Job Instruction (JI) course

This course was designed to teach supervisors how to teach new workers. These people knew their jobs well and had a lot of experience, but many didn't understand how to teach someone else. This course showed them how to dissect the job into its individual steps and provided them with a standard way of instructing on a step-by-step basis. This was the nidus for Lean standardized work.


Have a Time Table--
   how much skill you expect him to have, by what date.

Break down the job—
   list important steps.
   pick out the key points. (Safety is always a key point.)

Have everything ready—
   the right equipment, materials and supplies.

Have the workplace properly arranged—
   just as the worker will be expected to keep it.


Step  1—Prepare the worker
   Put him at ease.
   State the job and find out what he already knows about it.
   Get him interested in learning job.
   Place in correct position.

Step 2—Present the operation
   Tell, show and demonstrate one IMPORTANT STEP at a time.
   Stress each KEY POINT.
   Instruct clearly, completely and patiently, but no more than he can master.

Step 3—Try out performance
   Have him do the job—correct errors.
   Have him explain each KEY POINT to you as he does the job again.
   Make sure he understands.
   Continue until YOU know HE knows.

Step 4—Follow up
   Put him on his own.
   Designate to whom he goes for help.
   Encourage questions.
   Taper off extra coaching and close follow-up.

If the Worker Hasn't Learned,
The Instructor Hasn't Taught.

Below is an example of the Job Instruction method of teaching a new student how to clean an endotracheal tube after it has been used following our standardized work for the activity.

At this point, you can have the student go through the process another time or, if you feel confident of his ability, allow him to work independently. Be sure to praise him for his attentiveness, and give him permission to reconnect with you at any time for any additional assistance he may need.

As explained in the earlier post referenced above, the three TWI J-courses had a major influence on several of key concepts of the Toyota Production System, namely Standardized Work, respect for workers and continuous Improvement. But, true to Toyota’s character, they took that information, put their own “flavoring" on it, and developed what Mike Rother calls Toyota Kata.

Kata comes from  the world of oriental, martial arts. It means “form.” There are two primary kata; Improvement Kata and Coaching Kata. I will look at Toyota Kata in the next post.

Thanks for stoping by. If you enjoy and learn from this blog, please tell a friend or colleague. And, as always, comments always appreciated.

Tuesday, March 19, 2019

Great Scores For Kaizen At 2019 AVMA Veterinary Leadership Conference

This past January, Mark Graban and I had the honor and pleasure of speaking at the 2019 American Veterinary Medical Association's Veterinary Leadership Conference in Chicago. The title of the 90-minute lecture was The Lean Concept of Kaizen: Taking Your Practice To the Next Level...And the Next! The attendance was good.

I started the session with a brief introduction to the history of Lean, starting with Lean manufacturing through Lean management and Lean healthcare to, now, Lean veterinary medicine. Mark, then, took over in his usual dynamic and enthusiastic style. He explained the literal and common definition of kaizen, why it is a better system than suggestion boxes, the PDSA cycle, and ending with a description of a simple kaizen system using Idea cards, Summary cards and a conspicuous Idea board. Along the way, he gave numerous examples from both human and multi-species (veterinary) healthcare.

Just a few days earlier I presented a one hour webinar entitled The Lean Methodology: Evolution of Veterinary Practice Management for the AVMA's Lead and Learn webinar series. For this webinar, I took the approach that the Lean mindset is very much akin to the scientific method of diagnosing and treating disease, which we as veterinarians are extremely familiar with. I tried to demonstrate that in both cases we have an ideal vision (Health and True North), we perform a physical exam (in Lean it is "go to gemba" and create a current Value Stream Map), we define our current state and, then, list the gaps between the two conditions (master problems list). At this point, both methodologies analyze the list for root causes (tentative diagnoses) and perform an experiment (treatment) with their respective tools and processes. At the end of the experiment, we assess our success, or lack thereof, and either sustain the new condition or experiment again with a different set of countermeasures. 

I haven't received any follow-up from the webinar, but attendee scores for the lecture were very satisfying.

As the results show, 91.2 percent either agreed or strongly agreed that the information presented was useful. In addition, 87.9 percent either agreed or strongly agreed that the material was presented effectively.

Lean is starting to make its way into veterinary practice management. Something that Mark and I have been advocating for the past three years. But, even more exciting is that others within our profession see it as valuable. That has always been the benchmark.

Lean is not a complete abandonment of all the concepts of traditional management; it is not a dogma. However, many of the older, traditional management concepts are challenged by this different mindset. Just as a computer language does not dictate what program or application is produced; it only supplies the means. Lean is, also, an infrastructure...for adaption and continuous improvement in practice management.

The AVMA Lead and Learn webinars (including mine) are available for viewing free of charge to members here.

Thanks for stopping by. Dialogue is always welcome.

Tuesday, February 26, 2019

A Different Kind Of Rounds: Lean Daily Management

As doctors and veterinary staff, we are well acquainted with the daily ritual of morning or change of shift medical rounds. This is the gathering of hospital staff and doctors to be updated on the current status of all of the patients in the hospital for treatment, and for the dissemination of new treatment orders by the doctors in charge. This is a form of standardized work. It gets everyone on the same page in a routine and timely manner.

Lean Daily Management (LDM) serves the same purpose, but for the operations and management side of the practice.

Each morning, leadership and management go to the gemba to meet with staff of a particular area of the practice to go over that area's board. What numbers are up (and why?) and what numbers are down (and why?). Or, better yet, do the Process Behavior Charts (PBC) of the data show any "signals" or is it all just "noise?" (see also Mark Graban's book "Measures of Success") What countermeasures should be tried? Any new kaizen ideas? What, if anything, can management do to support the staff? Any evidence that standardized work is not being followed?

Sidebar: One of the two Process Behavior Charts above is showing two signals. Can you identify which chart it is and what the signals are?

LDM helps support our progress through that big PDSA cycle called hoshin kanri or strategy deployment. Remember, part of the Act (/Adjust) phase of a successful PDSA cycle is to sustain the results (for now), write new standardized work, scale up if appropriate, and start teaching to the new standard. This brings a new current state, and the next target condition is identified, initiating a new PDSA cycle of improvement.

In the figure above, the wheel has been moved up the ramp (improvement) through A3 thinking and kaizen. But, there are forces in any system that want to undo that which has been accomplished. Some call it entropy; I think of it as organizational gravity. The function of standardized work is to counter those evil forces by stabilizing and sustaining the new current state.

The role of LDM is to sustain and stabilize ("nail down") standardized work as it is currently written. LDM functions as a "checks and balance" for standardized work, which acts as a wedge to help prevent organizational backsliding. LDM is the setting aside of time on a daily basis to monitor for this potential.

So, to recap, standardized work sustains the current state, and LDM sustains the current standardized work.

Lean Daily Management meetings should take 10 to 20 minutes per day. They are typically done in the mornings, however, they need to be a scheduled, daily priority for all involved. Choose the time that’s best for your practice and team.

All extraneous interruptions should be put on hold for the entirety of the time. During the meeting, a staff member from the department or area of the practice, such as the Hospital Care team, quickly reviews the metrics, status of any countermeasures, new problems that have come up, any cross training efforts, new and ongoing kaizen, etc. with management. The staff member that leads the meeting should rotate from amongst the entire team, so that everyone gets the opportunity to lead the conversation and learn.

As is the Lean perspective, management takes on a teaching and mentoring capacity; asking questions to stimulate A3 thinking, encouraging all efforts and practicing servant leadership.

So, Lean Daily Management accomplishes several things:
1. Gets management to the places where work occurs (go to gemba)
2.  Facilitates conversation and consensus building with staff
3.  Demonstrates management's commitment to the staff
4.  Monitors the metrics that support the True North statement and KPIs
5.  Allows time to encourage and appreciate kaizen efforts
6.  Sustains and audits standardized work
7.  Creates increased engagement of the workers
8.  Show respect for workers

Thanks for stopping by. Comments, questions, and suggestions always welcome.

Also, to answer the sidebar questions, the bottom PBC is showing a signal that needs to be investigated. The first signal is the data point above the upper process limit.The second signal is three or four of the last four data being closer to one of the process limit lines than the average. In the case above, the last five data points are closer to the lower process limit line than the average. In fact, it appears that we may be trending around an entirely new, lower average, which indicates that the whole system has changed somehow. Both of these conditions should have been recognized earlier than now, if they weren't. The next step is root cause analysis and formation of countermeasures, i.e. PDSA problem solving.