Saturday, August 15, 2020

Lowering the River

Certainly, there is not a lot of good that comes out of a worldwide pandemic such as Covid-19. But one bright spot of it is that it has forced every aspect of life to be rethought, reimagined and re-engineered. Many of the things we thought were so necessary to the way we work and live may, in fact, be much less important. Coronavirus has made many of us innovate, improve, become more agile. It has triggered a rapid evolution of our systems and processes, much of which will become the new normal. This highlights a major advantage that Lean organizations possess. The Lean infrastructure is designed for continuous improvement, quick response and problem solving up and down the organization. 

An example of this that I heard about on the radio recently, was the changes that college entrance committees were being required to make in their selection process of new freshman students when the last semester of high school was so disrupted and taking SATs (or other admissions tests) has been impossible for health and safety reasons. In some high schools, they went to a Pass/Fail grading system versus the usual four point system. How do these college boards deal with this? How important are college entrance tests; are they really that informative? Many universities have instituted (re-instituted) the entrance essay as a metric for admission. Will these essays become a permanent requirement for admission post Covid-19?

One of the axioms in the Lean environment is to "lower the level of water in the river." When the water level is high, systems and processes seem to sail by smoothly because rocks are covered and we go over them; flow occurs effortlessly. However, this often leads to complacency; a false sense of well being. Lean organizations will routinely introduce small changes to their Value Stream that cause a little bit of chaos. It "lowers the water" just enough to show where the rocks (waste, defects, muda) are. These rocks are problems, never before illuminated, that need to be solved in order to avoid potential, future pitfalls; to survive and to be better tomorrow than we are today. Covid-19 has "lowered the river" exposing dangerous "rocks" among many of our systems, especially healthcare. Lean teaches that systems should be in place that make problems (or potential problems) quickly identifiable and corrected quickly at the root cause level.

For example, if one of your Value Streams (e.g. annual wellness exams) has been functioning very well with five staff members involved, then try changing it to only use four (and reallocate that fifth person to new work that can, perhaps, drive growth for the practice. What problems does removing a person introduce; what rocks pop up? How would your practice deal with that change? How might you have to evolve and improve? 

Or, if your inventory is set at a certain level with a certain reorder point, what changes would be needed to avoid rocks if you decided that these levels be decreased by ten percent, saving capital and carrying costs? But be mindful that lowering the water too quickly can make us crash the boat. You might be able to start by putting 10% of inventory in a separate “emergency use only” location -- and when you can improve your processes to the point of truly not needing it, then use up that 10% without replacing it. 

Or, what would your practice need to change in order to start seeing appointments every twenty minutes rather than every thirty minutes?  How can we do so in a way where nobody feels rushed and so that care and service doesn’t suffer, not to mention the quality of worklife?

By occasionally, but routinely, "lowering the level of the river", Lean organizations start seeing new "rocks" that stimulate innovation, creativity, problem solving techniques, staff engagement and place them even farther ahead of their competition; more capable of sailing in rough times.

It will be very interesting to see what life will be like (better? or worse?) one, two or five years from now because of what Covid-19 has invoked. Though, hopefully, in the future it will not take a worldwide pandemic to teach us the necessity of "lowering the river" and continuous improvement. 

How might this be experimented with in your practice?

Thanks for reading. 

Thursday, July 16, 2020

A Lean Reference List

These are most of the books that I have read over the last seven or so years and that I found most helpful. When I first started reading and learning about the Toyota Production System (Lean), one could probably fit all the available books on one shelf. Today, it would require one (or more) bookcases! More proof that Lean is real.


Lean Thinking: Banish Waste and Create Wealth in Your Corporation by James Womack and Daniel Jones

Lean Hospitals: Improving Quality, Patient Safety and Employee Engagement, 3rd Ed. by Mark Graban

Healthcare Kaizen: Engaging Front-line Staff in Sustainable Continuous Improvements by Mark Graban and Joseph Swartz

The Executive Guide to Healthcare Kaizen: Leadership for a Continuously Learning and Improving Organization by Mark Graban and Joseph Swartz

Measures of Success: React Less, Lead Better, Improve More by Mark Graban

The Toyota Way: 14 Management Principles from the World's Greatest Manufacturer by Jeffrey Liker

Follow the Learner: The Role of a Leader in Creating a Lean Culture by Dr. Sami Bahri

Lean Lexicon: A Graphical Glossary for Lean Thinkers compiled by Lean Enterprise Institute, Edited by Chet Marchwinski

Understanding Variation: The Key to Managing Chaos by Donald Wheeler

Toyota Production System: Beyond Large-Scale Production by Taiichi Ohno

Taiichi Ohno's Workplace Management by Taiichi Ohno

The Toyota Way Fieldbook by Jeffrey Liker and David Meier

Learning to See: Value Stream Mapping to Add Value and Eliminate MUDA by Mike Rother

Value Stream Mapping for Healthcare Made Easy by Cindy Jimmerson

Lean Daily Management for Healthcare: A Strategic Guide to Implementing Lean for Hospital Leaders by Brad White

Toyota Kata: Managing People for Improvement, Adaptiveness and Superior Results by Mike Rother

The Toyota Kata Practice Guide by Mike Rother

Training Within Industries: The Foundation of Lean by Donald Dinero

Out of the Crisis by W. Edwards Deming

The New Economics for Industry, Government, Education by W. Edwards Deming

The Deming Management Method by Mary Walton

Dr. Deming: The American Who Taught the Japanese About Quality by Rafael Aguayo

The Toyota Way to Lean Leadership: Achieving and Sustaining Excellence Through Leadership Development by Jeffrey Liker and Gary Convis

Toyota Talent: Developing Your People the Toyota Way by Jeffrey Liker and David Meier
Developing Leaders at all Levels: A Practical Guide
by Jeffrey Liker and George Trachilis

Toyota Culture: The Heart and Soul of the Toyota Way by Jeffrey Liker and Michael Hoseus

The Toyota Way to Continuous Improvement: Linking Strategy and Operational Excellence to Achieve Superior Performance by Jeffrey Liker and James Franz

The Toyota Way for Service Excellence: Lean Transformation in Service Organizations by Jeffrey Liker and Karyn Ross

Practicing Lean: Learning How to Learn How to Get Better…Better edited by Mark Graban

The Machine That Changed the World: The Story of Lean Production- Toyota’s Secret Weapon in the Global Car Wars That is Now Revolutionizing World Industry by James Womack, Daniel Jones and Daniel Roos

Lean Solutions: How Companies and Customers Can Create Value and Wealth Together by James Womack and Daniel Jones

Gemba Walks by James Womack

The Lean Turnaround: How Business Leaders Use Lean Principles to Create Value and Transform Their Company by Art Byrne

Lean for Dummies by Natalie Sayers and Bruce Williams

Creating a Lean Culture: Tools to Sustain Lean Conversions by David Mann

Managing to Learn: Using the A3 Management Process to Solve Problems, Gain Agreement, Mentor and Lead by John Shook

Beyond Heroes: A Lean Management System for Healthcare by Kim Barnes with Emily Adams

Transforming Health Care: Virginia Mason Medical Center's Pursuit of the Perfect Patient Experience by Charles Kenney

The Lean Guide to Transforming Healthcare: How to Implement Lean Principles in Hospitals, Medical Offices, Clinics and Other Healthcare Organizations by Thomas Zidel

Lean Doctors: A Bold and practical Guide to Using Lean Principles to Transform Healthcare Systems, One Doctor at a Time by Aneesh Suneja and Carolyn Suneja

On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry by John Toussaint

Value Stream Mapping: How to Visualize Work and Align Leadership for Organizations by Karen Martin and Mike Osterling

Hoshin Kanri for the Lean Enterprise: Developing Competitive Capabilities and Managing Profit by Thomas L. Jackson

The Basics of Hoshin Kanri by Randy Kesterson

Gemba Kaizen: A Commonsense Approach to a Continuous Improvement Strategy, 2nd Ed. by Masaaki Imai

The Spirit of Kaizen: Creating Lasting Excellence One Small Step at a Time by Robert Maurer

A Study of the Toyota Production System: From an Industrial Engineering Viewpoint by Shigeo Shingo
Patient-Centered Strategy: A Learning Strategy for Better Care
by Jeff Hunter

The Lean Startup: How Today's Entrepreneurs Use Continuous Innovation to Create Radically Successful Businesses by Eric Ries

Implementing TWI: Creating and Managing a Skills Based Culture by Patrick Graupp and Robert J. Wrona

The 7 Kata: Toyota Kata, TWI, and Lean Training by Conrad Soltero and Patrice Boutier

The TWI Facilitator’s Guide: How to Use the TWI Programs Successfully by Donald A. Dinero

A Lean Guide to Transforming Healthcare: How to Implement Lean Principles in Hospitals, Medical Offices, Clinic and Other Healthcare Organizations by Thomas G. Zidel

The Definitive Guide to Emergency Department Operational Improvement: Employing Lean Principles with Current ED Best Practices to Create the “No Wait” Department by Jody Crane and Chuck Noon

A3 Problem Solving: Applying Lean Thinking by Jamie Flinchbaugh

A Factory of One: Applying Lean Principles to Banish Waste and Improve Your Personal Performance by Daniel Markovitz

The Outstanding Organization by Karen Martin

Clarity First by Karen Martin

The Lean Strategy by Michael Belle, Daniel Jones, Jacques Chaize and Otest Fiume

Multipliers: How the Best Leaders Make Everyone Smarter by Liz Wiseman

Measure What Matters: How Google, Bono, and the Gates Foundation Rock the World with OKRs by John Doerr

The Five Dysfunctions of a Team: A Leadership Fable by Patrick Lencioni

Scrum: The Art of Doing Twice the Work in Half the Time by Jeff Sutherland, JJ Sutherland

The New Work by Aaron Dignon

On The Web

Lean Enterprise Institute

Dr. Ponsford's LeanVets blog

Mark Graban’s Leanblog

Shingo Institute

The Deming Institute

TWI (Training Within Industry) Institute

Catalysis (formally ThedaCare Center for Healthcare Value)

Kaizen Institute

Toyota TSSC

Toyota's TPS Page

Hope this helps.

Thursday, March 12, 2020

Systems Thinking: Bringing It Closer To Home

A mindmap illustration of a systems approach to many of the things that affect your take home (net) pay
When we think about all of things that we need to consider when negotiating compensation with a potential new owner/manager, most of us are probably only concerned about base pay, production percentages and benefits packages. If this is good, we're good. And, I used to be in this same group. But, experience can be a ruthless teacher.

So, let me share some of my experiences with those of you that have not racked up forty plus years in the profession, working on both side of the "boss" desk, in private and corporate environments, in practices of two to six doctors, in low cost/high volume and high cost/low volume practices. Maybe, you won't have to reinvent the wheel. Plus, I think this is a good illustration of understanding things from a systems point of view.

What is a system? Thank you for asking! A system is the "game" with all of its "rules" that affect us, the players, and determine if and how "we win or lose." It is all of the departments, policies, procedures, cultures, ways of thinking, agendas, biases and ignorance that come to bear on a particular area or person, namely us, the employee.  Workers are at the mercy of the systems. They have no control over systems. Leadership is responsible for systems. However, in order to know how you will fare, you need to appreciate the intricacies of the "game." You need to think from a systems stand point.

Most of us veterinarians, these days, work on a production basis, i.e. we are paid a certain percentage of what we produce in medical and surgical fees less taxes and certain deductions. Many times there is a base salary in the mix, also.  So, for example, we are paid the greater of X% of our gross production or a salary, whichever is higher for the current period. And we are happy!

But this is only the tip of the iceberg. Looking at the illustration above, one can see there is much more involved than one might expect.

U.S. Tax Code
  • Obviously, you have to pay your "favorite uncle" first. And, the government is a humongous system!

Employment Contract
  • Percent of gross, obviously.
  • Base salary. Usually, you either get your percentage of production (POP) or the base salary, whichever is higher for the period. Ideally, this is designed to give you a minimum paycheck while you are building your production. However, I have been in "systems" where the language of the contract was that POP was not based on gross production, but on gross COLLECTED production, i.e. if the client didn't pay the bill, I didn't get any POP for that invoice. So, my paycheck is dependent on the practice's accounts receivable system; an area I, as an employee, have no input or say about.
  • Negative ProSal. This is my terminology for having to pay the practice back for any base salary paid but that your POP failed to cover. For example, in the first pay period of the month, I get $500.00 base salary. At the end of the month,  I get paid another periodic base salary of $500.00. I produced $4000.00 by the end of the second pay period of which I'm entitled, by contract,  to 20%, or $800.00. They already paid me $1000.00, yet my POP only amounted to $800. So, they TAKE BACK $200.00 of "overpaid wages" and my last paycheck for the period is only $300.00. It wasn't an either/or situation, at all. It amounts to straight production. The base salary language in the contract was "smoke and mirrors." 
  • Play close attention to the Non-Compete clauses. It may not affect your earning potential with the present owner, but it very well could affect future earning potential with a different employer. (This also goes for relief Veterinary services. If you get asked to come to work for a practice that you worked at through a relief service, it might be a violation of the non-compete agreement you signed (Remember?) with the service.)
[A sideline note here. I contracted to work 4.5 days/ week for a set base salary. A pay period was every two weeks. So, I agreed to, and was available, to work  four days every week plus every other Saturday. During the first  two-week work period of my employment, my employer only scheduled me for three days each week and no Saturday. They weren't that busy. However, I only got paid for six days of base salary. This is not the definition of salary. That is per diem pay. I protested and received the other two days of salary. My point was that I was agrreable, available and willing to work the 4.5 days per week. It was their choice not to have me come in, not mine. Unless, it was my choice not to work, I was entitled to my base salary. Be careful, employers, especially of some smaller corporations (that may be under capitalized), may try to cut expenses any way they can dream up. Their "best interests" are sometimes in direct opposition to your best interests. Their systems are their systems!]

Policy Manual
  • This is where a lot of the detail about "perks" and "comps" are listed. The point here is that the Policy Manual may take on the same power as any other contract, especially if the contract refers to items in the manual. (So, get and read the Policy Manual as if it were a contract,  because it very well may be.)
  • Other items may also affect your take home pay. How much PTO do you get? How is it accumulated? How much is a "days wages"  worth if you take more PTO than allowed or take it before it has accumulated? What insurance is offered? What is the employee portion? Is there any allowance for CE? Is it enough to go to a major convention in order to cover all required hours for licensing? Who pays for uniforms? What retirement programs are available? When do they take effect? Is there employer matching? How much? When are you considered vested?

Practice Demographics
  • Where your practice is located may affect your potential pay. Which state? Urban, suburban, rural? High percent of nearby non-residential establishments (businesses)? Neighborhoods mostly house or apartments? Are the residents young with kids (and pets!), older and on Social Security, or single, career climbers? What socioeconomic level is the majority of the residents? What is the level of discretionary income? Unfortunately, considering these types of things is important.

  • It may not be immediately evident, but inventory is another system that can affect your paycheck. If you don't have it, you can't sell it. If you can't sell it, you can't earn your POP. And if this happens too much, frustrated clients will leave to go to practices that do have what they need, when they need it. (Diminished long-term growth; less net income in the future)
  • The inventory system is influenced by other sub-systems, policies and procedures. For example, the method of triggering reorders (tags, want lists, kanban bins, etc.) % of stock outs, availability of alternative drugs (variety), reorder point (is enough drug available to get through the next order/delivery cycle) to name a few.
  • The Lean concept of Just-In-Time thinking is the utilization of inventory (or any resource) only when it is needed, where it is needed and in the amount needed. Seems like a good rule of thumb, but, as with most things, it is relative. In reality, the time from selling out to ordering to receiving new product is not instantaneous. Therefore, some level of safety stock is necessary to keep on hand. How much depends on many of these aforementioned systems and sub-systems are at work and is the big question (Google 'Economic Reorder Point' and/or 'Economic Reorder Quantity').

Average Client Transaction (ACT)
  • One of the major drivers for net income is the the ACT.
  • But, the ACT is influenced by the practice's fee structure, the portfolio of services and procedures offered and whether the there are discounts and coupons available for clients to use (and how your contract counts their value toward gross production).

  • Appointments is another one of the systems that affects your net income, especially appointment density; the number of appointments available per hour or per hour per doctor. Are appointments scheduled on the hour? Half hour? Quarter hour?
  • What are the hours of operation each day? What days of the week?
  • How many surgery days per week? Who gets what days?
  • Can any Doctor see any client/patient who doesn't have a preference? Or, are all clients already assigned to other vets so that you will have to "build" your clientele from scratch with new clients to the practice? And, therefore...
  • How quickly is the practice growing and what is the practice's marketing strategy (another system)? You can't earn from clients that don't walk in the door!
  • How many other doctors are vying for clients? What is the internal competition like? (Believe me, there is ALWAYS some level of internal competition, especially as long as compensation is based on POP.)

Gender Differences 
  • Does this occur in Veterinary Medicine?

This is probably not an exhaustive or complete list of influencers on your net income. However, I'll bet it encompasses more than you previously considered.

Glance back at all of the different systems; all of the different policies, agreements, understandings, aspects of the practice you work for and/or all of the "games." How many of them do you have ANY control or, even influences, over? Taxes? Inventory? Your practice's demographics? Accounts Receivable policies? Fee structure? Appointments? Marketing? You have partial influence in the contract. The Policy Manual??  Yet they determine your ability to survive, grow, enjoy life, contribute to your world?

This is why thinking in terms of all the system involved is so important. And understanding how changes in one area can have profound effects in another.

The last time I interviewed for a job that paid on POP,  I asked to see the last several periods of ACTs, and gross income. I looked at their state of inventory and asked about how they order drugs. I asked how much a rabies and distemper vaccine, plus a fecal exam, routine deworming and flea/heartworm would cost the client. This is one of my "index" invoices that I use to evaluate fees between practices (other "index" invoices include routine canine spay + pre-anesthesia blood work + IV cath/ fluids + pain injection + pain meds to go home or a dental prophy without extractions + routine labs + IV cath/fluids. It is simular to how one might use the S&P 500 Index to evaluate other investments or how the Consumer Price Index works). I had them show me the appointments over the last few months. I drove around the practice to check out the neighborhood. I "Googled" the practice to see client reviews. I checked out if they board, do grooming or have dental xrays and ultrasound. What does the staff look like? Enough to support good client flow? Trained well enough that I only have to worry about that which I am uniquely trained and licensed for? I was interviewing the practice as much, or more, as they were interviewing me.

Just like playing Black Jack in Vegas, I know the odds are in the casino's favor (they set the rules; system) but, I want to get as much in my favor as I can. So, maybe I can choose to play at a casino where they use only three decks versus five, or one that reshuffles only after 75% of the boot is dealt, versus 50%. The more I understand the systems in use, the better my choices will be (hopefully!).

I worry about the young, naive vets coming up who haven't had the level of experiences that I have had.  They are at the mercy of their employer's systems, more and more of which are large, faceless corporations (or "wannabe" corporations) with much deeper pockets and, possibly, a different perspective and agenda. Who will speak up for these neophytes? Who will watch over them? The fox that is in charge of the hen house?

Maybe, it is time for the younger generation of veterinarians, vet techs, vet assistants  and receptionists to consider forming an employment union, the way workers had to during the Industrial Revolution, and for the same reasons. There is power in numbers they say! And, it is the "power" that determines the "game". The Registered Nurses had to do it.

Thanks for reading.

Thursday, January 2, 2020

Fractals In Your Practice, Oh My!

As I mentioned in the last post, I have been listening to the Audible version of the book "The New Work" by Aaron Dignon. I am really enjoying it and highly recommend it. At any rate, I continue to find inspiration and new perspectives with which to understand the Lean mindset. So, with that in mind…

Have you ever heard of 'fractals'? There are many applications of fractals, but I am most familiar with them as a kind of symmetrical art. The structure of much of nature is based on fractals. A very accurate measurement of the length of the craggy coastline of England was found using fractals. Animation software uses fractals to design mountains or forests, etc.

Wikipedia partially define fractals as:

Fractals exhibit similar patterns at increasingly small scales called self similarity, also known as expanding symmetry or unfolding symmetry; if this replication is exactly the same at every scale, as in the Menger sponge, it is called affine self-similar. Fractal geometry lies within the mathematical branch of topology.

Got that!?

Anyway, it might be easier to show you a sample of fractal art.

In this graphic, the branches and sub-branches are similar to the main tree trunk, but at decreasing scale. We could go on to draw successive smaller, similar branches on the sub-branches, theoretically ad infinitum.

Also, what is represented here as a complete tree very well could actually be a branch on a successively larger tree, ad infinitum. 

Any who...It reminded me of the process of strategy deployment (Hoshin Kanri) in our organizations. Recall that strategy deployment is the introduction, integration and alignment of our True North statement and focus areas down through the organization to the rest of the team.

Just like our fractal tree, each level of the practice should mirror the True North vision and focus area concepts, yet on a successively smaller, more discrete scope. In other words, the lead managers' level should reflect and further define the upper concepts as it affects them at their level and in their practice area. The lead reception's metrics would be similar in concept, but different in the data monitored than the lead surgery tech's metrics. Yet, both of them would be following and supporting Leadership's values.

The same is true for the frontline staff level as compared to the leadership level and manager level. They would monitor even more detailed metrics from their practice area's point view at their level. The frontline metrics support and give detail to the managers' metrics which, in turn, support and and give detail to the leadership level and the True North statement. 

Therefore, if we look at the entire practice, we can see that in each area, and at each level, the top most values are mirrored. Everyone is aligned and working towards the True North concepts from their perspective. Front line staff are monitoring those metrics that drive the manager metrics, and managers are monitoring those metrics that drive the Leadership (True North) metrics. The front line's "tree" is the same as the manager's "tree" which is the same as leadership's tree, but each appropriate for their particular level and function.Thus, Fractal Organization!

Thanks for reading. Let me know what you think about all of this.