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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Lean and Veterinary Medicine: Like a Glove

After reading, studying and thinking about Lean over the past seven years, I am convinced that Veterinary practice and Lean are destined for each other. As veterinarians and systematic problem solvers, we already know and are familiar with over eighty percent of Lean; we just don’t know it. Lean promotes greater value for the customer (from the customer’s perspective), with higher quality, better utilization of all resources  (especially our human resources), less expense and increased engagement of staff. I think most veterinarians want the same things.

Lean is the Western name for the Toyota Production System (TPS). Coined for its ability to remove the “fat” (wastes or muda) from processes.  Toyota developed TPS in an effort to rise out of war torn Japan, with its limited resources, to be able to go beyond truck manufacturing for the small, Japanese economy to complete with the American auto giants in a global economy. Since then, most other industries have found successes with Lean, including human healthcare. Can it do for veterinary medicine what it has done for many hospitals and healthcare system around the world? I think it can and that we need to try.

We’re Not That Different, Really

First of all, Lean takes a systems approach to problems. Problems are examined from a systems breakdown perspective before people are blamed. Lean asks “Why did this happen?”, or “How did this happen?” as opposed to “Who is responsible?” As doctors, we work with systems in our patients every day. We understand inputs, outputs, delays and feedback loops, both positive and negative. We know what can happen when one system is changed and how it can affect other systems for the better or the worse.

In order to identify the abnormal, we must first understand what is normal; what is ideal for this species, breed or animal. In veterinary school, we learned normal anatomy and physiology before we studied pathology. The same concept is true for Lean. We must have a very clear idea of what our ideal practice would look and function like. Notice, that I did not say an ideal practice. Lean is not trying to make your practice some management guru’s idea of the perfect “cookie cutter” practice. Lean understands that your practice is unique. The doctors are different. Their biases, philosophies and perspective are unique. The neighborhood where your practice is located is different than other neighborhoods. The mix of your employees is one of a kind. The Lean objective is to make your practice the best “your” practice it can be, now and into the future.

In the Lean mindset, this ideal is called our “True North.”  What would your practice look like if it was perfect? How would your practice perfectly relate to your clients? What would your ideal staff look and function like? How would your practice benefit your neighborhood and community if it is was perfect? It’s totally up to you. What ever you decide your True North is, Lean is designed to get you there. Forget, what a “Top 100 Best Practice” says you should be. What is important from the Lean perspective is that you are closer to your True North today than yesterday; closer this month than last month.  The perpetual destination of the Lean journey is perfection, knowing full well, of course, that this is impossible. The Lean journey never ends. As Vincent Lombardi said, we pursue perfection, knowing we will never get there, in order to reach excellence.

We Know This

As veterinarians, we are already quite familiar with eighty percent, or more, of the Lean methodology. We just don’t know it. Both mindsets are based on the scientific method of problem solving.

When a sick pet comes into our practice, health is our goal, our ideal state. The first step in diagnosing that pet is to understand fully the current state of that patient. We start with the primary client complaint. Regardless of whatever else we discover, we want to make sure we address this problem. Next, we collect a complete history; vaccinations, diet, current medications, symptoms and their progression, etc.

The second step is to perform a complete “tip of the nose to tip the tail” physical exam, paying particular attention to the client’s primary complaint. Can you imagine trying to make a diagnosis without performing a physical exam on the patient?

Next, we might perform diagnostic tests, such as a complete blood count, a general organ profile, urinalysis, radiography, and specific serology tests. We are attempting to explain why the patient is having the symptoms it is having. Medicine is based on facts, objective data, not fantasy.

At this point, we should have a reasonable understanding of the pet’s current state of health. Now, because we know what the ideal state of health is for this species, breed, gender and age, we can identify the problems; the gaps between our patient’s current state and the ideal state.

Based on our problems list, we formulate a treatment plan. This is an experiment. We don’t know if our treatments will work, but we decide, maybe with consultation with colleagues and specialists, what we are going to do. Later, we will follow up with the client and pet in order to analyze if we were successful  at reaching our ideal state of health. If we were successful, we will set a time for the next review, maybe in six months or a year. Remember the 3Rs; Recall, Re-examine or Reminder? If we were not successful, we reflect on what went wrong and start the process over again with additional history, another, possibly more in depth, physical exam, additional tests, a second, adjusted round of treatments (another experiment) and another analysis of the outcome.

As I said, the Lean methodology of management problem solving is also based on the scientific method. The process is almost identical to the one described above for diagnosing and treating sick pets. So how do we know we have problems? Because we have not reached our ideal state in one form or another.

The first step in Lean problem solving is to thoroughly define and understand our current state, just as it was with our patient. This step might include past and current metrics; key performance indicators. What is our story? “The facts, ma’am, only the facts!”

Defining the current state also includes an essential “physical exam.” In Lean, this is called “going to gemba.” Gemba is the Japanese word for the work floor, the place where the work (and problem) actually occurs. For instance, if the problem has to do with surgery, then the surgery room is the gemba. Lean emphasizes the importance of physically observing the flows and processes (the “value stream”) in real time in order to deeply understand the current state as it really is. A big difference in the Lean mindset, however, is that this observation (physical exam) should take place with the staff that are there on the floor, because they know better than anyone what the real issues are. They deal with it every minute of every day. They are an organization’s most valuable asset and resource, especially for helping to identify and provide solutions to problems. Lean promotes partnering with employees in this effort. Our staff wants to be part of the process of finding solutions, rather than always being seen as the cause of problems. This is a big part of what engages them.

Now, as in the diagnostic process, we can identify the gaps between our current state (disease) and our True North (health). However, many problems can appear to be caused by a particular cause when, in fact, it is caused by something much deeper; something more basic. Just as not diagnosing and treating the real problem versus treating symptoms will probably not yield a cure for or patients, not solving problems at their root cause will not provide a permanent solution to the problem at hand.

So, in Lean there is a “diagnostic” called “5 Whys.” This is the idea that one should ask “why” five times to insure the root cause has been identified. A fix for anything less will not solve the problem once and for all. The number five is somewhat arbitrary. It could be four or it could be seven. The idea is to ask enough times that the root (absolute) cause has been identified.

Does it ever seem like you are having to deal with the same problems over and over again? As if you are constantly playing the game “Whack-A-Mole?” As soon as you think a problem has been squashed in one place, it “pops up” again somewhere else? One of the main reasons for this could be the fact that the root cause (the definitive diagnosis) has not been found (another reason could be that your unique, valuable and knowledgeable staff played no part in the process). That it has always only been handled with “Band-Aids.” And, all of this effort is found to be just a waste of time and effort.

Once we know the gaps between our current state and our ideal state, we, in dialogue with our staff,  can devise the counter measures (treatments) we feel are indicated. This is an experiment, also, since we don’t know if it will work. It will give us an idea of what the future state should look like. Since our True North, or ideal state, is perfection, and we know that is impossible,  then the best we can do is aim for the next, improved, future state. Lean is a journey that never reaches its final destination of perfection. It is the process of continuous improvement toward ever better future states. We can never reach our True North, but with constant effort, we can get really, really close!

The final step, as with our patients, is to study the results of our tiny experiments. If the results are positive, then we institute it as the new, best method or standardized work and the staff is trained to this new current state. We will continually, from time to time revisit this process in order to improve it  even more down the road. If our “treatments” does not turn out well, then we (along with staff) will make adjustments and start the whole process over again with different countermeasures and experiments.
I hope it is evident, now, how much diagnosis and treating patients in our veterinary practices is similar to the Lean methodology of management and problem solving. I told you that you knew more about Lean than you realized!

SOAP vs PDSA

We are all familiar with the SOAP format for writing medical record. “S” stands for “Subjective, “O” stands for “Objective”, “A” stands for “Assessment” and “P” stands for “Plan.” The Subjective and Objective parts define the current state of the patient. Assessment delineates our tentative diagnosis. Plan communicates our, hopefully, successful treatment. It is not the medical record that is so important. It is the diagnostic thought process that is important. We could write medical records with a different format, but the thought process is the same, regardless.

In Lean, the written document is called an A3 report because it was written on an A3 sized (approximately 11 inches by 17 inches) piece of paper which was the largest paper that would fit in a fax machine at the time. It is based on the Deming (named for the American, W. Edwards Deming, one of the first to use statistics for quality control and improvement) or PDSA cycle that is the thought process.

“P” stand for “Plan.” In this part of the report (which typically occupies about 50% of the entire report), we provide a statement of the problem, any 5 Why analyses, the necessary information (e.g. data, charts, graphs, Value Stream maps, etc.) to describe our current state, possibly a Future State map, and any cost estimates relevant to the experiment . 

Following is the “D” or “Do” section. This section delineates the proposed countermeasures we will experiment with. 

Next is the "C" or "Check" (some use “S” or “Study”) portion of the report. Here, we explain and study the results of the experiment. 

The final section is the “A” section which stands for “Act” or “Adjust.” Here, we reflect (hansei) on the results of our experiment. If it was successful,  then we act on the results by instituting them within the practice. If not, we adjust, come up with new countermeasures and experiments in a new PDSA cycle and A3 report. Again, it is not the format of the report that is important (although the idea that everything should be concise enough to fit on one A3 sized paper is an important aspect), it is the process (called A3 thinking) that is.

Because the diagnostic process and Lean problem solving are both based on the scientific mindset, both reports are similar. More that we didn’t know that we know!


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A3 Reports

A3 reports are the written documents that succinctly record the PDCA cycle problem solving effort, often providing a bit more structure than the four steps. The thought process and steps are very similar to the Practical Problem Solving method. This is sometimes called “A3 thinking.” The PDCA thought process is more important than the specific A3 report format.

The name A3 comes from the international size of paper that’s approximately 11 by 17-inches (in landscape orientation) traditionally used by Toyota and Lean organizations for these reports.

The left side of the A3 is for the Plan step of PDCA. It should include a title, a statement of the problem and a description of the current state. This side is filled out with such information as facts, graphs, charts, key performance indicators, value stream maps and 5 Whys root cause analysis, to name a few. The fact that the Plan step takes close to fifty percent of the entire report is an indication of the importance Toyota places on planning.

The right side of the document contains the Do, Check and Act steps of the cycle. This side might contain the implementation plan (along with the “who”, “what”, “where”, “when” and “how”), the future state value stream map, a short cost/benefit analysis, the result of the implementation plan, the root causes that were eliminated (or not), the changes in policy and procedures (the new standardized work) and a date to revisit the issue in order to continually improve.