The Law of Interconnected Waste

I have been reading (re-reading) Lean Daily Management for Healthcare by Brad White. I was very impressed by the book the first time through, and am learning even more this time. This excerpt from the book concerns the relationships between waste, value, your staff and financial rewards. Thank you Brad for permission to post this material.

This law states that all the process waste of an organization manifests itself in three ways: 

1. Reduced value to the customer 
2. Reduced satisfaction to the employee 
3. Reduced profit to the company 

This law offers some very powerful results from attacking waste. First, one of the best ways to increase value and quality is not to spend more money but rather to eliminate the waste and friction in your processes that sap value during production. Second, eliminating process waste will increase profits by reducing expenses. (There may very well be an increase in demand and quality. That, though, is more of a marketing issue. The key observation here is that it costs money to produce waste. Any reduction in that waste results in less money that is spent on producing it.) Third, reducing process waste will increase the happiness of employees. This final point is vitally important to the success of a Lean management system.

The Law of Interconnected Waste

Taken together, these three points reveal that there is natural alignment among employees, patients, and finances. We can leverage this natural alignment by tapping in to the current frustrations that our people have regarding the workplace. Thus, one of the best places to start when seeking to eliminate waste is to simply ask your staff. 

What frustrates you about your job? 

Any frustration they have about the daily operation of their job will invariably lead back to a process waste that impacts patients and drains resources. The management system you build will be able to take these raw frustrations, convert them into hard metrics, and then use the scientific PDSA problemsolving to drill down to the root cause. 

This is the secret to gaining employee buy-in. By tapping in to the simple fact that people prefer to do the job that they were hired to do, and that, all else being equal, they prefer to do it well as opposed to poorly, you can leverage their expertise to sniff out waste from the bottom up. Also, because your staff are constantly connected to the customers, they will naturally steer the organization back toward a customer-centric model because, like a horse that naturally follows the path since walking is easier, they prefer to be highly productive with lots of patient contact because that is why they entered the field in the first place.

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FYI: I am writing a book!

I am writing a book explaining the Lean mindset and processes from a veterinary perspective (the first of its kind!). In it, I will be emphasizing the similarities between the scientific methods of diagnosising a pet with a disease and scientific methods of using Lean to fix veterinary practice dis-ease. I am very excited to share this information, especially with my colleagues and profession. Stay tuned for updates .


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What! No Research and Development Department!?!

Many of the major corporations in the world have a department they call "Research and Development" (R&D). These are the people responsible for innovating new products, improving previous products, fixing design defects, and adapting to new environments, including technological and economic; keeping the organization on the “cutting edge.”

Veterinary practices have an R&D group, also. We just don't recognize them as such.

I'm talking about our staff.  Our staff members know better than anyone what the problems are, where there is opportunity for new services or products, unmet client needs, wastes in our systems, etc.

They hear the comments made by clients that we are never aware of. They understand and recognize the gaps between our current state and our ideal state (True North) or the “cutting edge” of what's possible. And, they are willing and capable of partnering with us to correct those gaps, if we allow and empower them to do so.

When I first graduated from vet school and opened my practice, the business side of practice was coming into its own. One of the major subjects of management seminars at that time was to better delegate and leverage our staff members in our practices. It was like pulling teeth to get veterinarians to stop thinking they were the only ones that could pull blood samples, read a fecal exam or bandage a paw. The role of staff was to greet clients, restrain pets, clean cages and collect money.

These days, thankfully, we have evolved to delegating to staff almost everything in a veterinary practice except diagnosis, prescribing, surgery and... participating in identifying waste, innovating new products and service, meeting unmet client needs; to continuously improve, to become and stay ‘cutting edge.’

The concept of "kaizen" means partnering with staff (leveraging them) to continually improve value for the client, with value being defined from the client's point of view. It is part of the “bottom up” management philosophy of Lean (as opposed to the “top down” or “command and control” philosophy of contemporary Western management).

Vets and the "gurus" think they understand the terms 'teams', 'teamwork' and 'team building', but kaizen takes it to a whole new level. In kaizen, team means TEAM.

Isn't it time to take staff leveraging and delegation to the next level? Isn't it time to recognize and developed our potential "R&D" departments? Isn't it time to start developing a kaizen mindset and culture within our practices?  A culture that respects and recognizes the asset that our staff membrers represent, and, thereby engages them?

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Sayings of the Lean Fathers

Within the body of Jewish literature,  there is a book called "Pirke Avot", which means 'Sayings of the Fathers'. It is a collection of wisdom and quotes handed down from the ancient rabbis and the Jewish tradition. Taking that reference as a model, I decided to produce this "Sayings of the Lean Fathers." Enjoy!

Taiichi Ohno

(February 29, 1912 – May 28, 1990) was a Japanese industrial engineer and businessman. He is considered to be the father of the Toyota Production System, which became Lean Manufacturing in the U.S. He devised the seven wastes (or muda in Japanese) as part of this system. He wrote several books about the system, including Toyota Production System: Beyond Large-Scale Production.   https://es.wikipedia.org/wiki/Taiichi_Ohno 

We are doomed to failure without a daily destruction of our various preconceptions.

Progress cannot be generated when we are satisfied with existing situations.

Start from need.

Having no problems is the biggest problem of all.

If you assume that things are all right the way they are, you can’t do Kaizen. So change something!

Ask 'why' five times about every matter.

Why not make work easier and more interesting, so people do not have to sweat? The Toyota style is not to create results by working hard. It is a system that says there is no limit to people’s creativity. People don’t go to Toyota to ‘work’, they go there to ‘think’.

Without standards, there can be no improvement.

Where there is no Standard there can be no Kaizen.

Standards should not be forced down from above but rather set by the production workers themselves.

Make your workplace into showcase that can be understood by everyone at a glance. In terms of quality, it means to make the defects immediately apparent. In terms of quantity, it means that progress or delay, measured against the plan, is made immediately apparent. When this is done, problems can be discovered immediately, and everyone can initiate improvement plans.

The slower but consistent tortoise causes less waste and is more desirable than the speedy hare that races ahead and then stops occasionally to doze. The Toyota Production System can be realized only when all the workers become tortoises.

All we are doing is looking at the time line, from the moment a customer gives us an order to the point we collect the cash. And, we are reducing the time line by reducing the non-value-added wastes.

Something is wrong if workers do not look around each day, find things that are tedious or boring, and then rewrite the procedures. Even last month's manual should be out of date.

The more inventory a company has, the less likely they will have what they need.
We are doomed to failure without a daily destruction of our various preconceptions.

The key to the Toyota Way and what makes Toyota stand out is not any of the individual elements…But what is important is having all the elements together as a system. It must be practiced every day in a very consistent manner, not in spurts.

If you are going to do TPS you must do it all the way. You also need to change the way you think. You need to change how you look at things.

The only place that work and motion are the same thing is the zoo where people pay to see the animals move around.

People who can’t understand numbers are useless. The gemba where numbers are not visible is also bad. However,  people who only look at numbers are the worst of all.


Taiichi Ohno. (n.d.). AZQuotes.com. Retrieved June 16, 2017, from AZQuotes.com Web site: http://www.azquotes.com/quote/731341
https://www.slideshare.net/mobile/optimaltransformation/a-collection-of-quotes-from-taiichi-ohno
Https//www.inspiringquotes.us/author/2150-taaichi-ohno

W. Edwards Deming

(October 14, 1900 – December 20, 1993) was an American engineer, statistician, professor, author, lecturer, and management consultant. Educated initially as an electrical engineer and later specializing in mathematical physics, he helped develop the sampling techniques still used by the U.S. Department of the Census and the Bureau of Labor Statistics. In his book, The New Economics for Industry, Government, and Education, Deming championed the work of Walter Shewhart, including statistical process control, operational definitions, and what Deming called the "Shewhart Cycle" which had evolved into PDSA (Plan-Do-Study-Act). This was in response to the growing popularity of PDCA, which Deming viewed as tampering with the meaning of Shewhart's original work. Deming is best known for his work in Japan after WWII, particularly his work with the leaders of Japanese industry.    https://en.wikipedia.org/wiki/W._Edwards_Deming

People are entitled to joy in work.

Management by results -- like driving a car by looking in rear view mirror.

It is not necessary to change. Survival is not mandatory.

The greatest waste in America is failure to use the abilities of people.

The moral is that it is necessary to innovate, to predict needs of the customer, give him more. He that innovates and is lucky will take the market.

The consumer is the most important point on the production-line.

Export anything to a friendly country except American management.

Whenever there is fear, you will get wrong figures.

A bad system will beat a good person every time.

To manage one must lead. To lead, one must understand the work that he and his people are responsible for.

Does experience help? No! Not if we are doing the wrong things.

The supposition is prevalent the world over that there would be no problems in production or service if only our production workers would do their jobs in the way that they were taught. Pleasant dreams. The workers are handicapped by the system, and the system belongs to the management.

Defects are not free. Somebody makes them, and gets paid for making them.

Every system is perfectly designed to get the results it gets.

A leader is a coach, not a judge.

Pay is not a motivator.

The merit rating nourishes short-term performance, annihilates long-term planning, builds fear, demolishes teamwork, [and] nourishes rivalry and politics. It leaves people bitter, crushed, bruised, battered, desolate, despondent, dejected, feeling inferior, some even depressed, unfit for work for weeks after receipt of rating, unable to comprehend why they are inferior. It is unfair, as it ascribes to the people in a group differences that may be caused totally by the system that they work in.

Quality is made in the board room. A worker can deliver lower quality, but she cannot deliver quality better than the system allows.

http://quotes.deming.org/authors/W._Edwards_Deming

Shigeo Shingo

 (1909 - 1990), born in Saga City, Japan, was a Japanese industrial engineer who is considered as the world’s leading expert on manufacturing practices and the Toyota Production System.      https://en.wikipedia.org/wiki/Shigeo_Shingo

Lean is a way of thinking- not a list of things to do.

The most dangerous kind of waste is the waste we do not recognize.

Are you too busy for improvement? Frequently, I am rebuffed by people who say they are too busy and have no time for such activities. I make it a point to respond by telling people, look, you’ll stop being busy either when you die or when the company goes bankrupt.

Unless you change direction, you will end up where you are headed.

We have to grasp not only the Know-How but also 'Know Why', if we want to master the Toyota Production System.

Those who are not dissatisfied will never make any progress.

There are four purposes of improvement: easier, better, faster, and cheaper. These four goals appear in the order of priority.

A relentless barrage of 'why’s' is the best way to prepare your mind to pierce the clouded veil of thinking caused by the status quo. Use it often.

Shigeo Shingo. (n.d.). AZQuotes.com. Retrieved June 18, 2017, from AZQuotes.com Web site: http://www.azquotes.com/quote/731329

Masaaki Imai

(born, 1930) is a Japanese organizational theorist and management consultant, known for his work on quality management, specifically on Kaizen.     https://en.wikipedia.org/wiki/Masaaki_Imai

The message of the Kaizen strategy is that not a day should go by without some kind of improvement being made somewhere in the company.

The Kaizen Philosophy assumes that our way of life - be it our working life, our social life, or our home life - deserves to be constantly improved.

It is impossible to improve any process until it is standardized. If the process is shifting from here to there, then any improvement will just be one more variation that is occasionally used and mostly ignored. One must standardize, and thus stabilize the process, before continuous improvement can be made.

Progress is impossible without the ability to admit mistakes.

The standard is not written on the stone. The definition of the standard is that it is the best way to do the job for now. It should be regarded as a next step to make further improvement.

Where there is no standard, there can be no improvement. For these reasons, standards are the basis for both maintenance and improvement.

Kaizen means ongoing improvement involving everybody, without spending much money.

I believe that management should focus on two particular areas. One is Gemba (shop floor) and the other is customer (not the shareholder).

You can't do kaizen just once or twice and expect immediate results. You have to be in it for the long haul.

All of management's efforts for Kaizen boil down to two words: customer satisfaction.

I have a theory that among the large Western companies (mostly American) the higher an executive is promoted, the more wisdom is lost and by the time he or she reaches the top becomes a complete idiot. Certainly they do not deserve the outrageous salary.

Japanese management practices succeed simply because they are good management practices. This success has little to do with cultural factors. And the lack of cultural bias means that these practices can be - and are - just as successfully employed elsewhere.

Kaizen is like a hotbed that nurtures small and ongoing changes, while innovation is like magma that appears in abrupt eruptions from time to time.

Under the lean system, any tools which are required for solving problems are used.

Masaaki Imai. (n.d.). AZQuotes.com. Retrieved June 18, 2017, from AZQuotes.com Web site: http://www.azquotes.com/quote/1555116

Final Thoughts

Can you recognize some themes here? Do any of this quotes resonate with you? Maybe one or more hits a little closer to home?! Which ones are you going to take with you and/or share with others? Did any challenge your previous mindset?


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Standardized Work

Mary is licensed veterinary technician. When a shocky, weak puppy was presented, Dr. A tells her that a PCV and blood glucose is always indicated in cases such as this and should be performed even before the doctor sees the pet. Two weeks later, a similar case presents and Mary performs both tests immediately upon intake. Dr. B, the doctor on duty, pulls her aside and angrily instructs her to never perform any blood tests without orders from the case doctor.

Unfortunately, we have all been witness to such scenarios. The doctors may not realize these type of situations are occurring.  But, the effects on staff can be far reaching.  It engenders feelings on the part of staff of anger, resentment, confusion and loss of confidence in management.

In the Lean method, “standardized work” is our definition of the best way to do work in a way that ensures safety and quality, while driving the best productivity and minimizing delays for the customer. It is the foundation for continuous improvement and employee empowerment. It is necessary for “flow” and “pull”. Standardized work gets everybody on the same page and reduces employee anxiety. When processes are in chaos, they must first be brought into some semblance of stability. What is the best way to do our work? This stability (and ongoing improvement) is achieved through standardized work. Once there has been some degree of order established, then the processes can be improved by applying other Lean methodologies, such as kaizen.

Standardized work is not the same as “standard” work. Standard work might imply written in stone, inflexible, inappropriately detailed or micromanaged. Standardized work is broader in concept. Think in terms of simple algorithms or checklists. For example, requiring the drawing of a blood sample for a routine health profile into a 3 cc syringe as opposed to a 5cc syringe would, in most cases, be too detailed for standardized work. However, in the diagnosing of the cause of a “red eye,” it is important to specify that the Schirmer tear test be run prior to staining the cornea or using any topical anesthetic drops in order to check for glaucoma. “Canned” computer estimates might be thought of as another form of standardized work in that they do not dictate a specific recipe, but suggest considering the need for such drugs or services such as antibiotics, hospitalization, analgesics, diagnostic tests, etc. They act as a reminder.

When we create standardized work documents, it’s important to ask what should be standardized and to what level of detail. What problems are solved or prevented by having standardized work? What goals are being accomplished? The goal is not to have standardized work. The goal is better performance in all dimensions and a better workplace for all. Standardized work is a “means to an end”, not a raison d’etre. As mentioned above, the reason for standardized work is to start the process of improvement, which ultimately is for the purpose of increasing quality and value for the client, the “holy grail” of Lean.

Chaos must be brought under some control with Standardized Work before Lean "tools" can improve processes. Note that the blue dot becomes increasingly evident as abnormal as the process is first standardized and then improved. Lean helps identify problems.

But there are also some important ramifications. Like most of the methodologies that make up TPS, standardized work is designed by consensus with staff.  Consensus means obtaining ideas for problem solving from all stakeholders, including staff. It comes from the mindset that all workers have valuable input, knowledge and skills that are assets to the organization in problem solving. It is a sign of respect for workers. It does not mean that all opinions are valid and must be taken or that each individual gets to do the work however they want. Toyota has long emphasized that standardized work must be created by those who do the work. It is not dictated by managers or experts.

By involving workers in this way, a vital resource is utilized and leads to increased “buy in” and engagement. It improves communication and reduces anxiety on the part of everyone of not knowing what is the correct (preferred, agreed upon) way or doing something incorrectly. It helps insure that vital information is available even if a key staff member is absent or has moved on. Plus, standardized work becomes the basis for a formal, in-house training program and is the foundation for continuous improvement.