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. 

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.

A Response To a Comment About My Post "Lean Self"

Last month, shortly after my blog on the “Lean Self”, my friend and mentor Mark Graban posted a comment to that blog. This was unusual.  Usually, Mark emails his questions and points of concern to me after receiving my final draft of the blog post, but before I publish the final, final draft. His questions sometimes come from sheer confusion about what it is ‘that I am really trying to say’, but many times it is his way of teaching in the Socratic (and Toyota) method. That is, rather than lecturing, asking the student a series of questions that lead the student to discovering the answer or reflecting deeper on the subject. Occasionally, I am not sure which it is.

I have decided to answer in another blog post, rather than a reply to the comment that may go unnoticed.

Mark comments:

Thanks for sharing this, Chip.

I agree that having a personal “true north” and understanding your own “current state” can be beneficial.  I don't quite see how to apply the idea of a “value stream” though. What is “value?” How does it flow? How do you see that connection in one’s personal life?

Mark

Here is my response.

Mark, thank you for your comments. Please forgive my tardiness in replying. I have been recovering from a little bit of surgery.

Your questions have caused me to re-evaluate my premise as regards extrapolating the Lean mindset to the “self.” As they should.

What is ‘value’ in this context?

Another way to arrive at an answer to this question is to ask, “What is really important to you in healthcare?” Or, “What is really important to you in a car?” For the “self” it would be, “What is really important to you in your life?” I think (hope!?) for most people it would be “contentment.” To be contented financially. To be content at work. To be content in our relationships.  To be content with ourselves. The Hebrew word “shalom” is generally translated as meaning “peace.” And it does, but it is the peace that comes from being “whole” (content spiritually, physically, emotionally, psychologically); not having excess or being destitute, but from having enough or being grateful with what you do have.

Part of the Lean definition of “value” is that the customer be willing to pay for it. If you are not willing to put a price on what you want, it doesn’t really hold any value. This holds true for the “self”, also. But, it doesn’t necessarily mean money. It means doing the hard work of honest self reflection, letting go of false assumptions, admitting mistakes, mending relationships, simplifying, budgeting, pushing back the ego, stepping out of the forest and,then, prioritizing and starting, somewhere, on a lifelong journey of improvement.

What is the “value stream’?

The Lean concept of the “value stream” requires, amongst other things, a provider, a customer and a “gemba” (the place where the work actually occurs). Unlike other applications of Lean where the provider and customer are separate entities, for the “self” they are the same, us. And the “gemba” is our hearts and minds.

The steps we go through in our hearts, minds and lives to get whatever value we get is the “value stream”. Whether that process results in contentment or “dis-ease” in a particular area of our life depends on how much muda (waste, i.e. faulty thinking, biases, rewritten history, skewed priorities, energy vampires, B**l S**t, etc.) is embedded. Graphically representing this thought process produces a “value stream map”

For example: I must be perfect →  I burned the turkey → I’m a bad cook → I’m a lousy wife → I’m a bad person.  Not good “flow.” Lots of bad processes and “trash.” What’s the value here?

Note that using 5 Why might take you back through this process. For example:

     Why are you a bad person?  Because, I am a lousy wife.

     Why are you a lousy wife? Because, I am a bad cook.

     Why are you a bad cook? Because, I burned the turkey AND I must be perfect!

BINGO!! A possible root cause. The false belief that “I must be perfect!”!

Now, to be able to map this current state value stream may not be easy and it may require the help of “stakeholders” (others who have our best interest at heart). And, just as in any other Lean application, finding the “waste” in order to produce a better future value stream will work best if our “stakeholders” are given access to our gemba and are present; if we are open, honest and communicative about what is going on inside of us and in our lives.

Thus, I think the Lean concepts of value, true North, gemba, current value stream, future value stream, A3 thinking, 5S, 5 Why and kaizen are just as valid working on improving ourselves as it is in improving manufacturing, service industries, healthcare, etc. for the customer- us!

Systems, Value, Flow and Respect

Part of the mindset of thinking Lean is seeing and understanding your practice as a collection of systems. Individually, they seem appropriate and functional. However, many times our different systems unintentionally “bump” into each other. When this happens, chaos and waste can result.

Consider this collection of systems found in veterinary practice:

A multi-doctor practice operates on a “base or percent of production” format to pay associate doctors. The base salary is low to encourage production. Very typical within our industry. However, there are some problems.

First, the paperless computer system is slow and the doctors are required to input not only their original medical notes, but also generate any necessary supplementary reports and summaries. 

Tech staff are not allowed to have anything to do with inputting any part of the medical records other than a simple history, primary complaint, weight, temp, pulse and respiratory rate (TPR). They are not permitted to enter any of the physical exam findings, test results, diagnoses (differential or definitive), treatment orders or client home instructions. 

It is estimated that for every minute spent by doctors seeing patients, at least one other minute is needed to perform this non-value adding work.

Appointments are capped at two 20-minute appointments per hour per doctor. By the time the client is checked in by the receptionist, escorted to the exam room by a tech, and subjective information entered into the (sometimes mind-numbingly slow) computer system, the doctor notified of the appointment and briefed, half, or more, of the 20-minute time has passed.

There are four exam rooms for two doctors seeing appointments. The doctors (and, therefore, the exams rooms) are appointed at the same times each hour, i.e. at the :00 mark and at the :40 mark.

Tech staff are not allowed to have anything to do with entering any part of the medical records other than a simple history, primary complaint, weight, temp, pulse and respiratory rate (TPR). They are not permitted to enter any of the physical exam findings, test results, diagnoses (differential or definitive), treatment orders or client home instructions.

Systems thinking. As one can probably figure out, with only 60 minutes in an hour and every 20-minute appointment actually consuming 40, you are 20 minutes behind after the first hour and that increases linearly each hour thereafter. 

The first slot each hour has a 20-minute break afterwards until the next appointment at the last 20 minutes of the hour. However, this appointment butts up against the next first appointment of the next hour. There is no 20-minute “safety” period here.

Over an eight-hour shift, one of two scenarios can result. 

First, this allows twelve of sixteen potential appointments to be professionally serviced appointments per shift. This may be fine provided the takt (basically, the rate of demand) is less than that. But, if you are growing, it means hiring more doctors, thus increased overhead. Hardly in line with “do more, with less resources, with higher quality, and less waste” motto of Lean.

Second, and much more realistic, is that the 16 scheduled appointments will be seen, but many, if not all, of them after the first hour will be seen late. And, the doctor and staff will need to stay almost three hour longer than their shift to finish everything required per appointment. (Or, if the practice is willing to forego 16 appointments per doctor shift, then they concede to only see twelve; a 25% cut in production!).

From an associate doctor’s perspective, who is paid mostly on production, this is a problem. It severely caps their ability to earn income. We talked, in one of the first blog posts, about systems and how workers can be at the mercy of systems in which they have no control.

The associate doctor has very limited control over the systems that affect his/her ability to earn, e.g. appointment systems (number of appointments/hour, who gets which appointments and so on). There are systems that affect the extent to which staff are trained to assist and facilitate, computer systems, HR/payroll systems (contracted production percentage, hours/weeks, time of shifts, days on surgery), etc. Systems are the domain of upper management or practice ownership.

Respect. One of the two main pillars of Toyota and Lean is "respect for people" (the other is continuous improvement). This situation, as described here, is disrespectful to doctors and veterinary technicians. It disrespects doctors by forcing them to spend so much time performing work other than what they are uniquely trained for and can earn from. But, it also disrespects the trained techs that are not being utilized (or trained) to their fullest capacity.

Lean promotes the idea that resources should only be used when they are needed, where they are needed and only in the amount needed. Anything else is waste (muda). Doctors are highly trained, unique resources. Their use should be very purposeful and intentional. The only person in a veterinary office who can diagnose and treat patients, i.e. generate fees, is the doctor. Any other "job" than these should be seriously reconsidered - and maybe assigned to somebody else.

Value. Remember, part of the Lean definition of “value” from the client’s point of view is something they want and are willing to pay for. How much do you think a client is willing to pay for a take home “Examination Report” or a  “Welcome to Our Practice” card handwritten by the doctor they saw? How much do you think they value being able to get in for an appointment and being seen promptly by a doctor, having their pet diagnosed correctly and promptly, and efficaciously treated?

Flow. As I have blogged about before, flow directly and profoundly affects value from the client's perspective. All of the above scenario negatively impact flow. So, value likewise suffers. And this is a form of disrespect to the client.

I spent about five years working for a major corporate veterinary practice. As a solo doctor, I was able to routinely see 35 to 40 patients each day, including six surgeries. One way I accomplished this was by instituting a system of forms and tech training that freed me from much of the medical records input without sacrificing accuracy or neglecting my responsibility for those records. 

I never had any issues with routine audits of my records by my directors and in one of my last years with the practice, was one of the top 20 producers in the entire national practice. 

The vast majority of my time was spent in the exam rooms and surgery doing the work I was uniquely qualified to perform, improving flow and creating value for my patients and clients. But, from my very first days on the job, my practice manager and I invested extensive time and effort in tech training and doctor/tech “choreography.” Staff members are one of the only practice assets that has the potential to appreciate and get better over time.

At left is the simple, quick form I used. I would draw it on the back of the “Permission to Treat” form generated by the front desk whenever a patient was seen so I wouldn't use a new sheet of paper each time.

I divided the sheet into six sections as shown. Each section corresponds to a specific part of a “SOAP” medical record as indicated.

I would write my notes, findings, lab results, differential diagnosis or tentative diagnosis, treatment orders, client instructions and follow ups in the appropriate sections. I then gave the form to the tech on the case for input into the electronic medical record (EMR) and headed off to the next patient with a different assistant. This typically consumed about ten minutes of the 30 minute slot. The tech would then present the treatment plan, collect and/or run any lab tests, give any injections, prepare take home medications, go over home instructions and set follow up appointments. They would also enter the line item fees for invoicing and escort the the client to the receptionist for check out. It was at this point that they would input the EMR, before starting all over with a new client and patient in a different room.

We typically scheduled six or seven 15-minute exams per every two hours of available time, This allowed some flexibility in the schedule as the techs and I “leap frogged” from appointment to appointment. In addition, we tried to only book three of the four exam rooms each hour. If the value stream of an appointment could not be completed within 30 minutes, we asked that pet be dropped off and techs in Treatment took over. I would come back to that patient later, when I had a break between exam rooms.

The understanding (and training, training, training!) was that the techs were to put everything I wrote on the form into the appropriate ”SOAP” section of the EMR. If there was other information or details they felt were important, then they should include that, also. They signed their initials at the bottom and put the form in a specified area on my desk for review and editing later in the day. The final responsibility for the medical records was mine and only mine, as it should be.

We also, at a later date, did away with a separate tech history and tech physical exam. The only history and exam that was important was the doctor’s. The newly available tech time was utilized to input the history, physical exam findings, treatment orders and home care instructions into the EMR in the exam room in real-time as I informed the client.

Note: This is also a good example of Standardized Work!

Tell me what you think. How does this impact your concepts of respect? How much of the daily work in a hospital should staff be allowed to do? Understanding that doctors are ultimately responsible for the medical records, are they the only individuals that can input them into the electronic medical records (EMR)?  What situations have you been involved with where you felt at the mercy of systems; a “catch-22?”  How was it resolved? How many clients actually value “the personal touches,” such as doctor-written welcome cards or examination summary reports vs being able to get their pet seen (and out!) in a timely and cost effective manner? One client out ten; one out of 100; 1000? Where do (would) you balance a conflict between flow and “that personal touch?”

Thanks for stopping by.

"Pushy" Veterinary Processes

This is a continuation of the previous blog “‘Pushy’ Rescue Groups.” We are revisiting the difference between “pull” and “push” systems.

Veterinary practice is, in general, a “pull” system. Our services are initiated (“pulled”) by the client. We don’t go out and fix random pets and, then, hope one of them belongs to one of our clients! However, we have been talking about “external” customers (clients). Within the value stream, there are “internal” customers as well (the person who does work after you in a process or value stream). It is here that we can suffer from “push” systems.

The Lean concept of “pulling” value within the value stream means that each step in the sequence of treating the patient “flows like a river”, as often gets said in the Lean literature. There should be a person (an “internal customer”) ready to perform Step 2 as soon as Step 1 is finished; Step 3 as soon as Step 2 is finished, etc. through the rest of the value stream. Step X pulls from Step X-1 which pulls from Step X-2 which pulls from Step X-3, and so on back “up” the the value stream. Thus, it is said that ”value is pulled ‘up’ the value stream. If Step 3 is not ready and Step 2 sends the patient on, Step 2 is “pushing” the patient “down” the value stream. Since Step 3 is not ready, the flow of the patient stalls until Step 3 is ready. The patient is essentially “warehoused” and has to wait, which is one the types of muda (waste) that Lean organizations are trying to remove from the value stream in order to improve value to the customer (flow).

On a related issue, Dr. Eliyahu Goldratt put forth the “Theory of Constraints” which, in part, says that if you want to find the “bottlenecks” within a production sequence, look for piles of work in process (WIP) inventory. You should find a “bottleneck” at the next step. Waiting patients and clients are signs of “bottlenecks” in our sequence of production.

Check for yourself. Do a gemba walk; i.e. go to where the work is done and observe the value stream. If you see patients and/or clients waiting, check the status of the next step in the sequence. Chances are something is delaying the progress of that patient/client at that point. Utilizing 5 Why and problem solving methodologies are indicated to fix the issue.

Thanks for stopping by.  If there is a topic you would like discussed, please let us know.

Einstein's Equation of Lean Relativity

No, not Albert Einstein! Moraito “Morey” Einstein, Albert’s third cousin, twice removed on his mother’s side.

Just kidding! However, this, in a simple equation, explains Lean.

“F” stands for Flow and “V” stands for Value from the client’s point of view.

Taiichi Ohno’s equation states:

                                      Capacity = Work + Waste

What this equation states is that there is always waste in our current state. When we remove some waste, we create a new current state, but there is still waste. We pursue perfection, but never achieve perfection.

If we substitute our total “Value Streams” for “Present Capacity” and “Flow” for “Work”, we get:

                                     Value Streams = Flow + Waste

Rewriting the equation gives us:

                                     Flow = Value Streams - Waste



This, then, is essentially what flow means. Flow is all the different processes (value streams) that occur in the management of a veterinary practice with as much waste removed as possible (and then continually improved).

Also, remember that Value is defined as that which a client desires (Dc) and is willing to pay for, that moves (Mp) the patient's condition toward the desired outcome and is performed correctly (without waste; W) the first time.

                                           V = Dc + Mp - W


Everything about Lean is about improving flow, because flow ultimately results in greater value. A3 problem solving, 5S projects, kanban, Just-In-Time (JIT) concepts, error proofing (jidoka), visual management, continuous improvement (kaizen), everything is aimed at pursuing the perfection of flow. We continually improve systems and processes in order to improve flow, and therefore, value. 5S organizes the hospital by removing clutter from work areas, organizing the areas so that they have only the needed equipment close to hand with a consistent place for everything and everything in its place. 5S also makes problems visible, and solving those problems allows us to improve flow.

For example, at our hospital we were constantly having to leave the exams rooms to find this or that item. Not good for flow! So, we went to each of the exam rooms and got rid of duplicate suture scissors, hemostats, tourniquets, etc. Then, the staff and I created a list of the supplies and instruments that we routinely use within the rooms. We chose a roll of tape, Vetrap, cotton swabs, gauze squares, clippers, a small supply of various syringes, a digital thermometer, a Nye tourniquet, a stethoscope, fecal loops, etc. We even put some blood tubes, Idexx spinners, and a bottle of heparin in each room to facilitate quick blood draws for lab tests. Finally, we organized the drawers so that they were the same in each exam room. Now, each room is the same, with the most used resources close at hand. In addition, we all now know, regardless of which room we’re in, that tape is in the right hand drawer and the tourniquet is in the left. There is less confusion. We don't have to think, “This is exam room 1, so the suture scissors are here...no, there...no, in that drawer.” There’s no more time spent searching for items. Also, doctors and/or staff can now quickly (visually) tell if the drawers are complete (standardized). If not, the problem is fixed right then so it doesn't continue to be a disruption. This improves flow, thus value.

Kanban and JIT improve resource utilization by creating a system that provides drugs, supplies, staff schedules and doctor’s time, to name a few, only when needed, where needed and in the amount needed. This frees up cash, space, staff and doctors to do more patient care which improves flow which equates with higher value. Visual management techniques, A3 (PDSA) thinking, and “5 Whys” root cause analysis allow problems to be easily seen and fixed at the root cause(s), again, in order to improve flow and value. Even kaizen, the concept of utilizing our ultimate resource, our staff, to identify and fix problems and remove waste (muda) from our value streams is for the purpose of perfecting flow.

Time is money. And, time spent on wasteful activities and processes is money lost. Everything in our hospital, even wasted items, has to be paid for through income from clients. Otherwise, it comes out of our pockets, our bottom line. Value from the client's perspective means not being charged higher fees in order to cover waste.


All of this, then, is contained in the equation F=V. Simple, right?

The different individual concepts and “tools” of Lean are relatively simple. The difficulty is conceptualizing how the different elements interrelate to create Lean, putting it into operation within your practice and, then sustaining it long enough to get positive results and change the organizational mindset to automatically think Lean. But, that is a different equation and a different blog!

For now, just remember, “it's all about da flow, ‘bout da flow, ‘bout da flow…!“

What are your thoughts? Let us know.

Have You Checked Your SMED, Lately!

SMED stands for Single Minute Exchange of Dies. One of Shigeo Shingo’s and Toyota’s greatest gains in increasing flow was figuring out how to change the extremely large, heavy dies used to produce (stamp) the large body parts of different car models quickly. Toyota was able to improve this changeover time for one part to another from an industry standard of many hours (often eight or more) to less than five minutes!

So, what did this allow Toyota to do? It allowed them the ability to make smaller, more efficient, lots of the different models of cars. When you lose a whole day of production to change the dies, you can’t afford to do it very often. Which means, for economy's sake, you need to make large batches (there’s that “b-word”) at one time, which, also, means large inventories of parts, which then need to be paid for and stored at high costs. All very “un-Lean.” Toyota was a small company back then. They couldn’t afford any of that and stay competitive. Plus they had a small market in Japan and had to challenge themselves to produce a high mix of different products.

What did Toyota do? They had a need, a problem, that required a solution. Shingo and the workers got to work using what we’d recognize today as A3 Thinking. They went to the gemba, observed every aspect of the change over, “brainstormed”  possible countermeasures (together), and experimented until they reached their goal, or very close to it, being much better than before.

The equivalent of SMED in veterinary medicine is the time it takes to get an exam room ready for the next patient, or the surgery room ready for the next procedure, after you’re done with the previous. How fast can you go from spay to neuter to dental to cat abscess?

In essence, what we are are doing is looking at the flow between “flows”; identifying the time (delays and activity) between value added operations. A competitive swimmer must perfect his/her strokes and pace, but races can be lost by sloppy "flips" between the laps. So, swimmers must perfect this process, also. How fast can you “reload, aim and get ready to fire, again?” Consider ways to eliminate waste, 5S projects in the exam room or surgery room to facilitate quick change over, standardizes work to get everyone on the same page, and improved resource (doctors, staff, supplies, inventory, etc.) utilization through kanbans (signals).

What does this mean for a vet clinic? For example, could the previous surgery be recovered someplace other than the surgery table? Could a staff member clean and repack instruments while the doctor is busy performing the next procedure so they are ready to be autoclaved later? Could a trained, licensed tech induce anesthesia, intubate and prep the next patient while the doctor is placing skin sutures in the current patient? If so, what safety procedures and standardized work would need to be put in place? In the past, I have allowed trained staff to draw up injectable anesthesia, inject it, intubate the patient and start prepping. BUT, a second trained tech had to verify the proper type and amount of injectable anesthesia, and had to double-check the correct endotracheal tube placement. Any uncertainty or questions resulted in a halt of the process by those involved until verification and resolution by a doctor could occur.

In all of my years of practice ownership and management, I had never thought about, or even heard about, this concept before. That is one of the things that intrigues me so much about Lean. The different perspective and mindset that it brings to the day-to-day practice of veterinary medicine.

So, after some work on improving your value streams, take a look at your own SMEDs. Don’t be embarrassed!  And then, let us know how it went!

Flow (One Piece Flow)

In a Lean manufacturing setting, products are ideally “pulled” through the value stream, one piece at a time, continually. There might be times when batches greater than one are necessary. But, the goal with Lean is to find ways to reduce batch sizes in a way that improves flow without harming quality. Each step is ideally adding value, without waste, when the customer requests it (although there might be some “necessary waste.”) It is a similar process when performing a service for a client. 

Think of a value stream as a relay race. When the gun goes off (initiation of the value stream), each of the four runners advances one baton in a predetermined order (using standardized work). Each runner runs his leg of the race quickly and skillfully (adding value), and the hand-offs (pull) occur smoothly and without delay (waste), just at the right time (JIT) when the next runner signals his readiness (kanban). The result is, hopefully, a flawless (perfect) execution, in record time resulting in a first place medal (satisfied clients). The runners are ecstatic and proud (confident and engaged). The fans go wild (positive word of mouth advertising)!

This is opposed to “batch and queue” production where batches of product are produced at one time and then stored before going on to the next step. This results in much “hurry up and wait,” a lot of work in process (WIP) inventory, large amounts of warehousing space, and longer lead times.

For example, a product requires three steps to produce. Each step requires 10 minutes. In “batch and queue” mode, 10 units are produced at one time. The first step requires 10 units × 10 minutes = 100 minutes. The second step requires 10 units ×10 minutes = 100 minutes. The third step requires 10 units × 10 minutes = 100 minutes for the entire batch. However, the first unit is off the line in step 3 after 10 minutes. Therefore, it requires a total of 210 minutes (the lead time) for the first unit to be available to the consumer, and 300 minutes for the entire batch to be ready. This is not considering any waiting time between the batch processing steps (which tends to occur any time we have batching). 

Compare this with one-piece flow, where the first unit is through step 1 in 10 minutes. It then progresses straight through step 2 in 10 minutes and, finally, straight through step 3 in 10 minutes. The total elapsed time until the consumer receives his product is 30 minutes, plus any delays between steps. One-piece flow results in a savings of 180 minutes and is 85.7% faster.

In a multi-doctor hospital, four 10:00 am appointments arrive at the same time. Each client requires ten minutes to get the primary complaint, update the client information, pull the file, write the date and reason for the visit in the medical records, weigh the pet, and enter that data into the medical records.

The receptionist checks in all four clients before signaling to the techs that clients are ready to be seen.  This means that the first client is not seen until 40 minutes after his/her arrival.

In one-piece flow, the first client could be seen within ten minutes of arrival (and probably be checked out and on the way home before the fourth client gets into an exam room).

Or, techs draw all of the morning blood samples of hospitalized patients before centrifuging and running any of the tests. This keeps the doctor from being able to formulate any treatment orders as quickly as he could if blood samples were run as they were drawn.

Flow is the result of good value streams, JIT, kanban systems and standardized work. Flow equals value to the client. What’s also unintuitive is that reducing batch sizes can improve productivity. People often think working in batches in faster. Sometimes this is true, but not always. It depends on the work and the setting. We do know that working in batches creates a lot of waste -- sorting, moving, inspecting batches, logging them in computer systems, etc. -- work that wouldn’t be required if we had better flow. 

Improving flow in healthcare settings often requires changes to the process, such as the physical layout of a department or clinic. In the Lean mindset, we’d challenge ourselves to ask why we have batching or a particular office layout. “It’s always been that way” doesn’t mean it has to be that way in the future. If it is not adding value for the client or pet, it's probably muda and needs to be removed from the system.

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.