Today's Lean Term: Kanban Post

As explained in a previous blog, in the Lean methodology, a "kanban" is a signal that something needs to be done. This is a Japanese word that gets translated to mean "signal" or "signpost" or the like.

For example, a patient file in a file holder on an exam room door is a kanban signal that a patient is ready to be seen in that room. Ideally, this "pulls" the doctor or appropriate staff member to the patient. A kanban might also be an empty, small plastic basket labeled “3cc Syringes-Exam 2” that's placed at a specified, marked location in the pharmacy that signals exam room 2 is running low on 3cc syringes and needs a refill.

A "kanban post" is the specific location that the kanban is placed so it can be seen (as an example of visual management) and acted upon. In the above examples, the file holder on the exam room door and the specific, marked location in pharmacy are the kanban posts for those objects.

My employer has developed a kanban and a kanban post for medical records he has made follow-up calls on. The signal is the medical file  tossed on the floor in the middle of his office.  This indicates to staff that the file is ready to be refilled in the filing cabinet (No, we have not gone paperless. What computers we do have are forever under my employer’s threat of him personally heaving said computers into the dumpster out back. But, I digress!). The post, therefore, is the floor in the middle of his office

However, the floor in the middle of his office is not specific, nor is it marked!  So, as a lean advocate (and/or just being a bit obsessive/compulsive), I decided to correct the situation...

Marked and specific

Much better!

That's one of the things I like about Lean. It is adaptable; not much is written in stone. The spirit of the methodology is the important part..

This kanban post will probably need to undergo some continued improvement. ;>)  Have a little fun today!

Thanks for stopping by. Tell your friends about the blog and, as always, questions and comments are welcome.

This Kanban System Works

Several months ago, I helped a practice set up a small, experimental kanban system for drug inventory. This particular system uses a kanban card as the signal to re-order.

The other common system utilizes two bins to hold a predetermined amount of product. When the first bin is empty, it is  removed and placed in a specified place known as a kanban post. From here, someone routinely (determined by standardized work) collects the empty bins and refills them from a central supply area. These bins are then returned and placed under (behind) the bin currently in use. The cycle repeats. This type of system is most often utilized in work areas, such as exam rooms, treatment areas or the lab to manage syringes, blood tubes, gauze squares, microscope slides, etc.

This was the “system” that was used previously. Excess drugs were stored throughout the hospital wherever there was room, such as this exam room cabinet. Notice the somewhat haphazard way the bottles are arranged.  Nothing is labeled. There are two empty slots on the second shelf. What is missing and needs to be ordered? And, how many? How long has this shortage been going on?

This “system” requires a staff member to go to all the the different “nooks and crannies” in order to create a complete drug order. In addition, this person would need to be experienced enough to “know” what belongs in empty spaces and how many to order. Inventory must be taken daily in order to identify depleted drugs, and get them ordered and delivered, hopefully, before a doctor needs to prescribed them. There is no reserved supply to cover the time necessary to get a new order in. Fortunately, for this hospital, orders placed by 10:00a.m. would be delivered by 3:00p.m. Not horrible, but still a gap before anyone can use the drug. For many hospitals, the lead time is days, not hours. Daily ordering also means daily receiving, daily invoice reconciliation, and daily restocking of shelves. That’s a lot of muda (waste)!!

In the new system, a place was found to install a couple of shelf units to experiment with. The drugs and supplies chosen were arranged in alphabetical order, with a few spaces left open for future additions.

The front of the shelves were labeled for each item. A place for everything, and everything in its place!

Even at this point, a missing item would be noticeable and identifiable.

The final step was making and placing the kanban cards (the signals). In order to keep this experiment as inexpensive as possible and to allow for quick, easy changes, I used pink index cards. The cards were bent in an “L” shape so they would stand up and be more visible.

On the front of the cards, I wrote the name of the drug, its size (e.g. milligrams), the unit size (e.g. tablets per bottle), the number of units to order and the number of units to keep behind the card. Our goal with this system was to only need to order once weekly. We wanted no more than two months supply up front, if possible, and, at least, one week's worth behind the card. When a new order comes in, the inventory is rotated by placing the items behind the card in front and replacing the reserve stock behind; a FIFO ( First In, First Out) system.

Now, once a week, a staff member (any staff member, because the system makes this possible) looks at the shelves and records the item, size and quantity to order. Ba-da-bing, ba-da-boom!

An improvement experiment might be to place a bar code on the card and read it with a smartphone or tablet into a form to be faxed or transmitted directly into a vendor's ordering software.

There are several Lean concepts here.

1. It is visual. With a single glance and one can see what is needed and what is not.
2. Just-In-Time. Item are only ordered when they are needed and in the amount needed, but before they run out completely.
3. Elimination of waste (muda). Wasted time in ordering, receiving, reconciling  and shelving, i.e. once weekly vs once daily. Wasted space in warehousing large amounts of inventory. Wasted use of capital that might be needed for other situations. And, wasted transportation and motion by the vendor. Increased workload on the rest of the staff to “cover” for an employee to handle inventory on a daily basis.
4. Use of  small, inexpensive, manual systems to experiment with and work out the “bugs” before investing in and expanding the system to include all other drugs or supplies, such as office supplies, or implementing more advanced technology, such as expensive and cumbersome software.

I had the opportunity to speak with the doctors and staff last month. They are still using the system and admitted that it has resulted in near zero shortages of these drugs. They were planning to expand it to other areas in the very near future.

Thanks for visiting? Comments and questions always welcome.

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.

Kanban

The Japanese word for “sign” or “signboard” is kanban. It is a visual means of requesting a resource, e.g. supplies, inventory, maintenance, doctors, etc. In many practices, inventory management is a perpetual problem.  It seems like it is always “feast or famine”; balancing “stock-outs” and expired “over stocks.”  The problem is not the person in charge of inventory. The problem is the system.  And, it isn't just about inventory levels, it is about managing all resources.

One example of a kanban would be an inventory card with the name, location, amount, supplier name, etc. being written on it that would be placed at the reorder point of the particular unit on the shelf to signal reordering. Lean organizations often use “two-bin” kanban systems such as an empty microscope slide box set aside at a specific location (a kanban post) that triggers replenishment of the slides at the microscope in the lab from a central supply area. It could also be a file holder on the exam room door that holds patient records which indicates there is a client and patient in the room ready to be seen, “pulling” the doctor or tech to the room. Or, it could be the plastic, colored flags mounted next to an exam room door that request an action take place in the room such as a doctor is needed, the exam room needs cleaning, or the exam room is ready for a new patient. Kanban is part of visual management, and just-in-time philosophy that we discuss later.