Acknowledgements For My In-Progress Book "Lean Veterinary Practice Management"

I know it is not typical to publish acknowledgments separately, outside of the book and in a public forum. But, it is important for me to do so.

Below, are the acknowledgments for my in-progress book Lean Veterinary Practice Management: Higher Quality, Less Waste, Greater Staff Engagement and Continuous Improvement. 

Acknowledgements 

I have been so fortunate, in my life and career, to have been part of a profession that has been both rewarding (and frustrating!) and self satisfying (and humbling!). A veterinarian is all I ever wanted to be. I never had a backup plan, so it is good that it all worked out!

In the book Honey From the Rock, Lawrence Kushner, writes about Malachim Elyon, ordinary people who, knowingly or unknowingly, act as a messenger from God to intervene in the lives of other ordinary people in their times of need. We all are called for these “errands”, whether we know it or not. I have come to recognize, at least, some of these angel messengers.

I grew up in El Paso, Texas. It was there that I became interested in Veterinary Medicine. My second home, during my high school years, was Northeast Veterinary Clinic, and one of my second “Dads” was Dr. Robert Morrison, of blessed memory. He, more than anyone, helped to solidify my determination to pursue my “calling” of Veterinary Medicine and exemplified, for me, what it truly meant to be a healer for “creatures great and small.” Thank you, Doc.

The veterinarians of El Paso, Texas, are a unique group of individuals. Maybe, because they  were all trying do the same, often difficult and thankless, job in a place that is somewhat isolated in many ways; but mostly because they were just good people!  While we were friendly competitors, we all knew we were colleagues first and foremost, working toward the same honorable goals; we always had each other's “backs.” Of special importance to me were Dr. Bernie Page, Dr. Guy Johnsen, Dr. Robert Rohrbaugh, Dr. Robert Garrick and Dr. Ed Silverman. You all have been very special and very needed in my life.

My dad was a mechanical engineer with an incredible life story. He built a power plant in El Paso, TX, a dam on the Roanoke River in North Carolina, the first radio telescope at Green Bank, West Virginia, and a radiation fishery in Gloucester, Massachusetts, that preserved fish fresh off the boats for more than a year without refrigeration. We owned a toy store later in my youth (not as cool as one might think) and I learned the fundamentals of entrepreneurship and the discipline it takes to be self employed.  

He was my first teacher of the scientific method, of understanding flow, of the Plan-Do-Study-Act cycle (though it wasn't formally taught as such), continual improvement, deep understanding, self reliance, the importance of education, honoring yourself and your family, and of respecting everyone. He was “Lean” before anyone knew that term. Dad, I am so happy that my soul chose our family to be born into. I miss you everyday!

Several years ago, after discovering the Toyota Production System, or Lean, I reached out to Mark Graban. Mark had already firmly established himself as a world-renowned expert in Lean Healthcare. He has authored or co-authored three books: Lean Hospitals, Healthcare Kaizen and The Executive Guide to Healthcare Kaizen, two of which have been awarded the prestigious Shingo Research Award. He acted as Editor for a fourth anthology book, Practicing Lean, which contains practical Lean experiences with contributions from many of his colleagues. He has also published a fifth book dedicated to Process Behavior Charts, a book titled Measures of Success. Mark writes a post almost every day for his blog leanblog.org. He lectures across the globe, holds popular Lean workshops, hosts webinars, is part of the leadership of KaiNexus, a software company, is an advocate for patient safety and has a Lean consulting business. 

As if that weren't enough, he took on a “geeky” veterinarian who knew just enough about Lean to be dangerous, and has been such a friend and mentor to me since that fateful day. He has been my co-author for several articles about Lean in veterinary journals, co-presenter for a lecture on Lean in Veterinary Medicine at a Texas state veterinary conference and continues to edit (i.e. make intelligible) my blog posts at leanvets.com. 

In the ancient and honorable Japanese tradition, Mark is truly a sensei; a master and a teacher. Arigato, Mark.

People often say that they married their soul mates. But, with somewhere around fifty percent of marriages ending in divorce, finding your “true soul mate” evidently takes, at least, two tries. 

That wasn't the case with me. Chris recognized me as soon as she met me! Fortunately, I was aware enough to see the same in her. She was a client of my veterinary practice (imagine that!). Since then she has been my best friend, my wife, my teacher, my guiding light, my sun and my moon. She knows me better than I know myself. Just ask her!

But, it is true. She has an old and gentle soul. I often think of her as the Merlin to my Arthur; my guide in the physical and metaphysical worlds. If there was ever a “messenger of God” sent to someone in need, Chris has been that for me. God has indeed blessed me! I love you more!

In addition, Chris has given me three of the most wonderful children, Paul, Caitlin and Corinne. They have arrived at adulthood with intelligence, common sense, good hearts and the same gentle soul as their mother. Being a father to this group has, almost, been too easy…almost!

For the past seven years my family has indulged my constant obsession with the Toyota Production System and Lean. They have been my de facto sounding boards, proofreaders, editors, “critiquers”, champions and cheer squad. They have learned more about Lean than they ever really wanted to. For this, for their unwavering love and for their perpetual respect, I am truly humbled and so deeply appreciative. Thank you. I love you all.

Chip Ponsford
Dallas, Texas
May 2018

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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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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!

The 3rd edition of Mark Graban's Lean Hospitals is now available

You all can breathe again! Mark Graban's Lean Hospitals, 3rd Edition is now available. The fact that there is a 3rd edition speaks volumes about the quality information found in this book and the respect it has garnered within the field of Lean Health care. 

My copy of the 1st Ed. of Lean Hospitals by Mark Graban

The picture to the left shows my copy of the first edition of Lean Hospitals.

As you can tell, it has been well read and shared with many interested staff and colleagues. I also have the 2nd edition, but it is a Kindle ebook and, therefore, impossible for me to show how much I have referenced it, also. 






My copy of the 3rd edition has been ordered. I'm going back to the actual book format (although it is also available from Kindle). I like being able to "dog ear" page corners, write notes in the margins and stick different colored Post-em notes to the pages to remind me of the great ideas and insights I get every time I read Lean Hospitals.

If you only get one book to read about Lean in general, and Lean Healthcare specifically, Mark Graban's Lean Hospital, 3rd Ed. is, by far, the book to get. Order your copy here!