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. 

R-E-S-P-E-C-T

“Respect for people” is a fundamental principle of Lean and a major difference between Lean and the Western, more Taylor-esque, concept of management. The Western tradition, which is still a part of educating MBAs, is that management knows best and makes all decisions. Workers are to do as they are told.

There is a quotation by Henry Ford to the effect that the problem with workers is that, not only do they come with two hands, but also, unfortunately, a brain. Workers are not hired to think! Lean is much less of a top-down style of management, and much more of a bottom-up, inclusive, transparent style. This is not to say, however, that the asylum is completely handed over to the patients.

This core belief influences the relationship Toyota managers and supervisors have with their workers. For Toyota, management’s primary function is more of teacher and less of an organizational police officer. We now understand, more than before, that the focus for Toyota is not just on building quality automobiles, it is primarily focused on the building of problem solving, innovative, respected employees who, then, build quality, innovative automobiles.

Dealing with people from a basis of respect permeates every aspect of Lean.

Systems thinking:

Have you ever had the feeling that, at some point at work, you were damned if you do and damned if you don't? Or, that you are in the the middle of a Catch-22 situation? If so, you have probably been the victim of poor systems or systems colliding with each other. That feeling of not being in control or at the mercy of things bigger than you.

Thinking in terms of systems means understanding that the systems at work within an organization are management and leadership designed. Systems are the responsibility of management. Workers have no authority to control or overhaul systems. They are at the mercy of the systems. Yet, many times, staff are blamed for what is, in actuality, a system design problem.

For example, if a job is not being performed well, systems thinking would first consider such things as does the worker know that job is their responsibility, has the worker been trained adequately, does the worker have the necessary tools, and does the worker have timely and correct information?

Systems thinking is more respectful. It recognizes that systems should be investigated when problems occur before blaming people.

Value:

The Lean definition of value is that which the client wants and is willing to pay for, and that improves the health status of the pet, without defects and waste along the way. Our clients get exactly what they want, when want it and in the amount wanted. They pay for only value adding services. The concept of defining value from the client’s point of view shows respect for them.

Variance and overburdening:

Lean understands that large variances in workload can be the source of difficulties and overburden our staff. Lean suggests work loads try to be leveled as much as possible. Being watchful for the overburdening of staff comes from respect.

Just-In-Time

The Just-In-Time (JIT) concept is the procurement and delivery of resources, (whether that be drugs, supplies, access to diagnostic equipment and information, or patients, doctors and staff) just exactly where it is needed, just exactly when it is needed, and just exactly in the amount needed. Nothing more and nothing less.

With respect to staff and personnel, the Just-In-Time idea is based, in part, on recognizing and respecting the unique value of everyone's time and skills; to only use them when, where and in the amount needed.

Standardized work

Standardized work is the mutually agreed upon method to do or handle a certain process or situation that helps insure quality, timeliness and safety, and gets everyone on the same page working in the same direction. It shows respect by involving staff in its definition and formal writing, and by eliminating ambiguity and the anxiety it causes to workers that come from policy and process chaos.

Kaizen

Kaizen is a Japanese word that can be translated to mean “good change,” “change for the better,” or “continuous improvement.”

While improvements can be large, time consuming and expensive major changes, the most common are the small, daily, quick, inexpensive ideas submitted by staff that improve quality, flow, safety, value to the client and make work life just a little easier. Staff are on the frontline of our practices every minute of every day. They know, better than anyone, where and what the problems are. And, they probably know better how to remedy them than we owners and managers do.

Kaizen shows respect by recognizing what an asset our staff is, and allowing them to partner with us in improving the practice; to be engaged and be part of the solutions, rather than always being blamed for the problems.

5S

5S projects are the physical cleaning and reorganization of a particular room or area of the practice. It helps the staff to work with less clutter, frustration and confusion on a daily basis. It creates better flow within the hospital which increase value to clients; all ways of showing respect.

Go to gemba

"Genchi Genbutsu" (go and see) means that whenever there is a problem found, all relevant stakeholders (management and staff) should go to where the problem occurs (the “gemba”) and solve it together. It shows respect by recognizing that staff have valuable input to the situation.  

The Andon cord

On the Toyota production line, workers are provided with a mechanism to sound an alarm and ask for help anytime they find it necessary. The line stops if the problem is not quickly resolved. Toyota trains and trusts its employees to use the Andon cord when an issue of quality or safety is in question. It shows respect by creating a culture of safety and trust for anyone to speak up, even if they think there might possibly be an inkling of a concern.

It is my humble opinion that if veterinary staffs knew about and understood the Lean mindset and its worker-centric (and client-centric) philosophy, there would be such a grassroots revolution within the profession that owners, managers and corporation leadership would have no choice but to start thinking Lean within their practices. Maybe, we could start now and circumvent all of the "bloodshed."

Thanks for stopping by. Please share this blog with your contacts! And, let me know if you have any questions, comments or post ideas.

What Is This Takt Time You Speak About?

When I first started learning about Lean, one of the terms I seemed to have difficulty wrapping my brain around was "takt time."

Or, maybe it was getting straight the difference between takt time, cycle time, lead time, process time, value creating time, non-value creating time and all of the other “times.”

At any rate, if you read much about Lean, you will come across the term. So, I thought I would explain.

According to Lean Lexicon-5th Ed by the Lean Enterprise Institute:

Takt Time is the available production time divided by customer demand. For example, if a widget factory operates 480 minutes per day and customers demand 240 widgets per day, takt time is two minutes. Similarly, if customers want two new products per month, takt time is two weeks. The purpose of takt time is to precisely match production with demand. It provides the heartbeat of a lean production system. Takt time first was used as a production management tool in the German aircraft industry in the 1930s. (Takt is German for a precise interval of time such as a musical meter.) It was the interval at which aircraft were moved ahead to the next production station. The concept was widely utilized within Toyota in the 1950s and was in widespread use throughout the Toyota supply base by the late 1960s. Toyota typically reviews the takt time for a process every month, with a tweaking review every 10 days.

And:

Cycle Time is the time required to produce a part or complete a process, as timed by actual measurement.

For example, if you have 90 clients wanting routine annual exams and vaccinations performed on their pets each week and you have 30 planned hours available Monday through Saturday (40 hours/week/doctor, less surgery time, less in-patient treatment time, less new sick pet time), then your takt time is 30 hours/90 visits or or 1800 minutes/90 visits or 20 minutes per appointment.

Takt time is a time that represents the pace at which you need to work in order to meet current demand. To meet demand within the allotted time, a routine annual exam would need to be completed, on average, every 20 minutes.

In order to find the cycle time, an actual measured time, you would measure several appointments and calculate the the average time required to actually complete them. If you have a lot of variation, you might measure ten appointments, which is a good Industrial Engineering guideline (thanks to Mark Graban for that tip).

If the actual cycle time is less than or equal to takt time (meaning you can work faster than the demand rate), then you can meet demand within the available time restraints and everything should be good.

But, if cycle time is greater than takt time, then you definitely have a problem, because you cann not meet demand as performed within the time requirements. This scenario will necessitate a kaizen project and/or A3 thinking to work out some countermeasures. These might include finding more time for these exams sometime during the week (expanding your working hours), or eliminating waste and improving flow so the cycle time falls within takt time. We'd want to reduce the time it takes to complete the appointment, but without rushing or impacting quality or client satisfaction.

In manufacturing, it is sometimes a little less complicated because product is often moving through the production line at a much more precise interval and the time for each step has very little or no variation. So, cycle times in manufacturing are much more consistent. Manufacturers also have the opportunity to level their production rate by using inventory as a buffer against variation in demand. In a vet clinic, we might be able to somewhat level our workload through appointment schedule, but if we're taking walk ins, we have to be able to react and adjust to that variation in demand.

But, again in veterinary medicine, we have more variation. There is variability in how long an annual exam actually requires. Are there issues that need to be addressed? Will a fecal exam be required? How about a heartworm test? How many vaccinations are due? Do medicines needed to be filled and dispensed? In addition, there is variability in the arrival times of clients, even with appointments. This results in variance squared (variance X variance), and that = chaos.

There are two points that should be made here. The first is that variability is a form of waste and should be reduced as much as possible using the Lean mindset and methodologies. Meeting takt time is a first goal. The second point is that this is the reason you probably should not schedule more than 85% of your available appointment times. This allows you some "wiggle"room. I have heard some advocate high density scheduling, i.e. close to or at 100% booked.  But, even with a highly trained staff in a Lean environment, you just can't escape variation. The first time an appointment goes long or a client shows up late, you are behind schedule which means each subsequent appointment will have to wait. Waiting is muda. High density appointments are not value for the client, from the client's point of view.

In a later blog, I hope to write about queueing theory, exponential statistical distribution, and Poisson distributions. These concepts produce more realistic models that take into account the variabilities of arrivals and cycle times.

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.

Waste (Muda)

In Japanese, the word for waste is muda. Any time, activity or resources that do not add value can be considered waste. Traditionally, there are seven forms of muda. However, many Lean practitioners have added an eighth, in recent years.  The “waste of talent” or the “waste of underutilized human potential” is the waste of not utilizing staff effectively, not acknowledging their unique talents and perceptions, or potential intellectual contributions. Lean considers people to be the most valuable asset in an organization. Lean encourages us to seek the wisdom of ten people, rather than the knowledge of one.

As stated in the book Lean Hospitals, the types of waste and their definitions are:

Defects
Time spent doing something incorrectly, inspecting for errors, or fixing errors.
Ex.: Surgery pack missing the scalpel handle; replacing a bandage that was applied too tightly.

Overproduction
Doing more than what is needed by the customer or doing it sooner than needed.
Ex.: Labeling heartworm preventative before the test results are available.

Transportation
Unnecessary movement of the “product” (patients, specimens, materials) in a system.
Ex.: Repeatedly taking a patient back and forth to a cage because resources are not available when needed.

Waiting
Waiting for the next event to occur or next work activity.
Ex.: Waiting for the processor to be turned on and warmed up before being able to take a needed radiograph.

Inventory
Excess inventory cost through financial costs, storage and movement costs, spoilage, wastage.
Ex.: Ordering 3 years worth of ointment because you got a free pair of “earbuds” for your smart phone.

Motion
Unnecessary movement by employees in the system.
Ex.: Chasing down the pair of bandage scissors that belong in Exam 1.

Overprocessing
Doing work that is not valued by the customer or caused by definitions of quality that are not aligned with patient needs.
Ex.: Centrifuging a blood tube longer than necessary; collecting client email addresses that are never used.

Human potential
Waste and loss due to not engaging employees, listening to their ideas, or supporting their careers.
Ex.: Idea by staff to attach a small basket to front of cage to keep patient personal items and meds from being misplaced is ignored.

There are two types of muda. Type 1 muda is “necessary waste,” or at least necessary for the time being. For example, taking time to write medical records is not something that the client would voluntarily pay for and it does not physically make the patient any healthier (transform the product), but it is necessary in a veterinary practice for legal or other reasons.

Type 2 muda is unnecessary waste. It is waste that can be removed immediately without causing any other ill effect. For example, waiting an excessively long time for the doctor to get into the exam room. This is not something that the client would pay for and it does not make the patient healthier. It has no place in the value stream. This category is sometimes called “pure waste.”